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
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.
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).
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