• emergency
• thromboelastography
• trauma

Trauma causes 4.4 million victims every year, mainly between the ages of 1 and 44, accounting for approximately 8% of deaths globally.
The Trauma Center, Hub, is a highly specialized hospital indicated for complex polytrauma management after stabilization at a 1st level hospital, Spoke. Although in the United States this organization demonstrated its effectiveness in mortality, in the Italian context data available are limited.
The first preventable cause of death in polytrauma is bleeding, caused by injuries and the fearful “trauma-induced coagulopathy”, multifactorial pathological phenomenon that determines dysfunction of the coagulation cascade at multiple levels. Standardized protocols in accordance with the latest guidelines include the vital parameters, blood gases, ultrasound evaluation and point of care tools for a functional and real-time evaluation of the coagulation structure, to set up a goal-directed therapy. Therefore, techniques that evaluate the viscoelastic haemostatic properties of blood, such as Thromboelastography (TEG), were introduced into the trauma clinical practice.
On 30 September 2018, the University Hospital of Pisa formalized the introduction of the Trauma Center, optimising Emergency Department (ED) organization to guarantee the highest standard of care. From October 2019, the Early Coagulation Support (ECS) protocol was applied, aimed at early identify and appropriately manage trauma-related major bleeding. A crucial tool of the new protocol was TEG in the emergency room (ER).
The aim of the study was to verify the impact of these optimizations on the outcomes of polytrauma patients and evaluate the diagnostic and prognostic value of TEG parameters.
A total of 1248 patients were enrolled from October 2017 to March 2023. We conducted a comparative retrospective study on 1154 polytraumas over 24 months: the first 12 months (576 patients) correspond to the period before Trauma Center introduction, and the following 12 (457 patients) to the subsequent period. Furthermore, 237 hospitalized patients with Injury Severity Score (ISS) >15 were selected and compared with a prospective group of 94 with the same characteristics, after introduction of the ECS protocol with TEG.
Results showed increase in greater dynamics (p <0,001) after Trauma Center introduction. A systematic assessment with ABCDE algorithm was performed from 38,4 % to 80,3% (p<0,001). Focused Assessment with Sonography for Trauma (FAST) performed by the emergency doctor increased after Trauma Center introduction, p value <0,001. The data shows an increase of ATLS certification among staff from 51.9 to 71.4% and a reduction in early and late mortality after the Trauma Center introduction (p value 0,05 and <0,01). Fewer patients required intensive and surgical treatments, with a shorter hospital stay.
The analysis of hospitalized patients with ISS>15 compared the retrospective group with the prospective one, after introduction of the ECS protocol. The data show a reduction in the use of blood products (RBC transfusion 20,6% vs 8,5%, p 0,01) associated with better outcomes (ED mortality from 2,9% to 1,8 %, p value 0,31; days of hospitalization from 21,99±23,71, 16,42±14,27, p value 0,04).
The TEG indices correlate significantly with conventional laboratory tests: in particular, a statistically significant correlation is highlighted between the fibrinogen values and the parameters K (R2 =0.34 p<0.001) and MAff (R2 =0 .58 p<0.001). The alteration of TEG parameters was associated with an increased risk of mortality (R>7 with OR=4.12; α <52° with OR=4.41). Furthermore, it emerges that patients with alterations of the parameters α<52 and MA<49 received more administrations of fibrinogen (p<0.002; p<0.0004), according to the proposed protocol.
The results demonstrate the advantage in terms of outcomes in the organization of the Trauma Center. Better management through standardized protocols reduced the use of blood products, with obvious cost advantages, in addition to outcomes. Compared to conventional laboratory tests, TEG parameters present a significant advantage for an early diagnosis of the blood coagulation structure alterations and consequently for an adequate therapeutic choice. The significant association between TEG parameter and mortality demonstrates that this method has a role in the prognostic stratification of polytraumatized patients.