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Paper text:
in the 14th - century alliterative poem sir gawain and the green knight , the green knight seeks to best king arthur and his court in a game .
the green knight says that he will allow whomever accepts the challenge to strike him with his own axe , on the condition that the challenger find him in exactly 1 year to receive a blow in return .
sir gawain , the ostensibly least fitting of the knights of the round table , leaps to take on the challenge himself and provide honor to his king . in many respects ,
the valiancy of emerging diagnostics is put to a similar test as reported in the present issue by schchl and colleagues .
trauma - induced coagulopathy ( tic ) has been identified early after patient presentation , is associated with shock and massive transfusion ( mt ) requirements , may occur in the absence of coagulation factor depletion , and has been reported to complicate up to 30% of major trauma admissions .
accordingly , early and accurate diagnosis of tic is essential to facilitate and optimize rapid provision of appropriate blood products in order to decrease morbidity and mortality , to promote efficient utilization of valuable resources , and to avoid wastage of nonessential therapy .
conventional coagulation testing ( cct ) remains the predominant method of assessing coagulation status worldwide , including the prothrombin time , activated partial thromboplastin time , platelet tests , and fibrinogen concentration . despite this predominance ,
these tests have never been proven accurate in the hemorrhaging trauma patient   and suffer from a prolonged laboratory turnaround time of 1 hour or more in certain settings . finally ,
since they are plasma based , the assays do not accurately reflect the physiological milieu of whole blood , where multiple elements - including endothelium , platelet interactions , and subsequent thrombin generation - contribute to ultimate clot strength , leading to a meticulous balance of hemostasis and lysis .
usa ) and thromboelastometry ( rotem ; the name is a trademark of tem innovations gmbh , munich , germany ) tests that assess the viscoelastic properties of whole blood are relatively newer members of the diagnostic armamentarium currently under investigation for the assessment of patients at risk for tic .
both tests provide the potential to supersede cct in the diagnosis of tic because they provide real - time assessment of clot physiology from initial activation , subsequent achievement of tensile strength , and eventual resolution / degradation via a graphical tracing of fibrin polymerization and clot strength . beyond the early diagnosis of tic via point - of - care assessment ,
perhaps the most promising future for teg / rotem technology is the additional potential benefit of early goal - directed therapy , with the objective to optimize and possibly reduce blood product utilization . in the present issue of critical care , schchl and colleagues
evaluated whole blood rotem assays and the test 's ability to predict those seriously injured patients ( all with injury severity score > 16 ) likely to require mt ( > 10 units red blood cells/24 hours ) during the subsequent hospitalization . utilizing a variety of assays ( extrinsically activated assay with tissue factor , intrinsically activated assay using ellagic acid , and fibrin - based extrinsically activated assay with tissue factor and the platelet inhibitor cytochalastin d ) ,
the authors assessed the clotting time , clot formation time , clot amplitude at the end of the clotting time , and maximum clotting firmness , and compared the predictive value of these tests with cct and other physiologic parameters . although schchl and colleagues noted that the best predictive tests for mt were a simple hemoglobin or quick value , they observed that the predictive values of the clot amplitude at the end of the clotting time and the maxi - mum clotting firmness for the fibrin - based extrinsically activated assay with tissue factor and the platelet inhibitor cytochalastin d were similar , with the chief advantage being the availability of results within 10 minutes . at first glance
, the astute clinician may argue that severely injured patients at risk for tic can already be identified via cct or clinical factors , such as a variety of scoring systems , and hence why the need for another potentially expensive test to provide the same information albeit somewhat earlier ? accordingly , as with many excellent studies , the fine details raise more questions than provide answers . as pointed out by the authors ,
the rapid availability of point - of - care whole blood assays affords a much more comprehensive assessment of the true relational hemostatic state of the individual patient .
for instance , hyperfibrinolysis - which has recently been described by several investigators in the trauma setting [ 12 - 14 ] and can only be rapidly identified via viscoelastic tests - was clearly noted in 19 patients .
furthermore , the mean fibrinogen level in the mt group was 95 mg / dl . given the emerging significance of hyperfibrinolysis in the pathophysiology of tic , and the current use of fibrinogen concentrates for resuscitation in european centers , it would be interesting for the authors to correlate the frequency of this phenomenon in the mt group and its association with the fibrinogen level and clot strength .
furthermore , recent evidence supporting early use of antifibrinolytics   has prompted many centers to now include such therapy as a first - line adjunct to their mt protocols .
schchl and colleagues are to be congratulated for this important work , and we agree that current evidence continues to grow in support of point - of - care viscoelastic analysis of coagulation status . of note , however , the application and adaption of this technology present significant challenges .
for instance , it should be noted that the authors ' group have been working with these techniques for some time , and have no doubt moved beyond a significant learning curve for use of these techniques .
furthermore , recognizing the complex interactions of the hemostatic system , we posit that that teg / rotem should be considered as a tool to better appreciate relational hemostatic mechanisms that probably coexist in tic .
while we agree with the authors that rotem can a ord the clinician / surgeon a rapid diagnosis of tic , it must be noted that rotem - based assessments were similar to cct when only simply applied for predicting mt . in sum , the authors have clearly shown that teg / rotem holds promise as an important tool for the rapid diagnosis of tic .
we encourage the authors to continue their investigations , moving beyond observational trials to therapeutic interventions , utilizing this technology to improve our understanding of the complex physiologic changes to the coagulation system induced by significant injury .
such progress will firmly establish viscoelastic analyses as a notable and valiant member of the diagnostic roundtable .
cct : conventional coagulation testing ; mt : massive transfusion ; teg : thromboelastography ; tic : trauma - induced coagulopathy .
thromboelastography and thromboelastometry represent viscoelastic diagnostic methodologies with promising application to diseases of altered coagulation . their use in trauma - induced coagulopathy as a means of assessing the real - time status of the patient 's functional coagulation profile in addition to its impact on effective and appropriate use of blood product support 
 has been gaining acceptance among trauma surgeons , anesthesiologists , and transfusion medicine specialists . 
 however , the ability of viscoelastic testing to augment or supplant conventional coagulation testing for the diagnosis and management of trauma - induced coagulopathy remains controversial . 
 many of these issues pertain to the differences in methodology , instrumentation , logic , accessibility , ease of use , operator variability , and the method 's relationship to patient care , blood product use , cost , and conventional testing algorithms .