Acute fibrinolysis shutdown after traumatic injury is more common than hyperfibrinolysis and is associated with significantly increased mortality, according to new research.

Most severely injured trauma patients have impairment of fibrinolysis, which is associated with an increased risk of death from organ failure, but most studies have focused on hyperfibrinolysis and its possible treatment.

Dr. Hunter B. Moore, from the University of Colorado Denver, Denver Health Medical Center, and colleagues investigated the fibrinolysis spectrum in 2,540 patients admitted to two trauma centers. They used rapid thromboelastography (rTEG) to classify patients as having hyperfibrinolysis, fibrinolysis shutdown, or physiologic fibrinolysis.

Among these patients, fibrinolysis shutdown was the most common phenotype (46 percent), followed by physiologic fibrinolysis (36 percent) and hyperfibrinolysis (18 percent).

Fibrinolysis shutdown was associated with male gender and advanced age, whereas hyperfibrinolysis was associated with lower admission systolic blood pressure, penetrating (versus blunt) injury, and higher injury severity scores, according to the report in the Journal of the American College of Surgeons.

Overall crude mortality was 23 percent for fibrinolysis shutdown, 34 percent for hyperfibrinolysis, and 14 percent for physiologic fibrinolysis, but because fibrinolytic shutdown was most common, it accounted for 48 percent of all deaths.

“Appreciation that fibrinolysis shutdown is the most common phenotype after severe injury warrants careful reconsideration of the empiric use of antifibrinolytics in trauma and suggests a mechanism for the failure to document improved survival with the use of tranexamic acid (TXA) in recent studies,” the researchers concluded.

Dr. Marc Maegele from Koln-Merheim Medical Center, Private University of Witten/Herdecke, Koln, Germany, who has published extensively about the coagulopathy of trauma, told Reuters Health by email, “This underscores the importance of fibrinolysis in both ways, eg, hyper and hypo, for outcome of trauma hemorrhage. Total mortality due to derangements in this system was 64 percent, two out of three patients. This also when adjusting for age. Future research needs to look into this system in much more detail.”

“Fibrinolysis shutdown is the most common phenotype after severe injury and warrants careful reconsideration of the empiric use of TXA in trauma,” Dr. Maegele said. “This may explain why CRASH-2 and MATTERs results could not be reproduced in recent retrospective studies and may suggest a mechanism for TXA failure in recent studies. Not all patients benefit from the empiric use of TXA, and TXA use should be limited to those who are in fact hyperfibrinolytic. This can be detected via viscoelastic testing.”