Gall Lewis S, Brohi Karim, Davenport Ross A
Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
Semin Thromb Hemost. 2017 Mar;43(2):224-234. doi: 10.1055/s-0036-1598001. Epub 2017 Feb 20.
Fibrinolysis activation occurs almost universally after severe trauma. Systemic hyperfibrinolysis is a key component of acute traumatic coagulopathy and associated with poor clinical outcomes, although controversy exists over optimal treatment strategies. The mechanistic drivers and dynamics of fibrinolytic activation in response to injury and trauma resuscitation are currently unclear. Furthermore, therapeutic triggers are compounded by the lack of a sensitive and rapid diagnostic tool, with discrepancy between hyperfibrinolysis diagnosed by viscoelastic hemostatic assays versus biomarkers for fibrinolysis. Rotational thromboelastometry and thromboelastography appear capable of detecting the severest forms of hyperfibrinolysis but are relatively insensitive to moderate, yet clinically significant fibrinolytic activation. Rapid evaluation of the current status of the fibrinolytic system remains a challenge and therefore the decision whether to administer an antifibrinolytic agent should be based on available evidence from clinical trials. In line with current European guidelines, we recommend that all bleeding trauma patients, and in particular, severely injured patients with evidence of hemorrhagic shock, should receive early empiric tranexamic acid. This review explains our current knowledge of the pathophysiological pathways which induce hyperfibrinolysis in trauma hemorrhage, evaluates the available diagnostic modalities, and describes current treatment strategies.
严重创伤后几乎普遍会发生纤溶激活。全身性高纤溶是急性创伤性凝血病的关键组成部分，与不良临床结局相关，尽管对于最佳治疗策略存在争议。目前尚不清楚损伤和创伤复苏后纤溶激活的机制驱动因素和动态变化。此外，由于缺乏敏感且快速的诊断工具，使得治疗触发因素变得复杂，通过粘弹性止血检测诊断的高纤溶与纤溶生物标志物之间存在差异。旋转血栓弹力图和血栓弹力描记法似乎能够检测到最严重形式的高纤溶，但对中度但具有临床意义的纤溶激活相对不敏感。快速评估纤溶系统的当前状态仍然是一项挑战，因此是否使用抗纤溶药物的决定应基于临床试验的现有证据。根据当前欧洲指南，我们建议所有出血性创伤患者，尤其是有失血性休克证据的重伤患者，应尽早经验性使用氨甲环酸。本综述解释了我们目前对创伤出血中诱导高纤溶的病理生理途径的认识，评估了可用的诊断方法，并描述了当前的治疗策略。
