Case Study for a Critical Bleeding Patient and the use of TEG

TEG learning case:  
 
We had a patient on warfarin and plavix who had a GI bleed and was found to have INR>9.9. Prior to the start of my shift, her vital signs were stable so the decision overnight was to give vitamin K because she did not have yet have a diagnosed life threatening bleed. However, she became increasingly altered, and subsequent head CT showed spontaneous subarachnoid hemorrhage. By this time nearly 8 hours had passed and her INR was about 4. We ran a TEG platelet mapping assay before she received any reversal agents, which utilizes a green top (heparinized tube).
 
You can see the HKH (heparinized kaolin heparinase) TEG tracing in pink has a prolonged R time, indicating severe hypocoagulability. Furthermore, even though the patient was reported to be on plavix, you can see that the maximum amplitude (MA) of the platelet ADP tracing in green and the MA of the HKH tracing are approximately the same; both the green and pink curves approximate an MA of 60 mm. This indicates that she does not have significant antiplatelet effect. 
 
  
For whatever reason, the TEG machine does not report R time as a numerical value on the platelet mapping assay; however, you can see it is just under 15 minutes (pink tracing), and is far outside of reference values, which are posted on the wall by the machine.

 
She then got 4 factor PCC, and we gave DDAVP anyway given the life threatening nature of her bleed. However, I would not rush to transfuse platelets given her normal platelet mapping assay. 
 
2 hours after she got 4 factor PCC and DDAVP, we then ran a standard TEG (CK, CRT, CKH, CFF), which uses a blue top tube. We ran this test because we already knew her platelet function from the previous assay. Here you see that that R time has now normalized. The MA is high normal and the functional fibrinogen (CFF) channel is high normal. This indicated to us that our reversal during the resuscitation was sufficient. She definitely does not need more factors, lest she become hypercoagulable.  


 
 
She had stable hematocrit and stable interval head CT and was subsequently dispositioned. 
 
Thanks for reading !