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The Thromboelastogram (TEG®) : A Five-Minute Primer For The Emergency Physician
The Thromboelastogram (TEG®) : A Five-Minute Primer For The Emergency Physician
net – Emergency Medicine EducationThe Thromboelastogram (TEG®): A Five-Minute Primer for the Emergency Physicia…
Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) // Edited
by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial
Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC)
It’s three o’clock in the morning on your fourth night shift in a row. While mustering the courage
to rescue your energy drink from the dank, dark depths of the staff mini-fridge, you hear a familiar
page: “trauma team to the trauma room.” As you walk towards the ambulance bay, the trauma
surgeon approaches with information regarding the incoming transfer:
Drawing your attention to a piece of paper in his hand, detailing what appear to be labs from the
outside facility, the surgeon points to a colorful figure: “I’m very concerned about this”:
(http://www.emdocs.net/wp-
content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.18.26-PM.png)
Scanning your mind for intelligent thought, you realize that it’s been some time since you’ve
ordered a thromboelastogram (TEG), let alone interpreted one.
If you’re like this physician take a few minutes to scan the following review the quick and dirty
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8/22/2021 emDOCs.net – Emergency Medicine EducationThe Thromboelastogram (TEG®): A Five-Minute Primer for the Emergency Physicia…
If you’re like this physician, take a few minutes to scan the following review – the quick and dirty
on TEGs is coming your way.
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content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.20.43-PM.png)
(http://www.emdocs.net/wp-
content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.20.31-PM.png)
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8/22/2021 emDOCs.net – Emergency Medicine EducationThe Thromboelastogram (TEG®): A Five-Minute Primer for the Emergency Physicia…
Drs. Semon and Cheatham of the Orlando Regional Medical Center Department of Surgical
Education generated an excellent quick reference chart:
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8/22/2021 emDOCs.net – Emergency Medicine EducationThe Thromboelastogram (TEG®): A Five-Minute Primer for the Emergency Physicia…
content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.23.21-PM.png)
(http://www.emdocs.net/wp-
content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.23.39-PM.png)
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content/uploads/2016/12/Screen-Shot-2016-12-20-at-10.23.52-PM.png)
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8/22/2021 emDOCs.net – Emergency Medicine EducationThe Thromboelastogram (TEG®): A Five-Minute Primer for the Emergency Physicia…
Stage 1: Fibrinolysis results in the degradation of fibrin, increasing fibrin degradation products (FDPs).
Excess FDPs result in clot de-stabilization.1
Stage 2: The cycle of clot formation and breakdown results in platelet and clotting factor consumption.1
Pilot study to evaluate the timeliness of r-TEG results, their correlation to conventional coagulation
testing (CCT – PT, aPTT, INR, platelet count, fibrinogen), and the ability of r-TEG to predict early blood
transfusion.
272 patients meeting requirements for major trauma activation
Outcomes:
All r-TEG values available within 15 minutes vs. 48 minutes for CCTs
ACT, r-value, k-time correlated with PT, INR, PTT (r >0.70; p<0.001)
MA and a-angle correlated with platelet count (p<0.001, p<0.001)
Controlling for demographics and ED vitals: ACT>128 predicted massive transfusion (>10
U) in the first 6 hours of presentation and treatment
Bottom line – r-TEG results were available within minutes, results correlated with conventional
coagulation test results, and were predictive of the requirement for early massive transfusion.
Study to evaluate the reliability of r-TEGs versus CCTs in predicting blood product transfusion
1974 major trauma patients, median ISS 17 (25% meeting criteria for shock; 28% transfused, 6%
died within 24 hours)
Outcomes
When controlling for age, injury mechanism, weighted-Revised Trauma Score, base excess
and hemoglobin, ACT predicted RBC transfusion and a-angle predicted massive transfusion
better than PT/aPTT or INR (p<0.001).
a-angle was superior to fibrinogen for predicting plasma transfusion, and MA was superior
to platelet count for predicting platelet transfusion (p<0.001)
Bottom line – r-TEG was more accurate in the prediction of requirements for RBC, plasma, and
platelet transfusions as compared to traditional CCTs.
Bottom line – There is growing evidence to suggest that the utilization of TEG and ROTEM
reduce transfusion requirements and improve morbidity in patients with bleeding, but
additional studies are required.
R time 20.0 => well above the upper limit of normal (10.0 minutes) = significantly prolonged time for clot
formation
K time 13.2 => normal: up to 10.0 = prolonged fibrin cross-linking
a-angle 16.5 => normal >53.0 = limited clot formation
MA 38 => normal platelet function >50 = limited platelet function
More importantly, one quick glance at our TEG and through pattern recognition, we known that
aside from his significant traumatic injuries, the patient is in trouble. This waveform is
characteristic of DIC Stage 2.
Key Pearls
A TEG can be used as a rapid assessment of thrombosis and fibrinolysis.
Although additional RCTs are needed, TEGs utilized in trauma patients have been demonstrated to
reduce transfusion requirements (important when we consider TACO/TRALI, risk of DIC, and blood-
borne pathogens).
If nothing else, take a few minutes to review the characteristic TEG waveforms – depending on your
laboratory processing time, knowledge of above tracings could allow early identification of coagulopathy
and immediate treatment.
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cianmcdermott (http://gravatar.com/cianmcdermott)
DECEMBER 22, 2016 AT 5:01 AM (HTTP://WWW.EMDOCS.NET/THROMBOELASTOGRAM-TEG-FIVE-MINUTE-
PRIMER-EMERGENCY-PHYSICIAN/#COMMENT-1633)
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