All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy.

Background: Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG.
Methods: A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05.
Results: We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < -5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG.
Conclusion: POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability.
Level of Evidence: Diagnostic study, level III. Therapeutic/care management study, level IV.