Background: Mortality and morbidity from severe trauma constitute a major global burden. Major causes of early deaths are massive hemorrhage and brain injury. Both hemostatic and fibrinolytic abnormalities are present. The use of antifibrinolytic agents is controversial as the pathophysiology of trauma induced coagulopathy (TIC) remains unclear.Though there was benefit of tranexamic acid in the CRASH-2 study, not all trauma patients have excessive fibrinolysis. In fact, tranexamic acid may be harmful for the non-fibrinolytic cohort. There is thus a need to find out the incidence of hyperfibrinolysis, and their relationship to the outcome.

Aims: Identify fibrinolytic phenotypes in major trauma.
Characterize the fibrinolytic response and its temporal relationship to trauma.
Provide guidance for antifibrinolytic therapy.

Methods: Data identification: An English-language literature search using PubMed and Medline, 2009 -2019, for articles with search terms “trauma”, “coagulopathy” and “fibrinolysis”.
Study Selection: 284 articles that addressed the stated purpose.

Results: In addition to activation of coagulation and impaired platelet function, changes of fibrinolytic activity were present in all patients with major trauma.
The incidence and state of fibrinolytic activity and the relationship to outcome were identified.
Fibrinolytic activity undergoes temporal change during the early stage of trauma (1-2 days).
Fibrinolytic response includes vascular release of fibrinolytic activator, tPA, as a result of endothelial injury leading to hemorrhage, hypotension and catecholamine release; but only few investigations have been made into the role of inhibitors of fibrinolysis.
The antifibinolytic agent tranexamic acid is of benefit only to patients with excessive fibrinolysis, but harmful in those with hypofibrinolysis.

Conclusions: Among the elements of trauma induced coagulopathy, changes in the fibrinolytics factors have been observed to play a central role. The mechanism by which the fibrinolytic system respond to trauma remains unclear. There is an unmet need for guidance on use of antifibrinolytic agents.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/fibrinolytic-response-plays-a-central-role-in-trauma-induced-coagulopathy/