Optimizing hemorrhage management in trauma: integrative roles of tranexamic acid and tissue plasminogen activator-augmented viscoelastic testing.

Trauma-induced coagulopathy (TIC) is a dynamic process that contributes to early mortality following injury, with dysregulated fibrinolysis playing a central role in its pathophysiology. Tranexamic acid (TXA), a potent antifibrinolytic agent, is widely used in trauma and surgical settings for hemorrhage management. Its effectiveness is dependent on appropriate timing and patient selection, as indiscriminate use may increase the risk of thromboembolic events. As a result, real-time monitoring of coagulation status is essential to guide TXA therapy. Conventional coagulation tests (CCTs), such as the International Normalized Ratio (INR) and Activated Partial Thromboplastin Time (aPTT), are inadequate in trauma care, as they provide static snapshots of coagulation status. By contrast, viscoelastic testing (VET) platforms, including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), allow for real-time assessments of coagulation status. More recently, tissue plasminogen activator-augmented VET (tPA-VET) has been developed to more effectively distinguish between fibrinolysis phenotypes. This review explores the pathophysiology of TIC, current approaches to hemorrhage management including the use of TXA, the role of VET in guiding TXA therapy, the diagnostic value of tPA-VET, and future directions in implementing VET-guided trauma resuscitation protocols.