title: Fibrinolysis in Trauma: "Myth," "Reality," or "Something in Between".
abstract: The emphasis on fibrinolysis as an important contributor to trauma-induced coagulopathy (TIC) has led to a debate regarding the relative clinical significance of fibrinolysis in the setting of trauma. The debate has centered on two camps. The one camp defines fibrinolysis in trauma by standard coagulation tests as well as fibrin split products, D-dimers, and plasmin/antiplasmin levels. This camp favors a more liberal use of tranexamic acid and attributes more significance to hyperfibrinolysis in TIC. The other camp favors a definition of fibrinolysis based on the viscoelastic tests (VET), rotational thromboelastometry (ROTEM), and thromboelastography (TEG). These whole blood assays define hyperfibrinolysis at a higher threshold than plasma-based tests. Therefore, this VET camp reserves antifibrinolytic treatment for patients who demonstrate severe coagulopathy associated with hyperfibrinolysis. This bimodal attribution of the clinical relevance of fibrinolysis in trauma suggests that there may be an underlying "Myth" of the concept of TIC that was historically defined by plasma-based tests and a future "Reality" of the concept of TIC that is grounded on an understanding of TIC based on a VET-defined "fibrinolytic spectrum" of TIC. This narrative review explores this "Myth" and "Reality" of fibrinolysis in TIC and proposes a direction that will allow a "Future" interpretation of TIC that incorporates both the past "Myth" and present "Reality" of fibrinolysis TIC.
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Mark
authors.initials: M
authors.lastname: Walsh
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Jacob
authors.initials: J
authors.lastname: Shreve
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Scott
authors.initials: S
authors.lastname: Thomas
authors.affiliation: Department of Surgery, Denver General Hospital, Denver, Colorado.
authors.forename: Ernest
authors.initials: E
authors.lastname: Moore
authors.affiliation: Department of Surgery, Denver General Hospital, Denver, Colorado.
authors.forename: Hunter
authors.initials: H
authors.lastname: Moore
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Daniel
authors.initials: D
authors.lastname: Hake
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Tim
authors.initials: T
authors.lastname: Pohlman
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Patrick
authors.initials: P
authors.lastname: Davis
authors.affiliation: W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana.
authors.forename: Victoria
authors.initials: V
authors.lastname: Ploplis
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Andres
authors.initials: A
authors.lastname: Piscoya
authors.affiliation: Department of Surgery, Midwestern University Clinic, University of Arizona, Glendale, Arizona.
authors.forename: Julie
authors.initials: J
authors.lastname: Wegner
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: John
authors.initials: J
authors.lastname: Bryant
authors.affiliation: Departments of Surgery and Emergency Medicine, Memorial Hospital Trauma Center, South Bend, Indiana.
authors.forename: Anton
authors.initials: A
authors.lastname: Crepinsek
authors.affiliation: Department of Defense, ECMO Inpatient and Transport Programs, San Antonio Military Medicine Center/SAUSHEC, San Antonia, Texas.
authors.forename: James
authors.initials: J
authors.lastname: Lantry
authors.affiliation: Department Head, Expeditionary and Trauma Medicine, Naval Medical Research Unit, San Antonio, Texas.
authors.forename: Forest
authors.initials: F
authors.lastname: Sheppard
authors.affiliation: W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana.
authors.forename: Francis
authors.initials: F
authors.lastname: Castellino
mesh_terms: D005342:Fibrinolysis / Q000502:physiology*; D006801:Humans; D014947:Wounds and Injuries / Q000097:blood*