2. OUTLINE: I.Historical Perspective. A. Development of Thromboelastography. B. The expansion and transition from Cardiac Surgery to Trauma. II.Traditional Lab Tests vs. TEG tests. A. Clotting cascade B. Traditional Testing 1. Protime( (PT) 2. Partial thromboplastin time (PTT) 3. IVY bleeding time 4. Fibrinogen III.Clinical use of Point-of-Care testing for Trauma A. POC Tests 1. TEG (platelet mapping, V-curve, Rapid TEG) 2. I-stat (ph,pCO2,PO2,HCO3-,BE/BD,iCa2+,Hb/Hct,K+,Gluc.) B. Indications for POC. 1. Massive Transfusion 2. Head Injuries 3. Isolated Coagulopathies from Trauma related events. IV.Clinical Findings with the TEG A. Native TEG tracings B. Platelet Mapping and effects of drugs and the Interpretations. C. V- curve

3. Why Do we have a Perfusionist talking about Trauma? Training Experience Use of the TEG in Cardiac Surgery Similarities between Cardiac Surgery/ Trauma Lessons learned with TEG in Cardiac Surgery How can I make a difference in Trauma

4. Clotting Cascade

5. THROMBIN FIBRINOGEN PLATELETS

6. Clotting Factors Thrombin PlateletsFibrin Clot Activation Plasmin Clot Breakdown Coagulation Process Platelets

7. Hemostasis Components Interaction and Balance

8. Traditional Lab Test: PTT (partial thromboplastin time) PT (prothrombin time) Platelet Count (CBC)

9. Traditional testing: Partial thromboplastin time. (PTT) Intrinsic system. aPTT measures the integrity of the intrinsic system (factors XII, XI, VIII, IX) and the common pathway.

10. Traditional Testing: PT (prothrombin time) Extrinsic system Prothrombin time is specific to factors VII, V, X, Prothrombin and Fibrinogen.

11. Ivy Bleeding time: How effective is this test and what does it tell us? Platelet function Some of our clotting factors It is at BEST a very crude haemostatic test. Not really very accurate test and to many variables. How is it the test performed?

12. POC: Point of Care Testing: TEG: Native TEG Kaolin TEG Heparinase TEG Platelet Mapping ADP, Arachodonic Acid, Reptilase(XIII) “V” Curve Rapid TEG “Tissue Factor” I-stat: pH,PCO2,PO2,Na,K,iCa,Glu,Hct,Hb,HCO3,BE, SaO2.

13. TEG: Thrombelastograph Hemostasis System:

14. Devolopment and History of the TEG. 1948 Birth of the TEG in Germany Hellmut Harter. 1960’s Seen on the surgery front in the USA. Whole blood assay for blood clot analysis. TEG Device:

15. Bleeding Thrombosis Strength Stability Rate Defining the Position Looking at Clot Function

16. TEG Analyzer Whole blood analysis Initiation of clot Clot development Clot strength Clot lysis Information generated Coagulation pathway function Fibrinogen function Platelet function Fibrinolysis

18. TEG Technology

19. Platelet function Clot strength (G) Clotting time Clot kinetics Clot stability Clot breakdown TEG Tracing Time (min) Amplitude (mm)

21. TEG decision tree US Patent 6,787,363 U.S. Patent 6,787,363

22. “Normal” TEG ® Tracing 30 min

23. Prothrombotic TEG Tracing 30 min

24. Hemorrhagic TEG Tracing 30 min

25. Bleeding Pt

26. Heparin Effect Plain cup 5.8 2.2 59.1 0.0 56.2 6.4 *2.0* *0.4* -1.0 55.0 Heparinase cup

27. Platelet Function : MA Normal Abnormally low platelet function “Low MA” Abnormally high platelet function “High MA” 6.9 7.7 12.9 29.5 25.0 1.7 0.5 -12.4 0.5

28. Fibrinolysis – LY30 Normal Secondary fibrinolysis LY30 > 7.5%, CI >3.0) Primary fibrinolysis (LY30 > 7.5%, CI < 1.0) 5.8 6.0 1.2 74.5 55.5 5.8 63.0 -0.0 63.0

29. Tracing Comparison Rapid TEG Kaolin activated (standard TEG) Native TEG (no activator) Platelet function (MA) – thrombin generation dependent, not activator dependent…

30. Trauma Patient: 18 y/o Accidental gunshot wound to the Left neck.

32. Rapid TEG contains Tissue Factor (FIII) (tissuethromboplastin)

35. Rapid TEG

37. V-curve measure of the area under the curve represents the rate and production of Thrombin. Remember THROMBIN is the center of the clotting world.

38. MASSIVE TRANSFUSION PROTOCOL (MASSIVE HEMORRAGE PROTOCOL) HEAD INJURIES Rich in Tissue Factor (FIII) Pregnant Mothers Rich in Tissue Factor (FIII)

39. U SE OF R ECOMBINANT F ACTOR FVII A (T HESE ARE OFF LABEL USES WHEN USED IN T RAUMA )

40. Clotting Cascade

41. Any and all question?