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Ann Surg. 2010 Sep;252(3):434-42; discussion 443-4. doi: 10.1097/SLA.0b013e3181f09191.

Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma.

Author information

1
Division of Trauma, Acute Care, and Critical Care Surgery, Department of Surgery, Penn State Hershey Medical Center, College of Medicine, Hershey, PA 17033, USA. jkashuk@hmc.psu.edu.

Abstract

BACKGROUND:

The existence of primary fibrinolysis (PF) and a defined mechanistic link to the "Acute Coagulopathy of Trauma" is controversial. Rapid thrombelastography (r-TEG) offers point of care comprehensive assessment of the coagulation system. We hypothesized that postinjury PF occurs early in severe shock, leading to postinjury coagulopathy, and ultimately hemorrhage-related death.

METHODS:

Consecutive patients over 14 months at risk for postinjury coagulopathy were stratified by transfusion requirements into massive (MT) >10 units/6 hours (n = 32), moderate (Mod) 5 to 9 units/6 hours (n = 15), and minimal (Min) <5 units/6 hours (n = 14). r-TEG was performed by adding tissue factor to uncitrated whole blood. r-TEG estimated percent lysis was categorized as PF when >15% estimated percent lysis was detected. Coagulopathy was defined as r-TEG clot strength = G < 5.3 dynes/cm. Logistic regression was used to define independent predictors of PF.

RESULTS:

A total of 34% of injured patients requiring MT had PF, which was associated with lower emergency department systolic blood pressure, core temperature, and greater metabolic acidosis (analysis of variance, P < 0.0001). The risk of death correlated significantly with PF (P = 0.026). PF occurred early (median, 58 minutes; interquartile range, 1.2-95.9 minutes); every 1 unit drop in G increased the risk of PF by 30%, and death by over 10%.

CONCLUSIONS:

Our results confirm the existence of PF in severely injured patients. It occurs early (<1 hour), and is associated with MT requirements, coagulopathy, and hemorrhage-related death. These data warrant renewed emphasis on the early diagnosis and treatment of fibrinolysis in this cohort.

PMID:
20739843
DOI:
10.1097/SLA.0b013e3181f09191
[Indexed for MEDLINE]

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