title: Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma.
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.
authors.affiliation: 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.
authors.forename: Jeffry L
authors.initials: JL
authors.lastname: Kashuk
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Michael
authors.initials: M
authors.lastname: Sawyer
authors.forename: Max
authors.initials: M
authors.lastname: Wohlauer
authors.forename: Michael
authors.initials: M
authors.lastname: Pezold
authors.forename: Carlton
authors.initials: C
authors.lastname: Barnett
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Clay C
authors.initials: CC
authors.lastname: Burlew
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
authors.forename: Angela
authors.initials: A
authors.lastname: Sauaia
mesh_terms: D000208:Acute Disease; D000328:Adult; D001778:Blood Coagulation Disorders / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D016009:Chi-Square Distribution; D005260:Female; D005342:Fibrinolysis / Q000502:physiology*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D019095:Point-of-Care Systems; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D013916:Thrombelastography; D013997:Time Factors; D014947:Wounds and Injuries / Q000150:complications* / Q000628:therapy