II. Pathophysiology
- Consumptive Coagulopathy
- Uninhibited, widespread coagulation activation breaks down formed clot and depletes factors
- Results in both bleeding and clotting
- Factors depleted
- Platelets
- Antithrombin III
- Protein C
- Tissue factor pathway inhibitor
- Clotting (microvascular)
- Intravascular Fibrin deposition occludes small vessels
- Microemboli or thrombi form in vasculature
- Bleeding
- Results from uncontrolled Clotting Factor and Platelet consumption
- Final pathway
- Multiorgan failure
III. Causes
- Infection
- Neoplastic disease
- Mucin-Secreting adenocarcinoma
- Acute promyelocytic Leukemia
- Acute Lymphoblastic Leukemia
- Acute Myeloid Leukemia
- Prostate Cancer
- Lung Cancer
- Other solid tumors
- Tissue Damage
- Trauma
- Surgery (e.g. Prostate Surgery)
- Heat Stroke
- Burn Injury
- Dissecting aneurysm
- Rhabdomyolysis
- Obstetrical Complication
- Abruptio Placentae
- 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)
- Transfusion Hemolysis (Incompatible Blood Transfusion)
- Immunologic Disorders
- Immune complex disorders
- Allograft rejection
- Anaphylaxis
- Metabolic
- Miscellaneous
- Shock
- Snake Bite
- Cyanotic Congenital Heart Disease
- Fat embolism
- Severe liver disease (e.g. Cirrhosis)
- Acute Liver Disease or Acute Hepatitis
- Cavernous Hemangioma (or giant Hemangioma)
IV. Signs
- Profuse bleeding from many sites
- Needle puncture site bleeding
- Oozing from the insertion sites of inserted tubes, lines and drains
- Mucosal bleeding including Gastrointestinal Bleeding and Gingival Bleeding
- Surgical incision or Laceration bleeding
- Multiple Bruises or Petechiae
- Thrombosis
- End organ ischemia or infarction
- Multi-system failure
- Associated conditions
V. Labs: Initial
- See ISTH DIC Score
- 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]
VI. Labs: Monitoring (every 2 hours in DIC)
VII. Management
- Supportive care
- ABC Management
- Cardiopulmonary support
- Treat underlying disorder
- Example: Delivery in pregnancy related DIC
- Example: Antibiotics in Sepsis
- Transfuse Blood Products as needed
- Packed Red Blood Cells
- Platelet Transfusion
- Indicated in Platelet Count <20,000 without active bleeding (<50,000 with active bleeding)
- Goal Platelet Count >50,000/mm3
- Fresh Frozen Plasma (preferred over Cryoprecipitate) to supply Coagulation Factors, Fibrinogen
- Goal PT/INR and PTT <1.5x normal
- Avoid harmful measures
- Do not administer anti-Fibrinolytic 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
VIII. References
- Shinke and Ponce (2016) Crit Dec Emerg Med 30(8):13
- Jones (2024) Am Fam Physician 110(1): 58-64 [PubMed]
- Levi (1999) N Engl J Med 341:586-92 [PubMed]