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Updated: Dec 18 2021

Disseminated Intravascular Coagulation (DIC)

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  • Snapshot
    • A 46-year-old woman presents to the emergency room for a headache that worsens with flexion of the neck. She is started on broad-spectrum antibiotics and prepped for a lumbar puncture. However, laboratory evaluation reveals marked thrombocytopenia and elevated D-dimer. On physical exam, she is noted to have retiform purpura over the toes bilaterally, as well as dusky nasal tip. After platelet transfusion, a lumbar puncture is performed. (Meningitis-induced disseminated intravascular coagulation)
  • Introduction
    • Overview
      • disseminated intravascular coagulation (DIC) is characterized by abnormal widespread activation of clotting
  • Epidemiology
    • Incidence
      • ~1% of all hospitalizations
    • Risk factors
      • trauma
      • sepsis
        • particularly with gram-negative bacteria
      • obstetrical complications
      • acute pancreatitis
      • malignancy
      • nephrotic syndrome
      • transfusions
  • ETIOLOGY
    • Pathogenesis
      • mechanism
        • abnormal activation of coagulation cascade leads to thrombi production, which leads to consumption coagulopathy
        • fibrinolysis occurs at sites of thrombi, and fibrin degeneration products can interfere with coagulation
          • leads to end-organ damage
        • consumption coagulopathy exceeds production of clotting factors
          • in chronic cases, there may be compensation via increased production
  • Presentation
    • Physical exam
      • inspection
        • bleeding and oozing at catheter sites and mucosal surfaces
        • purpura fulminans
          • retiform purpura, particularly at acral sites
        • petechiae and ecchymoses
        • altered mental status
      • vital signs
        • hypotension
        • tachycardia
  • Studies
    • Serum labs
      • coagulation factor consumption
        • elevated PT and aPTT
        • low fibrinogen
        • increased thrombin time
      • decreased factors V and VIII
      • thrombocytopenia
      • fibrinolysis
        • elevated D-dimer
    • Peripheral blood smear with microangiopathic changes
      • schistocytes
  • Differential
    • Heparin-induced thrombocytopenia
      • key distinguishing factor
        • history of recent heparin exposure and positive laboratory testing for heparin-platelet factor 4 antibodies
  • DIAGNOSIS
    • Diagnosis is based on clinical and laboratory findings, including thrombocytopenia, coagulation factor consumption, and fibrinolysis
  • Treatment
    • Medical
      • treat underlying disorder
      • supportive care
        • indication
          • all patients
        • modalities
          • fluids
          • platelet transfusions if < 10,000/μL
            • particularly for those who need urgent procedures
          • fresh frozen plasma
          • consider heparin for any thrombosis
  • Complications
    • Renal failure
    • Liver injury
    • Neurologic symptoms
      • thrombi and hypoperfusion
    • Waterhouse-Friderichsen syndrome
      • adrenal insufficiency secondary to adrenal hemorrhage or infarct
      • commonly caused by Neisseria meningitidis
    • Purpura fulminans
      • characterized by hemorrhagic skin necrosis, often at distal sites, due to thrombi
      • retiform purpura
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