Updated: 1/26/2021

Disseminated Intravascular Coagulation (DIC)

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Snapshot
  • A 35-year-old man with a history of alcoholism is brought to the emergency room after being found clutching his abdomen at a grocery store. He is currently intoxicated. He reports significant pain in his epigastrium. A complete blood count shows anemia and thrombocytopenia. Lipase and amylase levels are both elevated. A peripheral blood smear shows schistocytes. Additional lab testing reveals elevated D-dimer and low fibronigen levels. (Pancreatitis-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
  • 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
  • Diagnosis is based on clinical and laboratory findings, including thrombocytopenia, coagulation factor consumption, and fibrinolysis
  • 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
Treatment
  • Medical
    • treat underlying disorder
    • supportive care
      • indication
        • all patients
      • modalities
        • fluids
        • platelet transfusions if < 10,000/μL
          • particularly for those who need urgent procedure
        • 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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Questions (2)
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(M1.HE.14.79) A 61-year-old male with a past medical history of lung cancer is hospitalized for shortness of breath. During his hospitalization, he is found to be septic and was oozing from his intravenous catheter site. He also develops petechiae on his shoulders and abdomen. Which of the following test results and blood smears is consistent with a diagnosis of disseminated intravascular coagulation?

QID: 106908
FIGURES:
1

Increased PT and PTT, decreased platelets and fibrinogen, smear from Figure A

80%

(61/76)

2

Increased PT and PTT, increased platelets and fibrinogen, smear from Figure A

7%

(5/76)

3

Increased PT and PTT, increased platelets and fibrinogen, smear from Figure B

7%

(5/76)

4

Decreased PT and PTT, decreased platelets and fibrinogen, smear from Figure B

5%

(4/76)

5

Decreased PT and PTT, increased platelets and fibrinogen, smear from Figure B

0%

(0/76)

M 2 C

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