Fibrinolysis in Trauma: "Myth," "Reality," or "Something in Between"

Area of Science:

• Trauma and Emergency Medicine
• Hematology
• Coagulation Science

Background:

• Trauma-induced coagulopathy (TIC) is a complex condition with ongoing debate regarding the role and significance of fibrinolysis.
• Two main perspectives exist: one defining fibrinolysis via standard coagulation tests and fibrin split products, favoring liberal tranexamic acid use, and another using viscoelastic tests (VET) with higher hyperfibrinolysis thresholds.

Purpose of the Study:

• To explore the historical "Myth" and current "Reality" of fibrinolysis in TIC.
• To reconcile differing definitions of hyperfibrinolysis in trauma patients.
• To propose a future framework for interpreting TIC that incorporates both historical and current understandings of fibrinolysis.

Main Methods:

• Narrative review of existing literature on fibrinolysis in trauma.
• Analysis of contrasting definitions of hyperfibrinolysis based on plasma-based tests versus viscoelastic tests (ROTEM, TEG).

Main Results:

• The definition of hyperfibrinolysis in TIC varies significantly between standard coagulation tests and viscoelastic tests.
• Plasma-based tests identify hyperfibrinolysis at lower thresholds, potentially leading to broader antifibrinolytic treatment.
• Viscoelastic tests define hyperfibrinolysis at higher thresholds, reserving treatment for more severe cases.

Conclusions:

• The concept of TIC has evolved from a "Myth" based on plasma tests to a "Reality" informed by VET.
• A "fibrinolytic spectrum" of TIC, defined by VET, offers a more nuanced understanding.
• Future interpretations of TIC should integrate historical perspectives with current VET-based insights for optimal patient management.