Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
J Thromb Haemost. 2013 May;11(5):826-35. doi: 10.1111/jth.12190.
Two concepts have been proposed for the hemostatic changes occurring early after trauma. Disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype is characterized by activation of the coagulation pathways, insufficient anticoagulant mechanisms and increased fibrinolysis. Coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS) occurs as a result of increased activation of the thrombomodulin and protein C pathways, leading to the suppression of coagulation and activation of fibrinolysis. Despite the differences between these two conditions, independent consideration of COT/ACOTS from DIC with the fibrinolytic phenotype is probably incorrect. Robust diagnostic criteria based on its pathophysiology are required to establish COT/ACOTS as a new independent disease concept. In addition, the independency of its characteristics, laboratory data, time courses and prognosis from DIC should be confirmed. Confusion between two concepts may be based on studies of trauma lacking the following: (i) a clear distinction of the properties of blood between the inside and outside of vessels, (ii) a clear distinction between physiologic and pathologic hemostatic changes, (iii) attention to the time courses of the changes in hemostatic parameters, (iv) unification of the study population, and (v) recognition that massive bleeding is not synonymous with coagulation disorders. More information is needed to elucidate the pathogenesis of these two entities, DIC with the fibrinolytic phenotype and COT/ACOTS after trauma. However, available data suggest that COT/ACOTS is not a new concept but a disease entity similar to or the same as DIC with the fibrinolytic phenotype.
创伤后早期发生的止血变化有两个概念。弥散性血管内凝血（DIC）伴纤溶表型的特征是凝血途径激活、抗凝机制不足和纤溶增加。创伤性凝血病和创伤性休克急性凝血病（COT/ACOTS）是由于血栓调节蛋白和蛋白 C 途径的过度激活导致凝血抑制和纤溶激活所致。尽管这两种情况存在差异，但将 COT/ACOTS 与纤溶表型的 DIC 分开考虑可能是不正确的。需要基于其病理生理学的稳健诊断标准来确立 COT/ACOTS 作为一个新的独立疾病概念。此外，还需要证实其特征、实验室数据、时间过程和预后与 DIC 的独立性。这两个概念之间的混淆可能基于缺乏以下几点的创伤研究：（i）明确区分血管内外血液的特性，（ii）明确区分生理和病理止血变化，（iii）注意止血参数变化的时间过程，（iv）研究人群的统一，以及（v）认识到大量出血与凝血障碍不是同义词。需要更多的信息来阐明创伤后这两种实体（DIC 伴纤溶表型和 COT/ACOTS）的发病机制。然而，现有数据表明，COT/ACOTS 不是一个新概念，而是与 DIC 伴纤溶表型相似或相同的疾病实体。
