Faculty Collaboration Database

Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg 2010 Sep;252(3):434-42; discussion 443-4

Date

08/27/2010

Pubmed ID

20739843

DOI

10.1097/SLA.0b013e3181f09191

Scopus ID

2-s2.0-77956201218 (requires institutional sign-in at Scopus site)   292 Citations

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.

Author List

Kashuk JL, Moore EE, Sawyer M, Wohlauer M, Pezold M, Barnett C, Biffl WL, Burlew CC, Johnson JL, Sauaia A

MESH terms used to index this publication - Major topics in bold

Acute Disease
Adult
Blood Coagulation Disorders
Blood Transfusion
Chi-Square Distribution
Female
Fibrinolysis
Humans
Injury Severity Score
Logistic Models
Male
Point-of-Care Systems
Prospective Studies
Statistics, Nonparametric
Thrombelastography
Time Factors
Wounds and Injuries