Disseminated Intravascular Coagulation (DIC)

Pathophys of DIC. Source: Lippincotts

Pathophys of DIC. Source: Lippincotts

DIC is a pathological process where tissue factor or other thromboplastic substances from endothelial cell injury are released into circulation-Leads to paradoxical formation of 1) microthrombi leading to organ failure and 2) hemorrhaging.

 Associated Clinical Causes

-Sepsis
-Trauma (especially neurotrauma)
-Cancer
-Shock
-Major Surgery
-Immunologic (transfusion/transplant reaction)
-Obstetric complications

Diagnosis

Can be complicated by the underlying causes, lab tests indicating DIC:

– Platelets <100,000 or recent rapid large decrease in number
– Prolonged PT and aPTT
– Elevated D-Dimer (>.5ug/ml)
– Schistocytes in blood smear
– Fibrinogen -if obtainable <1g/L (only in ~28% of pts)

A scoring system has been developed (click continued reading)

DDx: DIC, Hemolytic Uremic Syndrome, Liver Disease, Thrombotic Thrombocytopenic Purpura, Heparin-induced thrombocytopenia, HELLP syndrome in pregnancy

Treatment

Treat the underlying cause, platelet and blood factor replacement to treat bleeding can be used but won’t correct DIC. Heparin used when fibrin deposition is excessive and no risk of hemorrhage present (no petechiae or bruising).

Diamond_Line_Divider

Disseminated Intravascular Coagulation is a condition more commonly seen in intensive care situations, but can easily arise from emergencies in ED’s as well. It’s not something easily diagnosed, and is more common than the statistics show. Researchers now believe it to occur in 30% of severe sepsis cases, as many as 50 % of massive trauma patients, 10% of patients with metastatic tumors, and 50% of OB patients with abruptio placentae or an amniotic-fluid embolism (Levi).

Initially, DIC manifests as a microangiopathic hemolytic anemia, as a result of activation of the coagulation cascade from exposed subendothelium. The microthrombi formed become trapped in the vasculature, leading to ischemia of various organs and eventually their failure. Schistocytes are seen in blood smears due to RBC damage from the thrombi.

Paradoxically, hemorrhaging can occur. This is due to the massive amount of clotting, hence consumption of clotting factors, as well as activation of the fibrinolytic pathway (where the D-dimer elevation comes from). This condition manifests as petechia, ecchmoses, and classical oozing from IV sites and wounds.

DIC

Click for larger view. Source: emedicine

 

Reference:

Emergency Medicine Updates. Nov, 23. 2009. Web. http://emupdates.com

Levi, MD. Marcel. “Disseminated Intravascular Coagulation.” Medscape Reference. Web. 12 Nov 2012. http://emedicine.medscape.com/article/199627-overview

Levi, MD, Marcel. and Hugo Cate, MD. “Disseminated Intravascular Coagulation”. New England Journal of Medicine. 341.8 (2006): 587-592.12 Nov. 2012. https://residents.lsuhsc.edu/no/neurology/docs/DIC%20NEJM [1].pdf

Nickson, Chris. “Disseminated Intravascular Coagulation.” lifeinthefastlane.com 12 Nov 2012.

http://emedicine.medscape.com/article/779097-diagnosis

Compiled by: Nick Mancuso, M1

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