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Issue 018--Jul 2021

香港急症醫學會

Hong Kong Society
for Emergency Medicine & Surgery

Message from the President...

...misconceptions surrounding the safety of these vaccines, resulting in vaccine refusal. “Vaccine hesitancy” presents a huge challenge for extending the coverage of vaccination, or achieving herb immunity to curb the pandemic.....read more

From Editors...

Several important news in the field of EM happened in the last quarter. Internationally, there is retirement of Dr JudithTintinalli. Locally, Professor Colin Graham has received the ' Fellowship of the IFEM' ...read more

Council News...

Introducing to you the new look of HKSEMS website and the Emergency Medicine Day...read more

From Members

Members Area

Ultrasound has been widely adopted in various fields of medicine. It is a rather important skill to be learnt in EM practice. The Ultrasound Subcommittee core member of HKCEM, Dr Cheung Koon Ho, Ralph will introduce to us the application of POCUS in EM as well as his USG teaching experience...read more

Private EM Writes

The life of private EM physician can be exciting too. Dr Lam Ka Keung will write about three patients with lethal surgical emergencies having atypical presentation...read more

Nurse Corner

The digitalization in modern days has brought drastic change to our patient care. The paper record in AED has been in use for decades yet both data storage and retrieval are difficult. Ms Chan Siu Kau, APN of Pok Oi Hospital A&E will write about the implementation of eAED & Corporate Queue Management System (CQMS) and their impact on clinical care...read more

Advance in EM

The potential clinical application of viscoelastic assay in the management of major bleeding has attracted unprecedented interest in the last few years. Associate Consultant of PWH A&E, Dr Lai Chun Yu will have an in-depth discussion of two commercially available viscoelastic haemostatic assay method...read more

Message from the President Dr Ben Kuang-An WAN

COVID-19 has been troubling us since January of 2020, and the effects that the SARS-CoV-2 has brought upon us are undeniably challenging and rough. Ever since COVID-19 became a global pandemic, it has infected more than one hundred and seventy-eight million people, with a death toll of almost four million. This number will only continue to soar if we do not do something for it.

It is our duty to protect ourselves, our family, colleagues, friends and the public at large. This is why it is so important for us, as frontline healthcare providers, to get vaccinated against COVID-19. Those individuals who have underlying chronic health concerns such as heart diseases, asthma, diabetes mellitus or immunocompromised conditions, are more likely to have serious sequelae if they catch COVID-19. “Test, trace, isolate” and social distancing measures have been proven effective to curb the outbreaks in Hong Kong. However, they have also resulted in significant economic costs. From social restrictions, bars, movie theatres, restaurants and more are closing down, due to health concerns and economic downturns. Not only does vaccination help us protect one another, but it can also help us regain some sense of normality.

Vaccines are considered to be the most promising approach against the COVID-19 pandemic. By June 2021, there are more than 100 vaccines in clinical development, and 5 of them have entered phase 4 studies already. Most of the current vaccines against COVID-19 are injectable in a 2-dose regimen, but alternatives such as a 3-dose regimen or a 2-dose series consisting of vaccines on different platforms (e.g. mRNA vaccine with adenoviral vector vaccine) are being actively sought. New evidences are also emerging on vaccinating different populations such as pregnant individuals and young children. Vaccines don’t save people, but vaccination does. Vaccination reduces severe illnesses and death. Breakthrough infection and transmission might still occur despite vaccination, but the risk is substantially lowered to the extent that public health precautions could potentially be relaxed for individuals who have been fully vaccinated.

There has been a lot of controversies and misconceptions surrounding the safety of these vaccines, resulting in vaccine refusal. “Vaccine hesitancy” presents a huge challenge for extending the coverage of vaccination, or achieving herb immunity to curb the pandemic. Indeed, vaccine hesitancy is getting more prevalent and has been listed by WHO as a global health threat in 2019. As healthcare providers who embrace evidence-based medicine, and have professional obligations to safeguard the health of our patients and all individuals in our city, we are at a favourable position to, based on the current best evidence, educate people on the importance of vaccination, dispel their misconceptions and manage their expectations on the potential adverse effects, which are most often minor and transient. Very rare vaccine-associated adverse events do occur such as, anaphylaxis with the mRNA vaccines or even thrombotic events with thrombocytopenia associated with the adenoviral vector vaccine (not available in HK). However, other complications of concern such as Bell’s palsy has not been causally associated with BioNTech/Fosan mRNA vaccine. Of note, in view of the accelerated development of vaccines, questions on efficacy remain to be answered and safety issues of vaccines developed on different platforms have to be continuously addressed and monitored. Current evidences suggest that the vaccines are safe to use and potential benefits outweigh the risks to individuals.

With the news of the “variants of concerns” (VOC) of the SARS-CoV-2 virus, people start questioning the efficacy of vaccines against these new variants, which are potentially better at getting through the immunity established by vaccination. Multiple studies have shown that vaccine efficacy against these VOC may be lower when compared with the original coronavirus strain causing COVID-19. However, vaccines remain effective, especially against severe infections.

COVID-19 has taken its toll on all of us for far too long. It is time for all of us to take action, take back our control on our own livelihood, and return back to “normal”. We need to care and protect one another. Even if it is not for the good of others, do it for our own safety and protect ourselves. Get vaccinated, and be part of the solutions to this viral pandemic.

From Editors	Editors in chief	Dr Chor-man Lo, Dr Sam Siu-ming Yang
	Editors	Dr Ho-yin Chan, Dr Wendy Cheng, Dr Ka Keung Lam, Dr Kwun-bun Wong Mr Chun Pong Leung

Lately, the retirement of Dr Judith Tintinalli is an important piece of news in the field of Emergency Medicine (EM). As a professor in EM, she is also the editor-in-chief of one of the well-written textbooks in EM. Many of us had the experience of studying through her comprehensive textbook when we prepared for our EM examination. All of us will treasure the contribution by Dr Tintinalli to EM.

Locally, Professor Colin Graham, Director of the Accident and Emergency Medicine Academic Unit at CUHK, has received the Order of the International Federation for Emergency Medicine, also known as the ‘Fellowship of the IFEM’. This award recognizes individuals who demonstrated extensive and continuous commitment to EM, as well as having made significant contributions to supporting the development and advancement of IFEM. Apart from recognition of the contribution of Prof Colin, the award also serves as an encouragement to local EM physicians since it signifies the recognition of our local EM work by international experts.

The EEEM is going to take place in the coming October. Same as in previous years, the Society continues to organize the Preparatory Course for EEEM so as to better prepare our candidates for the examination. It is a two-day course which includes essential topics to be covered in the EEEM examination. Response from previous participants were positive, and passing rate of candidates taking the course was also encouraging. We wish all candidates good luck in the coming examination, and continue to contribute to EM development in their post-fellowship years to come.

As for the editorial group, we are glad that Dr Lam Ka Keung, the chairman of Private Fellows' Chapter of HKCEM will join the editorial group. At the same time, the editor-in-chief, Dr Lo CM, will end his work with this newsletter in the coming issue in preparation for his retirement. We are grateful for the contribution he made to the society and his lead on establishing the newsletter. Wish him a happy retirement.

Council News

Dear Members of HKSEMS,

Welcome to the 2nd issue of 2021. Let us refresh the activities organized the Council in the last 3 months!!

New look of HKSEMS website

Thanks to the IT team members of the society, Dr Billy Tse Choi Fung and Dr Marcus Lo Yat Hei, the official website of HKSEMS is revamped to make it more user friendly and modernized for easy surfing.
Please click our link https://www.hksems.org.hk/ and enjoy!!

Emergency Medicine Day 2021

The Emergency Medicine Day is an annual event, aiming at uniting the world population to think and talk about EM.
HKCEM was invited by EUSEM (European Society for Emergency Medicine) to join their promotion. The presidents of HKCEM and HKSEMS, and Dr. Ludwig Tsoi were invited to speak. Videos were uploaded to the official website.
Please click the link to watch the video !

Upcoming Events

Basic Point-of-care USG course for surgeons

HKSEMS has been offering this tailor-made course to our surgical colleagues since 2019. The 2020 course was cancelled due to the COVID-19 Pandemic. Since the local epidemic is under control, the 2021 course is resumed and is scheduled on 31^st July 2021.

EEEM Preparatory Course 2021

HKSEMS has been conducting this EEEM course throughout these years to facilitate her members to pass the EEEM. It is a 2 day program conducted by experienced fellows, and 26 participants have enrolled to this 2021 course!

ACEM 2021

Save the date !!
HKSEMS will be the organizer for the 11th ACEM.

This will be the ASEM’s first ever virtual conference!
Although the conference will go virtual due to COVID-19, it will not be an obstacle for organizing a great conference to share and stay connected!

Further information will be released in Facebook, IG and Twitter soon!
Please stay tune and join us!!

The deadline for submission of abstract is 31July 2021. Don’t be late and grab the chance to win a prize!!

Members Area	Dr Cheung Koon Ho, Ralph
	Consultant, A&E, Prince of Wales Hospital Ultrasound Subcommittee (HKCEM) core member

Point-of-care Emergency Ultrasound

Emergency physicians have been utilizing point-of-care ultrasound (POCUS) for quite some time, and the use has been more popular to facilitate patient care. There have been POCUS use in nursing and paramedic field in recent few years as well.

Classical applications of POCUS in emergency medicine include FAST (currently EFAST) in trauma, abdominal USG (hepatobiliary, aorta, renal, early pregnancy), and cardiac USG. Extended applications include musculoskeletal, procedures, respiratory tract, vascular and small parts (e.g. ocular).

On-job coaching has been traditional ways for trainees to learn ultrasound. A variety of emergency ultrasound courses are also available. (Fig 1 to 2) We have regular POCUS talks in academic seminar (e.g. Joint clinical meeting, scientific symposium in emergency medicine). There are plenty of free open access medical education (FOAM) in emergency ultrasound. Whereas other learning activities (e.g. quality assurance activities, regular ultrasound journal clubs) are done more frequently in some emergency ultrasound fellowship program overseas.

Fig 1. Didactic lecture in emergency ultrasound course

Basic emergency ultrasound course organized by HKCEM in Jun 2021.

Fig. 2.1 Practical training on cardiac USG with human model

Fig. 2.2 Practical training on transvaginal scan (TVS) using simulator

Hong Kong Society for Emergency Medicine and Surgery (HKSEMS) has been running POCUS course for surgery doctors since 2018. Course contents include common USG applications encountered by surgery doctors. All instructors are experienced USG emergency physicians. (Fig 3.1 to 3.4). The upcoming course is planned to be run in July 2021 (Fig 3.5).

Fig 3.1. First diet of POCUS course for surgeons, run by HKSEMS, in April 2018

Fig 3.2 Practical scanning during POCUS course for surgeons

Fig 3.3 First prize winner of POCUS game in 2018 POCUS course for surgeons

Fig 3.4 POCUS course for surgeons in Mar 2019

Fig 3.5 Upcoming POCUS course for surgeons in July 2021.

Emergency ultrasound teachings had also been extended to medical students. There were structured courses to teach emergency ultrasound applications for medical and nursing students, organized by local emergency medicine unit. (Fig 4)

Fig 4. Course in “ultrasound-assisted clinical skills for disasters” conducted by local emergency physicians, and Dr Toru Kameda (emergency physician in Japan), in July 2016. Hand-held USG machines were used throughout the course.

There have been USG teachings to nurses for nursing procedures since past few years in Hong Kong. (Fig 5.1 and 5.2)

Fig 5.1 Ultrasound enhanced nursing procedure course in 2017. (Photo courtesy of Dr KL Mok)

Fig 5.2 USG training to nurses regarding soft tissue infection in a local A&E department. Application of USG had been introduced to “Incision & drainage course” to nurses organized by COC A&E since 2020.

Regarding paramedic use of emergency ultrasound in Hong Kong, concept of FAST was incorporated in protocol regarding decision in pre-hospital trauma diversion by ambulance officers. (Fig 6)

Fig 6. Part of trauma patient diversion form regarding POCUS, utilized by ambulance officers.

Before the pandemic, our colleagues actively participated in overseas ultrasound activities
Fig 7. Hong Kong emergency medicine trainees (left photo) participated in POCUS competition game in Taipei (right photo) during annual conference of Taiwan Society of Emergency Medicine in Jun 2019.

Besides, Hong Kong emergency physicians, including ultrasound subcommittee Winfocus instructors, had been engaged in various overseas ultrasound teachings in past years.
Fig 8. Photo of the author together with other Winfocus emergency physicians from Singapore, Korea, and Thailand conducted Ultrasound Life Support Course in Bangkok, Thailand, in 2016.

Regarding publications, our local emergency physicians have on and off original research and review articles contributions in medical journals.
Finally, the author would recommend a few emergency ultrasound textbooks to trainees. The book authors are emergency physicians and the contents are practical with good illustrations. (Fig 9 to 11)

Fig. 9.1 Manual of Emergency and critical care ultrasound. Authored by Vicki Noble and Bret Nelson. Published in 2011. It is a classic and one of the best books containing concise texts and diagrams.

Fig 9.2 Picture with Vicki Noble, while the author underwent emergency ultrasound fellowship training in Massachusetts General Hospital (MGH), Boston, in 2013. Vicki Noble was the then director of emergency ultrasound division of MGH.

Fig 10. Introduction to bedside ultrasound. Authored by a myriad of great emergency ultrasound physicians. These e-books are easy to read, have video links, and is free.

Fig. 11.1 Practical guide to emergency ultrasound. Authored by Karen Cosby and John Kendall. Published in 2013. It contains detailed texts and images where one could search for details and specific queries.

Fig. 11.2 Picture with Karen Cosby while the author was in overseas ultrasound attachment in Cook County Hospital, Chicago, in 2016.

In summary, utilizing POCUS and interchanging such knowledge and skills in emergency medicine is a preferred attribute for emergency physicians. Motivation of such is POCUS’s profound clinical utility for patient car

Private EM Writes	Dr Lam, Ka Keung
	Chairman of Private Fellows’ Chapter, HKCEM Consultant, Hong Kong Baptist Hosptial, Out-patient Centre

Lethal surgical emergency with atypical presentations.

Life in a private hospital is never boring.

I still remember two years ago, when I encountered three cases of aortic aneurysms within 14 days. All three had different presentations and shot up my adrenaline level.

Case one was a 50+ years old gentleman who presented with low

grade fever and left lower abdomen numbness. History and physical examination were unremarkable, except a slightly higher body temperature and mild tenderness at left lower abdomen. An infective condition was supported by raised white cell count and C-reactive protein level. Common conditions like complicated upper urinary tract infection hit my brain. Intravenous ceftriaxone was given after septic work up. Computerized tomography (CT) studies and septic work-up revealed a left iliac artery aneurysm and Salmonella bacteraemia. Diagnosis was mycotic arterial aneurysm caused by Salmonella infection and he was transferred to a public hospital for further treatment due to financial reasons. Time taken to arrive at diagnosis was only two days.

The second case was a 30+ years old lady who presented with chest pain, low grade fever and blood-streaked sputum for 1 week. Chest x-ray showed a retrocardiac mass. CT scan revealed an aneurysm at descending aorta with a thin rim of pleural effusion suggestive of leakage. Endovascular stenting was performed in a public hospital. Subsequent sputum culture yielded mycobacterium tuberculosis, which was the culprit of the mycotic aneurysm. Follow-up CT scan one year after surgery showed resolution of the lesion.

CXR showing retrocardiac mass

CT reveled the mass was a descending aortic aneurysm with thin rim of pleural effusion suggestive of leaking complication.

CT 1 year later showing metallic stent in situ and resolved descending aortic aneurysm

I finally faced a classical presentation of abdominal aortic aneurysm (AAA). This time was an 80+ years old gentleman. He was being followed up in tertiary centre for infra-renal aneurysm with a size of 5-6cm in diameter; myelodysplastic syndrome with thrombocytopenia and anaemia requiring regular blood product transfusion; hypertrophic cardiomyopathy with pacemaker implantation; hypertension and diabetes mellitus. To scare me further, he came with a symptomatic aneurysm, but insisted on being managed in a private hospital. A clinical team consisting of top vascular surgeons, haematologist, cardiologist and intensivist was formed. Successful endovascular surgery was performed before the aneurysm got ruptured. He recovered well and was discharged six days after surgery.

All of those three cases had diagnoses made shortly after admission, enabling immediate treatment that further reduced morbidity1. I was very lucky and pleased to have taken care of two rare mycotic aneurysms2,3 and one complicated AAA case within just two weeks, while an ordinary doctor may only encounter one during her/his whole medical career. This was the greatest reward. My adventure is continuing to explore the next exciting and touching moments like this.

1.   Hsu RB, Chang CI, Wu IH and Lin FY Lin. Selective medical treatment of infected aneurysms of the aorta in high risk patients. Journal of Vascular Surgery 2009; 49(1): 66-70
2.   Wong SPY, Lai TKK Lai, Ng WL and Luk WK. Non-typhoid Salmonella mycotic aneurysm of the aortic arch. Hong Kong Med J 2007;13:234-7
3.   Kumar S, Babu NM S, Jarnet P and Sharma Ashok .Tubercular mycotic aortic aneurysm: A case report. Lung India. 2016 Mar-Apr; 33(2): 192–195.

Nurse Corner	Mr Chan Siu Kau
	APN, A&E, Pok Oi Hospital

The co-implementation of eAED & Corporate Queue Management System (CQMS) pave the road to paperless

In the era of information technology, we have to keep up with the newest technology in healthcare services for the day-to-day challenges. eAED is one example. eAED is an electronic system for clinical documentation in AED. CQMS is a queue system provided by HAIT with round-the- clock support. These two systems have been successfully rolled out in POH AED in Oct 2019. Meanwhile, AE card is still issued as a communication tool. However, with the continuous enhancements of the systems, paperless AED is our ultimate goal.

In POH A&E, the quality and safety of patient care is enhanced by electronic consultation and documentation. Firstly, it enables healthcare workers of AED and various departments to access the most updated information of patients, which enhances the efficiency of AE procedures, facilitates the immediate deployment of manpower, and shortens patient’s waiting time. Besides, it enhances the data accuracy and reduces the potential misunderstanding caused by handwriting. Lastly, the data interface between the two systems reduces redundant entries and enhance efficiency.

When the patient approaches Triage, triage nurses use the eAED system to call and triage cases. After saving the notes, the queue ticket will be printed out automatically for non-urgent cases. For no-show patients on CQMS, the call time will be displayed on eAED. The systems simplify procedures, eg. allowing triage and queueing in the same window. Announcements are made in English, Cantonese and Putonghua.

Ticket enquiry allows patient particulars, triage categories and status to be retrieved on CQMS. The patient’s status is available on CQMS even without an AE card or access to eAED.

Real-time capture for triage, consultation and admission is accomplished after notes are saved in eAED. This enhances the accuracy of patients’ waiting and admission time.

eAED’s feature of immediate notification allows doctors to be notified immediately when investigation results are available on eList. It reduces the waiting time of patients and facilitates the patient flow.

Limitations of these systems include occupational safety and health issue concerns caused by long-term use of computers. Also, during downtime of CMS, staff still has to rely on traditional AE cards.

A small step makes a big change. To achieve a paperless environment, the key step is to build up a good communication system among different ranks of users in AED, with the use of electronic ECG, checklists, MOE and admissions.

Advance in EM	Dr Lai Chun Yu
	Vice-chairman, Trauma Subcommittee, HKCEM Associate Consultant, A&E, Prince of Wales Hospital

Viscoelastic haemostatic assays (VHA) – thromboelastography (TEG) and rotational thromboelastometry (ROTEM®)

Overview
The potential clinical application of viscoelastic assay in the management of major bleeding has been attracting unprecedented interest in the last few years. Being a rapid point-of-care test for

haemostasis, viscoelastic haemostatic assay (VHA) is increasingly used in emergency departments, intensive care units and operating theatres. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM®) are the two main commercially available methods of VHA in the market. Unlike other routine coagulation assays, VHA assesses the viscoelastic properties of clot formation in real time, and provides information about clot initiation, clot strength and subsequent fibrinolysis.

Testing method
The mechanism of VHA is to assess the haemostatic process in a condition that mimics the sluggish blood flow in veins. The theories behind TEG and ROTEM® are similar, but these two machines operate in slightly different ways. TEG measures the physical properties of a clot in whole blood via a pin suspended in an oscillating cup. By contrast, in ROTEM®, the sample is placed into a cuvette in which a cylindrical pin is immersed. As the pin rotates at a particular angle, the blood sample clots, and the clot thickness is detected optically by an integrated computer that converts the measured data into numerical parameters.¹ In the following paragraphs, we shall focus on a description of ROTEM®. Figure 1 is the schematic diagram illustrating the operating method of ROTEM®.

Figure 1. ROTEM® Thromboelastometry detection method.¹

By measuring the speed and strength of clot formation, a graph of clot amplitude against time is derived. The following are the key parameters measured by ROTEM®:

Parameters related to the speed of clotting:
Clotting time (CT), Clot formation time (CFT), Alpha-angle
Parameters related to the clot firmness:
Maximum clot firmness (MCF), Amplitude at 5, 10 and 20 minutes (A5, A10 and A20)
Parameters related to the process of fibrinolysis:
Maximum lysis (ML), Lysis Index after 30 minutes (LI30)

Figure 2 is a graph of clot amplitude against time generated by a ROTEM® machine, and demonstrates how the key parameters are defined. Although TEG has different terminology, the principle is virtually the same.

Figure 2. ROTEM® thromboelastometry parameters and scaling.¹

To facilitate rapid differentiation among numerous clotting defects and the effects of anticoagulants, different reagents are added to assess the function of various coagulation pathways. Assays such as INTEM, HEPTEM, EXTEM, FIBTEM and APTEM are generated to address specific conditions.

By pattern recognition of ROTEM tracing or application of VHA-guided algorithm, clotting factor concentrates and haemostatic drugs are given according to the patient’s need (Figure 3). In general, fresh frozen plasma or prothrombin complex concentrate (PCC) is indicated to treat prolonged clotting time, while cryoprecipitate is specific for a decrease in alpha angle. If the amplitude and MCF are diminished, platelets should be the most suitable therapeutic option. Fibrinogen concentrate administration should be considered when there is evidence of functional fibrinogen deficit as shown by lowered FIBTEM amplitude. Apart from administering empirical tranexamic acid based on CRASH-2 trial, a repeated dose of tranexamic acid is indicated when the signs of hyperfibrinolysis exist.

Figure 3. Example of treatment algorithm based on ROTEM®²

Advantages of VHA and its clinical applications
Thanks to the rapid turnover time of VHA, there is growing interest in its practical use as a point-of-care test in trauma resuscitation. VHA enables early diagnosis of acute coagulopathy of trauma and shock, which was regarded as a major challenge in the past with the conventional coagulation test (CCT). A pilot study of protocolised VHA-guided haemostatic management conducted by Gratz et al. showed that, thromboelastometric results were available 38 minutes earlier than that of the CCT. This might lead to more rapid and precise coagulation management.³

Not only does VHA measure the speed of coagulation, but also it depicts a holistic picture of coagulation dynamics and the sustainability of clot formation. Thus, a targeted and individualized therapeutic approach in bleeding management is made feasible. By increasing the accuracy of diagnosis of trauma-induced coagulopathy, VHA parameters are better predictors of adverse outcome and mortality compared with the CCT. A systematic review of ROTEM® revealed that the parameters measured by EXTEM and FIBTEM (A5, A10, A20, MCF) were consistently capable of diagnosing coagulopathy and predicted an increased risk of bleeding, massive transfusion and mortality. By means of interpretation of LI30 and ML level, the value of ROTEM® was also pronounced in the early detection of hyperfibrinolysis, that was strongly associated with mortality.⁴

Assisting decision making about the administration of blood components, VHA-guided thrombostatic resuscitation protocols, such as the TACTIC algorithms, have been developed and may emerge as the standard in the near future.⁵ These protocols are user-friendly and simplify the steps of decision making. With improved design of the new automatic VHA machines, they can be operated by medical personnel efficiently without the need of intensive training.

In the trauma setting, there was growing evidence demonstrating that VHA-guided haemostatic therapy was associated with a reduction of mortality, bleeding rate, transfusion requirements, complication rates and health care costs.^2,6 According to the practice management guideline from the Eastern Association for Surgery and Trauma, a goal-directed component transfusion approach guided by TEG/ROTEM® was associated with fewer trauma patients requiring transfusion of packed cells (RR, 0.74; 95% CI, 0.67-0.82) and platelets (RR, 0.35; 95% CI, 0.22-0.55), fewer units of packed cells transfused (SMD, -0.38; 95% CI, -0.64 to -0.12) and a reduction in trauma mortality (RR, 0.75; 95% CI 0.59-0.95). It also led to a decrease in the number of blood transfusion-related complications.⁷

Besides, the application of VHA in other medical specialties similarly showed assuring results in clinical trials. First of all, the use of VHA in neurosurgery was shown to lead to consistent coagulation management, improved clot quality and decreased incidence of progressive haemorrhagic injury and neurosurgical re-intervention.⁸ Likewise, another recently published multi-centre randomised controlled trial on neurosurgical patients revealed the benefit of VHA use in a pre-specified subgroup with traumatic brain injury, 64% in the VHA arm were alive and free of massive transfusion compared to 46% in the CCT arm.⁹ Additionally, in the surgical patients and critically ill patients with ongoing haemorrhage and concern for coagulopathy, a reduction in blood component consumption and survival benefits were observed.⁷ To manage major bleeding in cardiac surgery, TEG/ROTEM® use was associated with decreased plasma and platelet exposure, reduced length of stay in ICU after surgery, lowered cost of haemostatic therapy and better patient survival.¹⁰ Furthermore, a systematic review and analysis published in 2019 indicated that TEG-guided haemostatic therapy could enhance blood product management and improve key patient outcomes, including length of stay, bleeding rate and mortality in elective cardiac and liver surgery and emergency resuscitation.¹¹

Bottom line
TEG and ROTEM® have recently caught much attention from trauma surgeons as a rapid point-of-care assessment of haemostasis, and is generally regarded as an improvement over traditional coagulation tests. The clinical applications of TEG/ROTEM® were also extensively investigated in various clinical aspects, such as the management of coagulopathy in sepsis, gastrointestinal bleeding, neurosurgery, cardiac surgery and obstetrics conditions etc. Goal-directed TEG/ROTEM®-guided treatment protocols allow a fast and more accurate assessment of coagulopathy, help guide haemostatic treatment, avoid unnecessary transfusion and improve survival.

References:

ROTEM® Analysis Targeted Treatment of Acute Haemostatic Disorders. https://www.ttuhsc.edu/medicine/odessa/internal/documents/ttim-manual/ROTEM®_Analysis.pdf
Maegele M. The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy. Dtsch Arztebl Int. 2019 Nov 22;116(47):799-806.
Gratz J, Güting H, Thorn S, Brazinova A, Görlinger K, Schäfer N, Schöchl H, Stanworth S, Maegele M. Protocolised thromboelastometric-guided haemostatic management in patients with traumatic brain injury: a pilot study. Anaesthesia. 2019 Jul;74(7):883-890.
Veigas PV, Callum J, Rizoli S, Nascimento B, da Luz LT. A systematic review on the rotational thrombelastometry (ROTEM®®) values for the diagnosis of coagulopathy, prediction and guidance of blood transfusion and prediction of mortality in trauma patients. Scand J Trauma Resusc Emerg Med. 2016 Oct 3;24(1):114.
Baksaas-Aasen K, Van Dieren S, Balvers K, Juffermans NP, Næss PA, Rourke C, Eaglestone S, Ostrowski SR, Stensballe J, Stanworth S, Maegele M, Goslings JC, Johansson PI, Brohi K, Gaarder C; TACTIC/INTRN collaborators. Data-driven Development of ROTEM® and TEG Algorithms for the Management of Trauma Hemorrhage: A Prospective Observational Multicenter Study. Ann Surg. 2019 Dec;270(6):1178-1185.
Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019 Aug;72(4):297-322.
Bugaev N, Como JJ, Golani G, Freeman JJ, Sawhney JS, Vatsaas CJ, Yorkgitis BK, Kreiner LA, Garcia NM, Aziz HA, Pappas PA, Mahoney EJ, Brown ZW, Kasotakis G. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020 Dec;89(6):999-1017.
Rimaitis M, Bilskienė D, Tamošuitis T, Vilcinis R, Rimaitis K, Macas A. Implementation of Thromboelastometry for Coagulation Management in Isolated Traumatic Brain Injury Patients Undergoing Craniotomy. Med Sci Monit. 2020 Jul 4;26:e922879.
Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, Maroni R, Vulliamy P, Henriksen HH, Pedersen KH, Kolstadbraaten KM, Wirtz MR, Kleinveld DJB, Schäfer N, Chinna S, Davenport RA, Naess PA, Goslings JC, Eaglestone S, Stanworth S, Johansson PI, Gaarder C, Brohi K. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med. 2021 Jan;47(1):49-59.
Weber CF, Görlinger K, Meininger D, Herrmann E, Bingold T, Moritz A, Cohn LH, Zacharowski K. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology. 2012 Sep;117(3):531-47.
Dias JD, Sauaia A, Achneck HE, Hartmann J, Moore EE. Thromboelastography-guided therapy improves patient blood management and certain clinical outcomes in elective cardiac and liver surgery and emergency resuscitation: A systematic review and analysis. J Thromb Haemost. 2019 Jun;17(6):984-994.