DIC resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Overview

Disseminated intravascular coagulation, is a pathological process in the body where the blood starts to coagulate throughout the whole body. This depletes the body of its platelets and coagulation factors, and there is a paradoxically increased risk of hemorrhage.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Disseminated intravascular coagulation in itself is a life-threatening condition and must be treated as such irrespective of the cause.

Common Causes

• Abruptio placentae
• Amniotic fluid embolism
• Aortic aneurysm
• Drugs (e.g. Amphetamines)
• Eclampsia
• Giant hemangioma
• HELLP syndrome
• Hemolytic transfusion reaction
• Malignancy (especially APL)
• Sepsis
• Severe allergic reaction
• Transplant rejection
• Trauma (e.g. Fat embolism, head injury)
• Venomous snake

Management

Below is an algorithm showing the initial approach to DIC.

Characterize the symptoms: ❑ Diffuse bleeding ❑ Jaundice ❑ Dyspnea ❑ Delirium ❑ Coma Obtain medical history: ❑ Prior thromboses ❑ Known hypercoagulability ❑ Known hemostatic defect

Examine the patient: ❑ Digital ischemia ❑ Hypotension ❑ Fever ❑ Acral cyanosis ❑ Bleeding from wounds/puncture sites ❑ Petechiae ❑ Purpura ❑ Ecchymosis ❑ Bedside Observations  :❑ Stroke  :❑ Acute MI  :❑ ARF  :❑ DVT  :❑ PE  :❑ Purpura fulminans

Consider alternative diagnosis: ❑ Severe liver disease ❑ TTP/HUS ❑ HIT

Order tests: ❑ Peripheral blood smear  :❑ ↓Platelet count < 100,000/mm³  :❑ + Schistocytes ❑ Clotting screen ❑ ↑PT ❑ ↑aPTT ❑ ↓Fibrinogen ❑ ↓Haptoglobin ❑ +D-dimer ❑ +FDP Other Investigations ❑ ↑ LDH ❑ ↓Factor V assay ❑ ↓Factor VIII assay ❑ ↓Protein C and S ❑ ↓AT levels

Do's

• The transfusion of platelets should be considered for those patients actively bleeding or at an increased risk of bleeding with a platelet count of less than 50,000 microliter.
• Fibrinogen level should be kept at a level greater than 100mg/dl
• Therapy with heparin used generally for patients with low grade DIC having predominantly thrombotic episodes such as acral ischemia and thrombophlebitis.

Dont's

• Do not transfuse platelets or plasma based primarily on laboratory results but should generally be for patients who are bleeding.
• Don't give recombinant human activated protein C to patients with increased risk of bleeding.
• Don't give recombinant human activated protein C to patients with platelet counts < 30,000 microliter.
• Avoid the intravenous bolus injection of heparin of 50,000-10,000 units.