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Updated: Jan 26 2021

Disseminated Intravascular Coagulation (DIC)

Images
https://upload.medbullets.com/topic/114067/images/schizocyte_smear_2009-12-22.jpg
  • 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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