American Surgical Association
130th Annual Meeting Abstracts

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Primary Fibrinolysis is Integral in the Pathogenesis of Acute Coagulopathy of Trauma
*Jeffry L Kashuk1, Ernest E Moore2, *Michael Sawyer2, *Max Wohlauer2, *Carlton Barnett2, *Walter Biffl2, *Clay C Burlew2, *Jeffrey L Johnson2, *Angela Sauaia2
1Penn-State Hershey Medical Center and Penn State University College of Medicine, Hershey, PA;2Denver Health Medical center and University of Colorado, Denver Health Sciences Center, Denver, CO

OBJECTIVE(S):
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 coagulation. We hypothesized that PF occurs early in 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), 5-9 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.Estimated percent lysis (EPL) was categorized as PF with >15% EPL. Coagulopathy was defined as clot strength= G< 5.3 dynes/cm².Logistic regression defined independent predictors of PF.
RESULTS: 34% of patients requiring MT had PF, which was associated with lower systolic blood pressure, temperature, and worse base deficit/pH/lactate (p<0.0001). Mortality correlated significantly with PF (p=0.026); occurred early (median 58 min, IQR 1.2 min-95.9 min); and every one unit drop in G increased the risk of PF by 30%, and death by over 10% (Figure).
CONCLUSIONS:
Our results confirm the existence of PF as detected by r-TEG in severely injured patients. It occurs early (< 1 hour) and is associated with massive transfusion requirements, coagulopathy, and hemorrhage related death. These data warrant renewed emphasis on early diagnosis and treatment of fibrinolysis in this cohort


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