48 year old male with alcoholism is injured after falling while riding a bull. He reported to an outside hospital with right flank ecchymosis and pancreatitis. He left AMA. Two days laters he reports to the ED with confusion, fever, jaundice and tremors. A CT of the abd/pelvis with contrast showed ascites and cholelithiasis but no other acute findings. A non contrast head CT showed a small right posterior subdural hematoma. The patient became hypotensive and tachycardia.
INR 2.2, PTT 42 (nl 24-36), fibrinogen 164 (nl 185-475)
Haptoglobin < 8
Diagnosis: Disseminated Intravascular Coagulation (DIC
- DIC is a systemic coagulopathy marked by endothelial damage, clot formation, fibrin degradation, consumption of coagulation factors and platelets, and secondary bleeding.
- Caused by sepsis, trauma, malignancy, to (amphetamines, MDMA), AAA, liver disease, heat stroke, burns, snake bites, pregnancy complications.
- These cause exposure to procoagulants (ie-tissue factor), causing thrombi formation leading to consumption of coagulation factors and platelets.
How to Diagnosis DIC
Clinical and laboratory diagnosis - no universally accepted diagnostic method
- Clinically diagnosis is considered in context of patient wick with primary problem (see above). Patient will have bleeding diathesis (bleeding from orifices, IV lines) or may have signs of micro thrombosis (skin necrosis, end organ damage).
- Lab findings indicating possible DIC: thrombocytopenia, prolonged PT, decreased fibrinogen, elevated d-dimer
- Severe Liver Disease - also gives coagulopathy, thrombocytopenia due to decreased liver synthetic function. If needed, factor VIII level may aid in diagnosis (decreased level indicates DIC - factor VIII partly made outside of liver).
- HIT (Heparin Induced Thrombocytopenia - thrombosis and bleeding, patients are not usually as sick, lack of other lab findings clinical context.
- TTP (Thrombotic Thrombocytopenic Purpura) - fever, intravascular hemolysis, thrombocytopenia (+/- renal failure, neuro symtpoms). Will have normal coagulation factors. If needed, may order ADAMTS-13 levels which will be decreased in TPP.
- Treat underlying cause
- Early hematology consult
- Transfuse PRBC for symptomatic anemia, no clear target hemoglobin
- Transfuse platelet if < 10,000 (do NOT hold platelets if actively bleeding for fear of "fueling the fire")
- Treatment also depends if patient is primarily bleeding or clotting:
- If bleeding supersedes, transfuse FFP to keep INR < 1.5
- Transfuse cryoprecipitate if fibrinogen < 100
- Amicar (Aminocaproic acid) - limited evidence, inhibits plasmin, causing decreased fibrinolysis (not to be used alone as it can worsen thrombosis)
- Tranexamic Acid - limited evidence, possibly useful with severe bleeding and hyperfibrinouytic state, no effect on mortality
- If clotting supersedes, then PT/PTT goal > 1.5-2x normal range, may give heparin, although studies show no difference in overall mortality and may worsen bleeding
Back to the Case
The patient received 5 units PRBCs, 7 units FPP, 1 unit platelets, and 2 units cryoprecipitate. He was given amicar 3 g IV q 6 hours over the first 24 hours. He was managed in the ICU with close hematology, neurosurgical and GI consultation. His levels improved as well as his clinical status, and he was discharged a few weeks later from he hospital in stable condition.
- No consensus on diagnosis or management for DIC
- Treat underlying cause, if able
- Early hematology consultation
- Give platelets for < 10k or if active physical site of bleeding/hemorrhage
- Give PRBCs for symptomatic anemia
- Give cryoprecipitate generally for fibrinogen < 50-100 initially
- Goal PT/PTT based on bleeding or clotting
- Decision for Amicar, TXA, or heparin made on individual basis
Up to Date, DIC retrieved April 2015
Robbins and Cotran, Pathologic Basis of Disease, 8th Ed
Levi M, et al. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Hematology. Br J Haematol 2009; 145:24.
Submitted by Dr. Andrew Wheeler, PGY-1