Key points
Early research links endothelial and other coagulation-related biomarkers with mortality and other adverse outcomes among children with traumatic injury.
Future studies can build on this research with an eye toward developing targeted therapies to personalize resuscitation techniques.
Next steps include studying a larger cohort and measuring biomarkers at different time points after injury, rather than only at the time of admission.
Understanding the broader impact of coagulopathy in injured children
Nearly 1 in 3 children admitted to the ICU show evidence of coagulopathy based on abnormal lab values. This can occur with or without active bleeding, suggesting that coagulopathy may function not only as a warning of hemorrhage but also as an indicator of broader physiologic disruption.
Barbara Gaines, M.D, Surgeon-in-Chief at Children’s Health℠ and Professor in Pediatric Surgery at UT Southwestern, co-led a 2025 study identifying clotting factor-related biomarkers that may predict adverse events. The findings lay the groundwork for future resuscitation strategies and protective treatments for pediatric patients in the first critical hours following injury.
In this Q&A, Dr. Gaines explains why she led this study and how it relates to her decades of work in pediatric trauma, including the use of whole blood for resuscitation of injured children.
Why is studying coagulopathy in injured children important?
We’re working toward targeted resuscitation techniques for traumatic injury, as opposed to the current paradigm where we provide every available treatment. That “kitchen sink” approach makes sense for now: We don’t want anyone to miss out on care that might be helpful, so we provide what is most likely to be most efficacious to the most patients.
But if we knew more about how different bodies respond to trauma, we could develop and deliver more personalized care. Some patients may not require everything in the kitchen sink and would benefit from more specific interventions we haven’t designed yet.
What therapies or treatment targets are you working toward?
One example is for traumatic brain injury, which is known to correlate with coagulopathy. Someday, children with these injuries could receive specific treatments prophylactically based on a biomarker, rather than waiting for coagulopathy to manifest and cause damage.
Or perhaps a patient is critically ill following an injury but isn’t bleeding. Lab tests show their endothelium is dysregulated, and we provide a specific infusion for that problem.
We’re still years away from having those interventions, but hypothesis-generating studies like our biomarker research get the ball rolling.
What did the 2025 study reveal?
We found adverse outcomes like mortality, shock and blood transfusion were associated with a group of factors including:
Endothelial markers like syndecan-1 and thrombomodulin
International Normalized Ratio (INR)
An overall measure of shock
Our study was a principal component analysis, so we don’t have mechanistic findings about these factors or their interactions. What we know is that, of all the components we studied, these rose to the top as most relevant.
How do these findings add to existing research?
This was the first study to look at endothelial markers in relation to coagulopathy in injured children. Previous studies have focused on the type of fluid used for resuscitation. But the endothelium is a dynamic membrane and is one of our bodies’ first defenses against injury. Our findings help us understand the endothelium's changes after multi-system injury and its role in both the healing process and the cascade of damage that occurs.
The study also helps us examine the role of whole blood in resuscitation. This has been a principal interest of mine for years, and we’re still exploring why whole blood is so effective for supporting patients with traumatic injury. Is it a matter of efficiency, having so many components premixed? Or is there something more dynamic and cumulative at play?
For example, perhaps whole blood helps the endothelium regulate in ways that individual components – platelets, for example – won’t do on their own. And perhaps that influences other multi-system healing processes.
Clearly, we’re still posing questions in these areas. But that’s where discoveries begin.
What’s next to explore?
Our study included only 56 patients, so a follow-up study with larger sample size might highlight components that didn’t appear relevant in ours. Researchers have identified more biomarkers since we published, and those would be worth studying as well.
Another factor to analyze is the time of analysis. All our blood samples were acquired at arrival to the emergency department, but not every child arrives directly from the site of injury. Some are transported from other centers. Time from injury might be a more meaningful factor in tracking coagulopathy and biomarkers.
To help future studies, we’re building a biobank using samples from other multi-institutional studies we’re participating in. Traumatic injury isn’t very common for kids, thankfully. But it is the leading cause of death. So, we have an obligation to collect samples when we can. If we hit on a breakthrough in two years, it would be great to have the samples on hand to verify it.
Connecting pediatric trauma research with clinical care
Physicians like Dr. Gaines lead outstanding teams both in clinic and in research. The most complex and critical surgical cases in the region often come to Children’s Health. And researchers move the field forward with both foundation-building studies, like the study discussed above, and treatment trials and innovations that directly change best practices and bring new opportunities to patients.
Learn more about innovations and care in Pediatric General Surgery.
