Leeper CM et al. – In this study, the authors aimed to trend fibrinolysis following injury and investigated the effect of traumatic brain injury (TBI) and massive transfusion on fibrinolysis. The authors concluded that fibrinolysis shutdown is common after injury and it predicts poor outcomes. Severe TBI is associated with sustained shutdown. Use of empiric antifibrinolytics in children should be questioned and thromboelastography–directed selective use should be considered for documented hyperfibrinolysis (HF).

Methods

• This is a prospective study of severely injured children at a level 1 pediatric trauma center.
• A total of 83 patients (median age 8 years) with an Injury Severity Score of 22 (13–34), 73.5% blunt mechanism, 47% severe TBI, 20.5% massively transfused were analyzed.
• Rapid thromboelastography was performed upon admission and daily for up to 7 days and any use of antifibrinolytic was documented.
• Standard definitions (SD) of HF (HF; LY30 ≥3), fibrinolysis shutdown (SD; LY30 ≤0.8), and normal (LY30 = 0.9–2.9) were applied.
• Outcomes were death, disability, and thromboembolic complications; exploratory subgroups included massively transfused and severe TBI patients.

Results

• The rate of mortality, disability, and deep vein thrombosis was 14.5%, 43.7%, and 9.8%, respectively, and trending to SD was associated with death (P = .007), disability (P = .012), and deep vein thrombosis (P = .048).
• Patients with poor outcome had a lower median LY30 on post–trauma day (PTD)1 to PTD4 when compared with patients with good outcome; median LY30 was lower on PTD1 to PTD3 in TBI patients when compared with non–TBI patients.
• Extreme HF (LY30 >30%, n = 3) was considered lethal, while HF without associated shutdown was not related to poor outcome.
• In addition, 50% of massively transfused patients in hemorrhagic shock demonstrated SD physiology on admission and all patients with HF (fc31.2%) corrected following hemostatic resuscitation without tranexamic acid.