Defining Rotational Thromboelastometry Thresholds for Fibrinolysis Phenotyping and Massive Transfusion Prediction in Trauma
In brief
ROTEM hyperfibrinolysis marked 37% massive transfusion and 58% mortality rates
Among 2,257 trauma patients, 5.3% had hyperfibrinolysis by ROTEM; 37% required massive transfusion within 4 hours and 58% died. Both rates were higher than in patients with physiologic clot breakdown or shutdown, and shutdown also marked a higher-risk group; the thresholds were validated in this cohort, but whether phenotype-guided treatment improves outcomes remains unknown.
- Journal
- The Journal of surgical research (Q1)
- Published
- 30 September 2026
- Study design
- Prospective / inception cohort
- Evidence level
- Level 2, Moderate (CEBM 2b)
- Authors
- Rodrigo Meade, Stephen M Bowman, Hanna K Jensen, Kyle J Kalkwarf
- PMID
- 42815292
- DOI
- 10.1016/j.jss.2026.08.056
Why clinicians should know about it
- Picked for Emergency Medicine (paper of the day, 3 October 2026): ROTEM fibrinolysis thresholds guide trauma resuscitation
Abstract
INTRODUCTION: Fibrinolysis, or clot breakdown, is a major contributor to death in severely injured patients. Thromboelastography (TEG) has established cutoffs for fibrinolysis phenotypes, hyperfibrinolysis, physiologic fibrinolysis, and fibrinolytic shutdown, but analogous thresholds for rotational thromboelastometry (ROTEM) remain limited. This study aimed to characterize fibrinolysis phenotypes using ROTEM and identify predictors of massive transfusion (MT) in trauma patients. METHODS: Among 2474 trauma patients who underwent ROTEM testing at an adult level I trauma center from 2018 to 2024, 2257 had an available EXTEM maximum lysis (ML) value and were included in the fibrinolysis phenotype analysis. Patients were categorized by EXTEM ML: shutdown (ML < 3%), physiologic (ML 3-15%), or hyperfibrinolysis (ML > 15%). The primary outcome was MT within 4 h; secondary outcomes included 24-h transfusion requirements, length of stay, and mortality. RESULTS: The median age was 46 y; 70.9% were male, and the median Injury Severity Score was 24.3. Hyperfibrinolysis occurred in 5.3% (n = 119), physiologic fibrinolysis in 64.6% (n = 1458), and shutdown in 30.1% (n = 680). Mortality was highest in hyperfibrinolysis (58.0%; 95% confidence interval [CI]: 49.0-66.5%) versus physiologic (10.6%; 95% CI: 9.2-12.3%) and shutdown (20.4%; 95% CI: 17.6-23.6%) (P < 0.001). MT within 4 h was 37.0% (95% CI: 28.8-45.9%) in hyperfibrinolysis versus 6.9% (95% CI: 5.7-8.3%) and 11.3% (95% CI: 9.2-13.9%), respectively. CONCLUSIONS: This study externally validates previously described ROTEM-specific EXTEM ML thresholds for fibrinolysis phenotyping in an independent trauma cohort. Hyperfibrinolysis strongly predicted MT and was associated with high mortality, whereas shutdown identified a distinct high-risk group. These findings support integration of ROTEM-specific fibrinolysis criteria into trauma protocols and prospective evaluation of phenotype-directed resuscitation strategies.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.