Initial assessment ^(1-4)

• Is the patient stable or unstable?
  • Perform ABCDE assessment.
  • If unstable, start a “MOVIE” (monitors, oxygen, vitals, large bore IV access/investigations, ECG).
• What is the underlying cause?
  • Start treating it.
• Collect blood to monitor coagulation factors.

• Supportive care and prepare for patient deterioration.
  • Keep patient warm (give blankets, warm room, warm any IV fluids).
  • Prepare for red cell, platelet, FFP transfusions.
  • Measure blood losses.

For pregnant patients, notify obstetrics team early on. Delivery may be component of management.

Background ^(1,2,5-8)

• Definition
  • Acquired coagulation disorder leading to widespread bleeding and clotting.
  • Infectious and non-infectious causes.
  • Strong mortality predictor.
• Prevention is essential.
  • Suspect DIC in patients with known DIC-causing disease processes.
• Causes
  • Infection ± sepsis (50% of DIC cases).
  • Head trauma (45% of patients with head injury, burns can develop DIC).
  • Giant hemangiomas.
  • Cancers (solid and leukemias).
  • Major surgery.
  • Obstetrical causes (especially placental abruption, pre-eclampsia).
  • MAHAs (TTP, HUS, chemotherapy-induced, malignant HTN, HELLP syndrome).
  • Severe immune or toxic reactions.
  • Snake bite.
• Pathophysiology
  • Trigger (infection, immune, trauma, etc.)→ Pro-inflammatory state (IL-6, TNF-a)→ Widespread platelet activation

    → Disproportionate platelet/coagulation factor consumption

    → Endothelial dysfunction

    → Vascular leakage, edema

  • Small vessel ischemia-reperfusion injury → can lead to multi-organ failure
  • Endothelial dysfunction + anticoag issues → thrombin activation (fibrin activation)

Image source: The pathophysiology, diagnosis, and management of sepsis-associated disseminated intravascular coagulation.

Diagnosis ^(1-5)

Clinical and lab-based diagnosis

• DDx
  • Liver disease – looks same in labs, so rule out with clinical exam, Hx.
  • Heparin-induced thrombocytopenia (HIT) – recent heparin administration.
  • Thrombotic microangiopathy (TMA) – usually normal coagulation markers, platelets.
  • Hemophagocytic lymphohistiocytosis (HLH) – results from uncontrolled immune activation, treatment targets.
• History
  • Presence of known DIC-related disease process?
  • Bleeding and clotting history.
  • Urination history (kidney injury)?
  • Dyspnea or hemoptysis (lung injury)?
  • Neurological ROS.

Physical Exam

• Bleeding signs
  • Petechiae, ecchymoses.
  • Mucosal bleeding.
  • Bleeding at sites of line or device insertions.
  • Post-op bleeding.
• Thrombotic signs
  • VTE.
  • Reduced organ or limb perfusion secondary to thrombosis.
  • Signs of endocarditis.
• Organ dysfunction signs
  • Jaundice (liver injury)?
  • Neurological screen.
• Purpura fulminans (cutaneous necrosis, widespread tissue thrombosis).

Purpura fulminans in septic shock patient. Source: https://emcrit.org/ibcc/pf/

• Labs
  • Perform serial labs to track degree of coagulation, fibrinolysis.

• • Calculator: Consider using DIC Score calculator to assess likelihood of DIC (based on platelet count, fibrin markers, PT time, fibrinogen).

Management ^(1-4)

• Continue initial stabilization measures.
• Treat underlying condition
  • Sepsis → 2 sets blood cultures draw, then broad spectrum Abx; consider anticoagulation (thrombomodulin or antithrombin).
  • Trauma → stabilize other injuries. Consider TXA.
  • Pregnancy → Consult OB/GYN. Give tranexamic acid early (1 g over 10 min IV, repeat if bleeding still at 30 min).
  • Consult specialists as needed.
• Tailor DIC treatment according to presentation.

• Provide supportive measures for everyone
  • Volume resuscitation where needed.
  • Ventilatory support where needed.
  • LMWH for DVT prophylaxis according to local guidelines.

Additional considerations for pregnant patients.

Unstable patient

• Call for help – notify obstetrics, anesthesia, neonatology, transfusion medicine.
• Oxygen – Maintain SpO2 ≥95%.
• Transfusions – group/screen/cross-match blood. 1:1:1 of red cells to plasma to platelets (O- blood at first, switch to cross-matched blood next).
• Fluids – Crystalloid and/or blood products to maintain MAP ≤65 mmHg, urine output ≥0.5ml/kg/h (blood ideal but lactated ringers can be used first if no blood available).
• Maintain warmth – give blankets, warm any IV fluids.
• Drugs – give TXA early (1 g over 10 min IV, repeat if bleeding still at 30 min).
• Coagulation monitoring (CBC, PT/aPTT, fibrinogens, FDPs).
  • Hb ≥7 g/dL
  • Fibrinogen ≥200 mg/dL
  • Platelets ≥50,000/microL
  • PT, aPTT <1.5x control
• Monitor fetus

Stable patient

• Monitor coagulation panel
  • If fibrinogen <200 mg/dL AND active or expected bleeding, then give fibrinogen concentrate to get level >300 mg/dL.
• Expect uterine bleeding and manage it. Group/screen/cross-match blood. Consult obstetrics to make delivery decisions.
• Monitor fetus

• Patient is unstable.
• Patient presented with overt DIC and coagulation profile hasn’t resolved (can take days).
• Requires continued interventions or frequent monitoring (e.g., IV medications or supportive care, non-improving DIC lab markers, transfusions indicated).
• Risk factors for poor prognosis: older age, severe organ injury, persistent hematological disturbances.

1. DIC Score – Assess likelihood of disseminated intravascular coagulation (DIC) (from International Society of Thrombosis and Hemostasis consensus guidelines.

   Sepsis-Induced Coagulopathy (SIC) Score

   Bloody Easy Coagulation Handbook – Transfusion Ontario

   
   

1. Wang H. Disseminated intravascular coagulation – Symptoms, diagnosis and treatment. BMJ Best Practice US [Internet]. Kaye A, Toh CH, editors. BMJ Best Practice. 2021 [cited 2024 Apr 16]. Available from: https://bestpractice.bmj.com/topics/en-gb/184?q=Disseminated%20intravascular%20coagulation&c=recentlyviewed

   
   

2. Tintinalli JE, O. John Ma, Yealy D, Meckler GD, J. Stephan Stapczynski, Cline DM, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional; 2019.

   
   

3. Belfort M. UpToDate [Internet]. Lockwood C, Hepner D, Leung L, Uhl L, Barss V, editors. www.uptodate.com. 2024 [cited 2024 May 2]. Available from: https://www.uptodate.com/contents/disseminated-intravascular-coagulation-dic-during-pregnancy-clinical-findings-etiology-and-diagnosis?topicRef=1306&source=see_link

   
   

4. Belfort M. UpToDate [Internet]. Lockwood C, Hepner D, Leung L, Uhl L, Barss V, editors. www.uptodate.com. 2024 [cited 2024 May 2]. Available from: https://www.uptodate.com/contents/disseminated-intravascular-coagulation-dic-during-pregnancy-management-and-prognosis?search=dic%20pregnancy&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#topicContent

   
   

5. Iba T, Helms J, Connors JM, Levy JH. The pathophysiology, diagnosis, and management of sepsis-associated disseminated intravascular coagulation. Journal of Intensive Care. 2023 May 23;11(1):24.

   
   

6. Levi M, de Jonge E, van der Poll T, ten Cate H. Disseminated intravascular coagulation. Thrombosis and haemostasis. 1999;82(08):695-705.

   
   

7. Disseminated intravascular coagulation. Nature Reviews Disease Primers. 2016 Jun 2;2(1).

   
   

8. Leung L. Evaluation and management of disseminated intravascular coagulation (DIC) in adults [Internet]. Mannucci P, Tirnauer J, editors. UptoDate; 2023 [cited 2024 Apr 16]. Available from: https://www.uptodate.com/contents/evaluation-and-management-of-disseminated-intravascular-coagulation-dic-in-adults?search=Disseminated%20intravascular%20coagulation%3A%20an%20update%20on%20pathogenesis%20and%20diagnosis.&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#references