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Dimitris Bliamplias1, Dimitris Pinas2, Polixeni Zogrfidou2, Maria Tsiotsiou2, Georgios Anagnostou2, Athanasios Mitsokapas2, Euaggelia Gkoutziomitrou3.
Anesthesiology Department, «Papageorgiou» General Hospital, Thessaloniki Greece 1 Consultant,
2 Resident,
3 Director
     Introduction: Rotational thromboelastometry (ROTEM) is a point of care method, that was introduced a decade ago into extensive clinical practice. It helped clinicians to counterbalance the consequences of traumatic hemorrhage reducing both time to diagnosis and treatment, especially when factor concentrates are used. We present the clinical course of a multi-fractured patient, emphasizing into hemostatic derangements and how they were approached and treated according to repeated ROTEM examinations intraoperatively.
Case Presentation: Α young male patient, fell into a 10-meter well during his work shift, standing upright (burst into the ground with the heels). He was taken to the hospital immobilized on a long board. On arrival he had excellent level of consciousness, blood pressure of 130/75 mmHg, arterial oxygen saturation 97%, respiratory rate 18/min, heart rate120 /min. A primary survey was repeated. He undergone a computed tomography scan that revealed extensive chest and spine lacerations (right side rib fractures, right sided hemothorax, anterior fracture T11, T12-01 dislocation, shift of the lumbar spine to the left, front and up, O4 and O5 vertebrae body fracture, fracture of transverse processes in O1, O4 and O5 vertebrae). He was transferred to the ICU and a neurosurgical consultation was requested. Clinical situation deteriorated, due to hypoxemia, that led to intubation and initiation of mechanical ventilation. A right-side chest tube was placed. After patient stabilization, spine ΜRI was performed and he was led to the operating room two days later. Ιnduction of anesthesia was uneventful, initial ROTEM analysis was performed. Prolonged Clotting Time in EXTEM (165 sec), normal fibrinogen width (A10 17mm), Maximum Lysis 8% were most profound findings. One gram of Tranexamic Acid, and 1500 IU Prothrombin Complex Concentrate were used. Αs the surgery progressed, repeated ROTEM analysis showed normal EXTEM, FIBTEM results. Two units of erythrocytes was used due to Hb levels of 7.5 mg/dl. Another ROTEM study was performed two hours later, showed moderate decline in fibrinogen levels and ML 7%. Due to ongoing losses, 3 grams of fibrinogen were given and a repeated dose of 1 gr tranexamic acid. After that A10 FIBTEM was 19mm, ML 3 %, CT EXTEM 70 sec, CT INTEM 133 sec, A10 EXTEM 53 mm. Another unit of erythrocytes were used due to Hb levels < 8 mg/dl. Final RΟΤΕΜ showed Α10 FIBTEM 18 mm, CT EXTEM 77 sec, A10 EXTEM 52 mm with another unit of RPCs used to maintain Hb above 8 mg/dl. After nine hours of spine stabilization surgery, patient was transferred back to ICU.
Conclusion: Contribution of thromboelastometry in diagnosing trauma induced coagulopathy is well documented. Even though this was not a case of massive hemorrhage, anesthesiologists dealt with a patient that slowly lost substantial amount of blood both preoperatively and intaoperatively. Its value in this case, allowed shortening time to diagnose hemostatic deficits and using correct therapeutic approach prevented clinicians, running behind the consequences of a major bleeding.
Keywords: Rotational thromboelastometry, trauma induced coagulopathy, factor concentrates.

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