Disseminated Intravascular Coagulation

Question 1

Define Disseminated Intravascular Coagulation

Answer 1

Acquired syndrome characterised by activation of coagulation pathways and depletion of platelets and coagulation factors.

Question 2

What are the types of Disseminated Intravascular Coagulation

Answer 2

Acute overt form: bleeding and depletion of platelets and clotting factors

Chronic non-overt form: thromboembolism is accompanied by generalised activation of the coagulation system

Question 3

What are the causes of Disseminated Intravascular Coagulation

Answer 3

Sepsis/infection particularly gram -ve
Major trauma and burns
Malignancies: AML, metastatic mucin-secreting adenocarcinoma
Obstetric: amniotic fluid embolism, eclampsia, placental abruption
Severe organ destruction or failure: pancreatitis, hepatic failure
Vascular
Severe toxic or immunological reaction: blood transfusion reaction, haemolytic reaction, transplant rejection, snake bite

Question 4

What are the symptoms and signs of Disseminated Intravascular Coagulation

Answer 4

Critically ill - signs of severe sepsis or shock or extensive tissue damage
Bleeding: petechiae, ecchymoses, haematuria, epistaxis, mucosal bleeding
Haemolytic: jaundice, conjunctival pallor
Non-blanching purpuric rash
Conjunctival haemorrhage
Dyspnoea
Delirium, coma

Question 5

What is the difference between the signs of haemorrhagic vs thrombotic Disseminated Intravascular Coagulation

Answer 5

Bleeding venepuncture sites, indwelling catheters, drain sites, surgical wounds
Spontaneous or minimal trauma-related generalised ecchymoses
Large, bullous haemorrhagic skin lesions on previous viral exanthematous sites
Mucosal bleeding from gingiva, gastrointestinal or renal tracts

Thrombophlebitis
Renal impairment in the absence of other explanations
Fluctuating central nervous system disturbances like confusion, and seizures (microcirculatory ischaemia)
Respiratory distress syndrome with no obvious explanation
Dermal infarcts and skin necrosis
Greyish discolouration of finger tips, toes or ear lobes, which has been termed ‘acral cyanosis’; usually seen in extreme cases

Question 6

What investigations should be done for Disseminated Intravascular Coagulation

Answer 6

Septic screen (urinalysis, NPA, blood cultures, blood gas, CXR)
Bloods:
- clotting (APTT prolonged, PT prolonged, protein C/S and antithrombin reduced
- Fibrinogen and fibrin degradation productions: fibrinogen reduced, products elevated
- FBC: thrombocytopenia, macrocytic anaemia
- D-dimer: raised
- Blood film: schistocytes
- LFTs
- U&Es

Question 7

What is the management for Disseminated Intravascular Coagulation

Answer 7

1. Find and treat the underlying cause e.g. sepsis
2. Supportive:
   - a. Fresh frozen plasma 10-20ml/kg
   - b. Cryoprecipitate (when fibrinogen level <1.5)
   - c. Platelet transfusion
3. Inhibition of the effects of excess thrombin
4. Non-bleeding DIC → LMWH
5. Regular clinical and laboratory surveillance

Question 8

What are the complications of Disseminated Intravascular Coagulation

Answer 8

Acute renal failure
Life-threatening haemorrhage
- Cardiac tamponade
- Haemothorax
- Intracerebral haematoma
Gangrene and amputation