**Author details**

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

Since current laboratory tests do not reliably supply enough diagnostic information about patients that experience acute hemorrhage, which includes trauma patients in hemorrhagic shock, global hemostatic coagulation tests, such as ROTEM/TEG, have emerged as an alternative to traditional coagulation tests such as PT/INR [67]. Though PT/INR can accurately identify the initiation of clotting, these tests do not identify hemostatic capacity in terms of clot formation and maximal thrombin generation [67]. The two semiautomated commercial devices currently on the market for thromboelastography are the ROTEM analyzer and the TEG analyzer; both devices can effectively measure the maximum fibrin clot formation, thus serving as an estimate of the capacity of the coagulation cascade [67]. Thromboelastography has become a valuable asset in identifying coagulopathies and guiding hemostatic therapy and could potentially even prevent unnecessary blood transfusions [67]. These tests are quickly emerging as possible point-of-care devices that can monitor hemorrhage in either the ICU or ED settings [67]. Along with thromboelastography, clot waveform analysis also seems to be a promising

In principle, clot waveform analysis (CWA) is based on the aPTT assay and was first described when aPTT and PT were assessed with light transmission [67]. However, the distinct difference with CWA is that the readout from photo-optic registration is prolonged, creating a graph registered over time, whereas aPTT is solely the clotting time [67]. The tracing produced in clot waveform analysis thus reflects the entire process of clot formation and clot lysis [67]. CWA has been used to monitor the course of disseminated intravascular coagulation (DIC) and may be sensitive to even mild deficiencies in Factors II, V, VII, IX, X, and XII, which may prove the test useful in identifying hemophilias A and B [67]. Some studies have even found CWA to be more accurate than CRP and procalcitonin in monitoring the severity and prognosis of sepsis [67]. More clinical data and prospective studies are required, however, to support this evidence. Other emerging technologies that may prove to be highly valuable in the resuscitation of trauma patients are the

The FloTrac™/Vigileo™ and PiCCOplus™ systems have emerged as dynamic indicators that can accurately predict fluid responsiveness in critically ill patients [68, 69]. By utilizing stroke volume variation (SVV), or the percentage of changes in stroke volume (SV) during the ventilatory cycle, both systems have been shown comparable outcomes in predicting fluid responsiveness [69]. These systems serve as an alternative to static indicators such as central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP), which have been classically shown to

Despite tremendous progress in the management of trauma, universally applicable and highly reliable markers for adequacy of resuscitation remain elusive. For most trauma resuscitations involving patients who may be in shock, the use of lactic acid and base deficit as measurements of the overall physiological derangement will

**11. Miscellaneous topics**

resource in monitoring hemorrhagic shock.

FloTrac™/Vigileo™ system and the PiCCOplus™ system.

be poor predictors of fluid responsiveness [68].

**34**

**12. Conclusions**

be sufficient.

Kathryn C. Kelley1 , Kyle Dammann1 , Alex Alers2 , Thomas B. Zanders3 , Charles Bendas2 and Stanislaw P. Stawicki4 \*

1 Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

2 Section of Surgical Critical Care, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

3 Department of Medicine, Section of Pulmonology and Critical Care, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

4 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

\*Address all correspondence to: stanislaw.stawicki@sluhn.org

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