Disseminated intravascular coagulation: Clinical sciences

intravascular coagulation or dic for short occurs when a trigger over activates the coagulation and fibrinolytic cascades leading to widespread thrombosis and organ ischemia as progresses excessive bleeding occurs due to the consumption of platelets and coagulation factors Based on the timing of onset clinical presentation and lab findings can be classified as acute and chronic Now if your patient presents with chief concerns suggesting dic you should first perform an ABCDE assessment to determine if the patient is unstable or stable If the patient is unstable stabilize the airway breathing and circulation obtain IV access and give IV fluids Next Put your patient on continuous vital sign monitoring including BP heart rate and pulse oximetry Finally if your patient is hypotensive add vasopressors and if their saturation is low don't forget to provide supplemental oxygen to keep saturation above 90% Now once you stabilize your patient obtain a focused history and physical examination your patient is likely to report an acute onset of bleeding and in some cases they might report symptoms of thrombosis such as sudden onset dyspnea or limb pain The sudden onset of dyspnea should make you suspect pulmonary embolism while limb pain could be associated with limb ischemia due to thrombosis Next history will typically reveal a trigger like sepsis trauma malignancy or obstetric complications such as placental abruption and amniotic fluid embolism The physical exam will reveal petechia purpura aosis and possibly evidence of thrombosis such as limb swelling and redness Additionally you might find signs of underlying illness like fever hypotension and tachycardia or findings consistent with organ dysfunction like respiratory distress jaundice and decreased urine output With these findings you should suspect acute So your next step is to order labs including CBCP ta PTT fibrinogen D dimer and peripheral smear massive formation of blood clots throughout the body depletes thrombocytes and clotting factors So the labs will typically reveal thrombocytopenia with a platelet count of less than 100 and 50,000 cells per microliter and a prolonged PT and aptt Additionally during blood clot formation fibrinogen is converted into fibrin So your patient might have low fibrinogen levels But keep in mind that fibrinogen is also an acute phase reactant So in a patient with fibrinogen could be elevated despite the ongoing blood clot formation simultaneously the body will try to break down blood clots So you will typically find elevated ddimer levels which is a degradation product of fibrin Finally the peripheral smear may reveal fragmented red blood cells known as schistocytes With these findings you can diagnose acute Now here's a clinical pearl in acute i the rapid consumption of platelets and coagulation factors outpaces the body's ability to compensate with new production So bleeding generally predominates over thrombosis So while it is possible for an acute dic patient to be hemodynamically stable the overwhelming bleeding and clotting known as decompensated is why these patients are typically unstable Now once you diagnose acute dic the most important step in management is treatment of the underlying cause to remove the trigger initiating the process For example if the underlying cause of dic is sepsis be sure to start your patient on broad spectrum antibiotics Additionally these patients often require supportive treatment like hemodynamic and ventilatory support Next if there's evidence of thrombosis consider anti coagulation therapy with unfractionated heparin or low molecular weight heparin Finally if there's severe acute bleeding or if your patient requires invasive procedures you might need to transfuse blood components Moreover if the hemoglobin is less than seven mg per deciliter transfuse packed red blood cells and if the platelets drop below 50,000 cells per microliter give platelets Next If fibrinogen is below 100 mg per deciliter give a cryoprecipitate which contains concentrated fibrinogen Finally to resolve prolonged PT and APTT consider fresh frozen plasma or F FP for short which contains all coagulation factors or prothrombin complex concentrate or PCC for short which contains factors 279 and 10 as well as protein C and S on the flip side If there's no severe bleeding and your patient doesn't require invasive procedures you should avoid transfusion of blood products because the donor platelets and the coagulation factors can also become activated and consumed One exception is when the platelet count is below 10,000 since there's an increased risk of spontaneous bleeding In this case you should transfuse platelets Ok Now let's go back to the ABCDE assessment and look at stable patients again Start with a focused history and physical exam Stable patients with dic tend to have a gradual or chronic onset Usually over weeks to months History typically reveals symptoms of thrombosis like limb pain But in some cases your patient might report bleeding such as nosebleeds Again history will usually reveal a trigger which could be an advanced malignancy especially pancreatic gastric ovarian or brain tumors vasculitis such as polyarteritis nodosa or the presence of a chronic vascular injury such as an aortic aneurysm Physical exam typically reveals evidence of current thrombosis like lower extremity swelling or limb gangrene In some individuals you could also see petechia purpura and ecchymosis Finally you might notice signs suggestive of an underlying condition like an abdominal mass or an abnormal neurologic exam Based on these findings you should suspect chronic D IC So your next step is ordering the same set of labs as with acute D IC including CBCP ta PTT fibrinogen D dimer and peripheral smear Lab results typically reveal normal or slightly reduced platelets in combination with normal or slightly prolonged PT and APTT You will also see normal or slightly elevated fibrinogen with elevated ddimer levels Finally the peripheral smear often reveals cystocyte but this might not always be the case with these findings You can diagnose chronic D I Here's a high yield fact In chronic D I the body is able to compensate for the consumption of platelets and coagulation factors with new production leading to fewer abnormal lab findings And the predominance of thrombosis over bleeding for this reason its sometimes referred to as compensated dic once you diagnose chronic D begin management by treating the underlying cause that's triggering it If the patient has thrombosis initiate anticoagulation therapy with unfractionated heparin or low molecular weight heparin But keep in mind that your patient might require long term therapeutic anticoagulation Finally in the case of severe bleeding or the need for an invasive procedure you may need to transfuse blood products like packed red blood cells platelets F FP or PC and cryoprecipitate All right As a quick recap In acute D I there's rapid consumption of platelets and coagulation factors which outpaces the body's ability to compensate with new production Therefore bleeding generally predominates over thrombosis Labs show thrombocytopenia prolonged PT and aptt decreased fibrinogen and elevated ddimer While peripheral smear may show cystocyte management involves treating the underlying cause supportive care anticoagulation therapy If there's thrombosis and transfusion of blood components if there's severe bleeding or need for an invasive procedure chronic D I occurs more gradually over time So the patient is able to produce new platelets and coagulation factors to compensate for their consumption In this case you're more likely to see thrombosis than bleeding Labs are often normal except for elevated DDIMER and sometimes the presence of cystocyte Again management is based on treating the underlying cause with the addition of anti coagulation and blood products if needed