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Primary Fibrinolysis Is Integral in the Pathogenesis of the Acute Coagulopathy of Trauma

Kashuk, Jeffry L. MD*†; Moore, Ernest E. MD*†; Sawyer, Michael MD*†; Wohlauer, Max MD*†; Pezold, Michael BA*†; Barnett, Carlton MD*†; Biffl, Walter L. MD*†; Burlew, Clay C. MD*†; Johnson, Jeffrey L. MD*†; Sauaia, Angela MD, PhD*†

doi: 10.1097/SLA.0b013e3181f09191
Original Articles

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/cm2. 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.

Although primary fibrinolysis has been recognized as being associated with shock, a defined mechanistic link to the “Acute Coagulopathy of Trauma” has not been well elucidated. Using point-of-care rapid thrombelastography, a measure of the viscoelastic properties of blood, early fibrinolysis was found to be significantly associated with shock, massive transfusions, and hemorrhage-related death. Future studies should focus on the potential for early use of antifibrinolytics to improve survival in this group.

From the *Division of Trauma, Acute Care, and Critical Care Surgery, Department of Surgery, Penn State Hershey Medical Center, College of Medicine, Hershey, PA; and †Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, Denver and Aurora, CO.

Presented at the annual meeting of the American Surgical Association, Chicago, IL, April 8–10, 2010.

Reprints: Jeffry L. Kashuk, MD, Division of Trauma, Acute Care and Critical Care Surgery, Penn-State Hershey Medical Center and College of Medicine, 500 University Dr MC H075, Hershey, PA 17033. E-mail: jkashuk@hmc.psu.edu.

© 2010 Lippincott Williams & Wilkins, Inc.