The Bleeding Edge: A Deep Dive into Trauma-Induced Coagulopathy in Children
Shawn Jackson MD PhD, Ethan Sanford MD, and Justin L. Lockman MD MSEd
It’s 2:00 am and you’ve finally managed to find the call room after a night filled with elbow fractures and appendectomies. As you begin to melt into your pillow, the pager goes off blaring “TRAUMA ALERT” across the screen. You run to the emergency department, to see a 3-year-old who had been involved in a “pedestrian struck” trauma several hours ago. The trauma surgeon and neurosurgeon ask you to prepare for emergent surgery. You open the Pedi Crisis checklist for “Trauma” and stop at the section on blood products.
Pediatric trauma cases require consideration of complex and sometime competing clinical management of the initial traumatic injury, blood product resuscitation, and significant coagulopathy caused by hypothermia, unbalanced resuscitation, and the bleeding/clotting disturbances caused by the trauma itself. This phenomenon has been described by experienced clinicians for decades1, but our understanding of Trauma-Induced Coagulopathy (TIC) has increased exponentially over the past 10 years2.
Original Article
Deshpande SJ, Tsang HC, Phuong J, et al. Trauma-induced coagulopathy across age pediatric groups: A retrospective cohort study evaluating testing and frequency. Paediatr Anaesth 2025;35(1):57-65. DOI: 10.1111/pan.15024. Epub 2024 Oct 22. PMID: 39435581.
In today’s PAAD3, Shyam Desphande and colleagues performed a large retrospective analysis to better understand coagulopathy in pediatric trauma patients. While the study is a single-site retrospective analysis, it was notably performed at Seattle Children’s Hospital which has a large catchment area for pediatric trauma cases including a volume of approximately 800 acute injury care admissions per year.
From this study, we learn several valuable lessons. Despite recognition of the risk of trauma-induced coagulopathy, clinicians are less likely to assess for coagulopathy in younger children. Several etiologies for what the authors describe as data ‘missingness’ may exist, including minimizing blood draws or a an underappreciation of the coagulopathy in the first place. Even more critically, in the least injured patients (a lower Injury Severity Score [ISS]), younger children were more likely to experience TIC compared with older cohorts. So our first takeaway from this study: we should be more vigilant looking for (and treating) TIC in young infants and children.
A second valuable lesson is that patients with isolated neurologic trauma (traumatic brain injury [TBI]) had similar rates of TIC as compared to the larger trauma cohort that included multi-system trauma. While some of the earliest publications on TIC in pediatrics were documented in patients with TBI, this observation is worth keeping in mind1. This is especially important because we know that TBI is far more common in children than adults.
While today’s PAAD advances our understanding of the epidemiology of TIC, many questions still remain. Most conspicuously is the absence of point-of-care coagulopathy testing, such as thromboelastography (TEG) or rotational thromboelastometry (ROTEM). These tests have become standard in the management of trauma and surgical resuscitation in adults, but their adoption in pediatric care has lagged – largely due to access to devices and education gaps in interpretation of results. In the liver failure population, the recognition of balanced coagulopathy states in which the INR is elevated, but the TEG is normal has led to TEG-based transfusion strategies and decreases in unnecessary transfusions. Unlike standard coagulation tests, the results of which are often delayed and provide limited insight into the dynamic nature of clot formation and breakdown, TEG and ROTEM offer real-time, comprehensive assessments of hemostatic function. This may prove to be uniquely valuable in pediatric trauma, where unique physiological differences demand precise and rapid interventions to mitigate bleeding risks and improve outcomes. We eagerly await the follow-up investigations that will help to fill in the gaps, and we anticipate there will need to be ongoing discussions with our colleagues in pathology and transfusion medicine surrounding access to these devices and the education of our teams in the resulting interpretation.
How do you manage coagulopathy in the pediatric OR? Do you have access to viscoelastic testing such as TEG or ROTEM on a point-of-care basis? Do you see a role for more focused and functional coagulopathy testing in this patient population? Please send Myron your responses to add to the discussion!
1. Miner ME, Kaufman HH, Graham SH, Haar FH, Gildenberg PL. Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: frequency and prognostic implications. J Pediatr 1982;100(5):687-91. DOI: 10.1016/s0022-3476(82)80565-9.
2. Christiaans SC, Duhachek-Stapelman AL, Russell RT, Lisco SJ, Kerby JD, Pittet JF. Coagulopathy after severe pediatric trauma. Shock 2014;41(6):476-490. DOI: 10.1097/SHK.0000000000000151.
3. Deshpande SJ, Tsang HC, Phuong J, et al. Trauma-induced coagulopathy across age pediatric groups: A retrospective cohort study evaluating testing and frequency. Paediatr Anaesth 2025;35(1):57-65. DOI: 10.1111/pan.15024.