title: Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma.
abstract: BACKGROUND
  The acute coagulopathy of trauma has been identified as a critical determinant of outcomes. Antifibrinolytic agents have recently been demonstrated to improve outcomes. This prospective study was designed to assess coagulopathy in trauma patients using thromboelastography.
  
  
  METHODS
  Trauma patients meeting our institution's highest tier of trauma team activation criteria were prospectively enrolled during a 5-month period ending April 1, 2011. Thromboelastography was performed at admission, +1 hour, +2 hours, and +6 hours using citrated blood. Hyperfibrinolysis was defined as estimated percent lysis ≥15%. Patients were followed throughout their hospital course to collect clinical data and outcomes.
  
  
  RESULTS
  One hundred and eighteen patients were enrolled (77.1% were male, 51.7% had penetrating trauma, 7.6% had systolic blood pressure <90 mmHg, 47.5% had Injury Severity Score >16, and 23.7% had Glasgow Coma Scale score ≤8). Hyperfibrinolysis was present in 13 patients (11.0%), with a mean time to detection of 13 minutes (range 2 to 60 minutes). By the 6-hour sampling, 8 (61.5%) of the hyperfibrinolytic patients had expired from hemorrhage. Survivors at this point demonstrated correction of coagulopathy, however, 12 patients (92.3%) ultimately expired (75% hemorrhage, 25% head injury). On stepwise logistic regression, hyperfibrinolysis was a strong predictor of early (24 hours) mortality (odds ratio = 25.0; 95% CI, 2.8-221.4; p = 0.004), predicting 53% of early deaths. Compared with patients without hyperfibrinolysis, patients with hyperfibrinolysis had a greater need for massive transfusion (76.9% vs 8.7%; adjusted odds ratio = 19.1; 95% CI, 3.6-101.3; p < 0.001) and had a greater early mortality (69.2% vs 1.9%; adjusted odds ratio = 55.8; 95% CI, 7.2-432.3; p < 0.001) and in-hospital mortality (92.3% vs 9.5%; adjusted odds ratio = 55.5; 95% CI, 4.8-649.7; p = 0.001).
  
  
  CONCLUSIONS
  In this prospective analysis, hyperfibrinolysis on thromboelastography developed in approximately 10% of patients and was considerably more likely to require massive transfusion. Hyperfibrinolysis was a strong independent predictor of mortality. Additional evaluation of the role of thromboelastography-directed antifibrinolytic therapies is warranted.
authors: Department of Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA 90033, USA.
authors: Crystal
authors: C
authors: Ives
authors: Kenji
authors: K
authors: Inaba
authors: Bernardino C
authors: BC
authors: Branco
authors: Obi
authors: O
authors: Okoye
authors: Herbert
authors: H
authors: Schochl
authors: Peep
authors: P
authors: Talving
authors: Lydia
authors: L
authors: Lam
authors: Ira
authors: I
authors: Shulman
authors: Janice
authors: J
authors: Nelson
authors: Demetrios
authors: D
authors: Demetriades
mesh_terms: D000208:Acute Disease; D000328:Adult; D001778:Blood Coagulation Disorders / Q000150:complications* / Q000175:diagnosis*; D005260:Female; D005342:Fibrinolysis; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D013916:Thrombelastography; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality*