Coags
Disseminated Intravascular Coagulation
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Disseminated Intravascular Coagulation
, Disseminated Intravascular Coagulopathy, DIC
Pathophysiology
Intravascular
Fibrin
deposition occludes small vessels
Microemboli or thrombi form in vasculature
Consumptive
Coagulopathy
Widespread coagulation activation breaks down formed clot and depletes factors
Results in both bleeding and clotting
Factors depleted
Platelet
s
Antithrombin III
Protein
C
Tissue factor pathway inhibitor
Causes
Infection
Sepsis
(most common)
Gram Negative
Sepsis
Meningococcemia
Rocky Mountain Spotted Fever
Neoplastic disease
Mucin-
Secretin
g adenocarcinoma
Promyelocytic
Leukemia
Prostate Cancer
Lung Cancer
Tissue Damage
Trauma
Surgery (e.g.
Prostate
Surgery)
Heat Stroke
Burn Injury
Dissecting aneurysm
Obstetrical Complication
Abruptio Placenta
e
Amniotic Fluid Embolism
Retained fetal products on intrauterine fetal death
Severe Preeclampsia
HELLP Syndrome
Acute Fatty Liver of Pregnancy
Hemolytic disease
Thrombotic Thrombocytopenic Purpura
(TTP)
Hemolytic Uremic Syndrome
(HUS)
Immunologic Disorders
Immune complex disorders
Allograft
rejection
Incompatible
Blood Transfusion
Anaphylaxis
Metabolic
Diabetic Ketoacidosis
Miscellaneous
Shock
Snake Bite
Cyanotic Congenital Heart Disease
Fat embolism
Severe liver disease
Cavernous
Hemangioma
Signs
Profuse bleeding from many sites
Needle puncture site bleeding
Mucosal bleeding
Surgical incision or
Laceration
bleeding
Multiple
Bruise
s or
Petechiae
Thrombosis
End organ ischemia or infarction
Multi-system failure
Associated conditions
Acute Tubular Necrosis
Adult Respiratory Distress Syndrome
Purpura fulminans
Labs
Initial
Platelet Count
<100,000/mm3
Fibrinogen
<300 mg/dl
Fibrin
split product >40 mg/dl
Prothrombin Time
(aPT) >14 seconds or INR increased
Partial Thromboplastin Time
(PTT) >40 seconds
D-Dimer
Early indicator of DIC in
Preeclampsia
Trofatter (1989) Obstet Gynecol 73:435-40 [PubMed]
Labs
Monitoring (every 2 hours in DIC)
Platelet Count
Fibrinogen
Management
Supportive care
ABC Management
Cardiopulmonary support
Treat underlying disorder
Example: Delivery in pregnancy related DIC
Example: Antibiotics in
Sepsis
Transfuse
Blood Product
s as needed
Packed Red Blood Cells
Platelet Transfusion
Goal
Platelet Count
>50,000/mm3
Fresh Frozen Plasma
(preferred over
Cryoprecipitate
) to supply
Coagulation Factor
s,
Fibrinogen
Goal PT/INR and PTT <1.5x normal
Avoid harmful measures
Do not administer anti-
Fibrin
olytic agents (e.g.
Tranexamic Acid
)
Heparin
use is controversial
Heparin
has been used in DIC (use is debated)
Heparin
continuous infusion at 300 to 500 IU/hour
References
Shinke and Ponce (2016) Crit Dec Emerg Med 30(8):13
Levi (1999) N Engl J Med 341:586-92 [PubMed]
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