Bored and Bleeding: DIC

Don’t FREAK OUT. While dissemminated intravascular coagulation (DIC) sounds complicated (at least based on the number of syllables), the important part in treating DIC is keeping it in mind when there is a critically ill patient.

The two main issues in DIC are hyperactive clot formation (it’s in the name) and subsequently hyperactive bleeding (contrary to the name).
It is caused by a variety of pathologic disorders that have the same end result: Overactivation of the intrinsic clotting cascade. Platelets and clotting factors (protein C, S, antithrombin, fibrinogen) are over-consumed when clots are formed. At the same time, hyperfibrinolysis results in coagulopathy and bleeding.

Sepsis
Malignancy – commonly leukemia
Trauma
Organ Failure
Liver Disease
Pancreatitis
Pregnancy complications – placental rupture, IUFD, HELLP syndrome, amniotic fluid embolus
ARDS
Transfusion Reactions
Vascular Disease
Envenomation

The end result is tissue ischemia and damage from microvascular clots and circulatory shock from bleeding. Signs of end organ damage may be present as well as cutaneous signs (thrombotic purpura or cutaneous gangrene). Clotting sequelae tend to be more common in DIC due to sepsis. Trauma, malignancy, pregnancy complications, and liver disease tend to result in DIC where increased bleeding predominates, resulting in signs such as ecchymoses, petechiae, hematuria and bleeding from IV assess sites.

CBC – low platelets are sensitive not specific for DIC
Coagulation Profile – increased PT and aPTT time
Fibrinogen – will be decreased
D-dimers, Fibrin-Degradation Product – will be elevated
Specific factors- decreased; less clinically useful
The International Society of Thrombosis and Haemostasis (ISTH) DIC score is a simple objective tool that can be used to help diagnose and prognose DIC. It takes into account platelet count, PT, fibrinogen and fdp/d-dimer.

TREAT the underlying disorder! It is imperative that you fully evaluate the patient to determine the underlying cause and treat it appropriately. Don’t be afraid to load the boat as this is a sick patient and contact the MICU as this patient will need intensive care.
Therapies such as transfusions would temporize but not stop DIC. The strategy is to replace what is being consumed or lost.
Packed Red Blood Cells should be given only if there is evidence of bleeding.
Platelets should be given if there is bleeding in the setting of low platelets (<50,000).
FFP should be administered if PT/PTT is greater than 1.5xs normal or there is a drop in fibrinogen below 150. If the patient is fluid overloaded, small volume 4-factor PCC is an alternative.
Cryoprecipitate can be added if fibrinogen continues to be low. TXA is given for trauma related DIC.
If there is no evidence of major bleeding, enoxaparin is recommended to prevent thrombotic events