title: The incidence and magnitude of fibrinolytic activation in trauma patients.
abstract: BACKGROUND
  Trauma is a global disease, with over 2.5 million deaths annually from hemorrhage and coagulopathy. Overt hyperfibrinolysis is rare in trauma, and is associated with massive fatal injuries. Paradoxically, clinical trials suggest a much broader indication for antifibrinolytics.
  
  
  OBJECTIVE
  To determine the incidence and magnitude of fibrinolytic activation in trauma patients and its relationship to clot lysis as measured by thromboelastometry.
  
  
  METHODS
  A prospective cohort study of 303 consecutive trauma patients admitted between January 2007 and June 2009 was performed. Blood was drawn on arrival for thromboelastometry (TEM) and coagulation assays. Follow-up was until hospital discharge or death. TEM hyperfibrinolysis was defined as maximum clot lysis of > 15%. Fibrinolytic activation (FA) was determined according to plasmin-antiplasmin (PAP) complex and D-dimer levels. Data were collected on demographics, mechanism, severity of injury, and baseline vital signs. The primary outcome measure was 28-day mortality. The secondary outcome measures were 28-day ventilator-free days and 24-h transfusion requirement.
  
  
  RESULTS
  Only 5% of patients had severe fibrinolysis on TEM, but 57% of patients had evidence of 'moderate' fibrinolysis, with PAP complex levels elevated to over twice normal (> 1500 μg L(-1)) without lysis on TEM. TEM detected clot lysis only when PAP complex levels were increased to 30 times normal (P < 0.001) and antiplasmin levels were < 75% of normal. Patients with FA had increased 28-day mortality as compared with those with no FA (12% vs. 1%, P < 0.001), fewer ventilator-free days, and longer hospital stay.
  
  
  CONCLUSIONS
  FA occurs in the majority of trauma patients, and the magnitude of FA correlates with poor clinical outcome. This was not detected by conventional TEM, which is an insensitive measure of endogenous fibrinolytic activity.
authors.affiliation: Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of, London, UK.
authors.forename: I
authors.initials: I
authors.lastname: Raza
authors.forename: R
authors.initials: R
authors.lastname: Davenport
authors.forename: C
authors.initials: C
authors.lastname: Rourke
authors.forename: S
authors.initials: S
authors.lastname: Platton
authors.forename: J
authors.initials: J
authors.lastname: Manson
authors.forename: C
authors.initials: C
authors.lastname: Spoors
authors.forename: S
authors.initials: S
authors.lastname: Khan
authors.forename: H D
authors.initials: HD
authors.lastname: De'Ath
authors.forename: S
authors.initials: S
authors.lastname: Allard
authors.forename: D P
authors.initials: DP
authors.lastname: Hart
authors.forename: K J
authors.initials: KJ
authors.lastname: Pasi
authors.forename: B J
authors.initials: BJ
authors.lastname: Hunt
authors.forename: S
authors.initials: S
authors.lastname: Stanworth
authors.forename: P K
authors.initials: PK
authors.lastname: MacCallum
authors.forename: K
authors.initials: K
authors.lastname: Brohi
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D015415:Biomarkers / Q000097:blood; D001778:Blood Coagulation Disorders / Q000097:blood* / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism; D005341:Fibrinolysin / Q000378:metabolism; D005342:Fibrinolysis; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012121:Respiration, Artificial; D012307:Risk Factors; D013916:Thrombelastography; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000097:blood; D014947:Wounds and Injuries / Q000097:blood* / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D000979:alpha-2-Antiplasmin / Q000378:metabolism
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; D000979:alpha-2-Antiplasmin; C036309:fibrin fragment D; C037742:plasmin-plasmin inhibitor complex; D010959:Tissue Plasminogen Activator; D005341:Fibrinolysin