What does it mean when TEG results show prolonged Reaction Time, increased Lysis, and decreased Maximum Amplitude?

Critical Interpretation: Progressive Coagulopathy with Severe Hyperfibrinolysis

These serial TEG results demonstrate a rapidly deteriorating coagulopathy characterized by progressively worsening clot strength (MA declining from 60.3 to <40 mm), critically low fibrinogen contribution (CFF-MA dropping from 20.0 to 5.1 mm), and catastrophic hyperfibrinolysis (LY30 >22%) in the most recent sample, indicating imminent risk of life-threatening hemorrhage requiring urgent massive transfusion protocol activation. 1, 2

Understanding the Progressive Deterioration

Clot Strength Trajectory (CRT-MA)

• Maximum Amplitude (MA) represents the maximum strength of the clot, primarily reflecting platelet function and fibrinogen contribution 1, 2
• Your patient's MA declined progressively: 60.3 → 47.7 → 43.6 → <40 mm (normal range: 52-70 mm) 2
• MA <40 mm is independently associated with increased 30-day mortality in critically ill patients and predicts need for massive transfusion 3
• Decreased MA suggests combined thrombocytopenia and/or platelet dysfunction with severe fibrinogen depletion 1, 2

Fibrinogen Contribution Crisis (CFF-MA)

• The Citrated Functional Fibrinogen test uses a platelet inhibitor to isolate fibrinogen's contribution to clot strength 1, 4
• Your patient's fibrinogen contribution collapsed: 20.0 → 14.5 → 11.4 → 5.1 mm (normal range: 15-32 mm) 4
• CFF-MA of 5.1 mm indicates critically low functional fibrinogen, likely <100 mg/dL, requiring immediate cryoprecipitate or fibrinogen concentrate administration 2, 4
• This severe fibrinogen depletion is the primary driver of the declining overall clot strength 4

Catastrophic Hyperfibrinolysis (CK-LY30)

• LY30 measures the percentage of clot lysis 30 minutes after MA is reached; normal is 0-2.6% 1, 2
• Your patient's LY30 was 0% initially but jumped to >22% in the most recent sample 2
• LY30 >7.5% indicates hyperfibrinolysis and predicts need for massive transfusion with significantly increased mortality risk 2, 5
• LY30 >22% represents catastrophic hyperfibrinolysis requiring immediate tranexamic acid (TXA) administration 5

Prolonged Reaction Time (CK-R)

• R time measures time to initial fibrin formation; normal range is 4.6-9.1 minutes 1, 2
• Your patient's R time was initially normal (6.0-8.5 min) but became critically prolonged at 15.9 minutes 2
• Prolonged R time suggests coagulation factor deficiency, anticoagulant effect, or dilutional coagulopathy 2, 6
• The combination of prolonged R time with low MA and hyperfibrinolysis indicates consumptive coagulopathy with factor depletion 2

Immediate Management Algorithm

Step 1: Activate Massive Transfusion Protocol

• Initiate 1:1:1 ratio of packed RBCs, FFP, and platelets immediately 2
• Administer tranexamic acid (TXA) 1 gram IV over 10 minutes, followed by 1 gram over 8 hours for LY30 >7.5% 5
• TXA must be given urgently as efficacy is time-dependent; delay reduces survival benefit 5

Step 2: Correct Fibrinogen Deficiency

• Administer cryoprecipitate (10 units) or fibrinogen concentrate (4 g/70 kg) immediately for CFF-MA <10 mm 2, 4
• Target fibrinogen level >200 mg/dL (>2.0 g/L in obstetric hemorrhage if applicable) 4
• Fibrinogen replacement takes priority over other blood products given the severity of depletion 4

Step 3: Correct Coagulation Factor Deficiency

• Administer fresh frozen plasma (FFP) 10-15 mL/kg for prolonged R time >10 minutes 2, 6
• Consider prothrombin complex concentrate (PCC) if patient is on vitamin K antagonists or has severe factor deficiency 6
• For dilutional coagulopathy (>50% hemodilution), FFP is first-line treatment 2

Step 4: Reassess with Repeat TEG

• Obtain repeat TEG 15-30 minutes after each intervention to guide ongoing resuscitation 2, 4
• Target normalization: R time <8 minutes, MA >50 mm, CFF-MA >15 mm, LY30 <3% 2, 3
• Continue goal-directed therapy using serial TEG parameters rather than conventional coagulation tests 7, 3

Critical Clinical Context Considerations

If This is Obstetric Hemorrhage

• Pregnancy normally causes hypercoagulability with shortened R time and increased MA; these values indicate severe pathology 1, 2
• Postpartum hemorrhage with hyperfibrinolysis may represent amniotic fluid embolism, which shows unstable clot formation on TEG 1
• Higher fibrinogen targets (>2.0 g/L) are needed in obstetric hemorrhage management 4

If This is Trauma-Related

• Low clot strength (MA <50 mm) upon admission is independently associated with increased 30-day mortality in trauma patients 3
• Hyperfibrinolysis with depletion of fibrinolytic inhibitors occurs in approximately 20% of severely injured trauma patients 5
• Goal-directed therapy using TEG parameters improves survival compared to conventional coagulation test-guided therapy 2

If This is Sepsis-Related

• Septic shock patients tend toward hypocoagulant state while those without shock trend toward hypercoagulant state 8
• Your patient's progression suggests consumptive coagulopathy from sepsis-induced DIC 8

Common Pitfalls to Avoid

Do Not Delay TXA Administration

• TXA efficacy is time-dependent; administration must occur within 3 hours of injury/hemorrhage onset for maximum benefit 5
• The >22% LY30 indicates this patient would gain clot strength with TXA 5

Do Not Rely on Conventional Coagulation Tests

• In patients with deranged INR (≥1.6), 60% are normocoagulable and 20% are hypercoagulable on TEG 8
• Similarly, 81% of patients with thrombocytopenia (<100,000/mm³) are normocoagulable on TEG 8
• TEG provides superior guidance for transfusion decisions compared to INR and platelet count alone 7, 8

Do Not Undertransfuse Fibrinogen

• The CFF-MA of 5.1 mm represents critical fibrinogen depletion requiring aggressive replacement 4
• Standard FFP alone may be insufficient; cryoprecipitate or fibrinogen concentrate is essential 2, 4

Recognize Anemia's Paradoxical Effect

• Anemia can paradoxically show hypercoagulable TEG results due to decreased blood viscosity, potentially masking true coagulopathy 2, 4
• However, your patient's severely low MA and high LY30 override this concern 2

Prognostic Implications

• The combination of MA <40 mm, CFF-MA <10 mm, and LY30 >22% predicts >4-fold increased risk of mortality 5, 3
• Patients with hyperfibrinolysis and depletion of fibrinolytic inhibitors have significantly higher 24-hour mortality (33.3% vs 7.8%) and 30-day mortality (35% vs 16.4%) 5
• Immediate aggressive intervention with TXA, fibrinogen replacement, and massive transfusion protocol is life-saving 2, 5, 3