Posted in Med Surg

Disseminated intravascular coagulation (DIC) is a type of coagulopathy typically seen in patients with infection, trauma, cancer, inflammation and shock. Additionally it is also a complication of obstetrical abnormalities such as placental abruption and amniotic fluid embolism. DIC is referred to as a “consumption coagulopathy” and can develop quickly, sometimes in a matter of hours or days.

Before we talk through the pathophysiology of disseminated intravascular coagulation, let’s review a few key terms and the coagulation cascade.

Thrombin: An enzyme that facilitates blood clotting by catalyzing the conversion of fibrinogen to fibrin.
Fibrinogen: A protein produced in the liver that is converted into fibrin during blood clot formation.
Fibrin: The protein end-product of the coagulation cascade. Fibrin is a tough protein that is arranged in a fibrous mesh to impede the flow of blood and create a clot.

Coagulation Review

  • Now that you’ve reviewed the key terms, let’s review the basics of coagulation when it occurs in response to a wound:
  • Vessels upstream from the injury constrict in response.
  • Platelets arrive to start sealing off the wound. This is called platelet aggregation and it creates a platelet plug.
  • The coagulation cascade begins, which is a complex pathway of many clotting factors that “cascade” toward the end goal – converting fibrinogen to fibrin.
  • There are two pathways of the coagulation cascade – the extrinsic pathway and the intrinsic pathway.
  • The two pathways converge at the formation of Factor Xa which cleaves prothrombin to form thrombin.
  • Thrombin converts fibrinogen to fibrin and the clot forms.

What Happens in DIC?

DIC occurs when thrombin uncontrollably converts fibrinogen to fibrin. Initially, this causes clots to be formed system-wide, which means organs and limbs don’t get properly perfused and may even suffer permanent damage. As the disease process continues, clotting factors and platelets are consumed faster than they can be created (this is why it is called a consumption coagulopathy). At this point, the patient has an extremely high risk for bleeding, both internally and externally.

Now, let’s go through DIC using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

The patient with DIC may initially present with generalized or localized bruising. The classic sign of DIC, however, is petechiae. These are pin-point brown to purple spots on the skin. Additionally, the patient may also have purpura, a rash or purple spots, all of which indicate bleeding is present.

The patient may appear pale and fatigued due to low hemoglobin and hematocrit. They may also report localized pain and/or shortness of breath.

KEY TAKEAWAY: Petechiae

A: How do you ASSESS the patient?

  • Perform a thorough skin assessment to look for petechiae, bruising, swelling and tenderness. An area often overlooked is the oral mucosa, which will tend to blend before other parts of the body.
  • Complete a thorough head-to-toe assessment, carefully looking at each body system for dysfunction or signs of bleeding.
  • GU: In the urinary system, you may see blood in the urine. A UA will also be able to determine if blood is present. If the patient is female and of menstruating age, ask about their last menstrual period. Did they bleed more than normal? Was the consistency of the blood/discharge different than normal? Did they notice any clots?
  • Cardiac: To assess for cardiac system involvement, ask the patient if they are having chest pain. Perform a 12-lead ECG to assess the heart rhythm. The presence of a clot can cause chest pain and affect the heart’s rhythm.
  • GI: In the GI system, there may be blood in the stool. An occult stool test can detect blood in the stool that may go unnoticed visually.
  • Neuro: Depending on what stage of DIC the patient is in, they are at risk for both ischemic and hemorrhagic stroke. Signs to assess for include one-sided deficits, facial droop, double or blurry vision, headaches, slurred speech, and decreased LOC.
  • Respiratory: How is the patient’s breathing? It may be labored and the patient may display shortness of breath. One way to assess shortness of breath is to assess how many words they can speak before they have to pause. Do they have pain with respirations and have decreased oxygen saturation levels? This may indicate blood clots in the lungs (pulmonary embolism).
  • Vascular: Assess the patient’s limbs, looking to see if the presentation matches bilaterally. Are any limbs cool to the touch, is there any loss of sensation, any blue or dusky discoloration? All can be indications of blood clots in the limbs that, if not treated promptly, could lead to permanent damage, dysfunction, or even loss of the limb.
  • Additionally, ask the patient if they’ve experienced any recent falls or traumas. If so, be sure to include a focused assessment at any site with trauma to observe for bruising, active bleeding, and pain.

KEY TAKEAWAY: Assess for bleeding and organ involvement

T: What TESTS will be ordered?

Lab tests for DIC screening and testing can include:

  • Platelets – decreased
  • Fibrinogen – decreased
  • Fibrin degradation products – increased
  • Fibrinopeptide A – increased
  • D-dimer – increased
  • PTT – decreased in early stages; prolonged in later stage
  • PT – prolonged
  • Prothrombin fragment – Increased
  • INR – increased
  • Hgb/Hct – decreased as the bleeding continues
  • RBC – decreased due to RBC passing through partially clogged vessels which damages them, leading to hemolytic anemia
  • Coagulation factors I, II, VIII, X, XIII – decreased
  • If the patient is presenting with chest pain, an EKG, TTE (transthoracic echocardiogram), and/or CT of the chest may be completed to assess for acute myocardial infarction.
  • Urinalysis will be performed to ensure that there is no blood in the urine; a stool sample will also need to be collected and processed to check for GI bleeding.
  • Patients presenting with stroke symptoms will get a STAT head CT to assess for bleeding, possibly also an MRI/MRA.

KEY TAKEAWAY: Increased PTT, decreased Hgb, decreased PLTs

T: What TREATMENTS will be provided?

In addition to treating the underlying cause, treatments focus on controlling bleeding. We do this by replacing platelets and clotting factors with platelet infusion, cryoprecipitate, and fresh frozen plasma. Some patients, if actively hemorrhaging, may also require PRBCs. In some cases, heparin is used for its anticoagulation properties.

Additionally, any patient with suspected or confirmed DIC must be placed on bleeding precautions for their safety. This includes avoiding falls, minimizing or avoiding venipuncture, no IMs, no razors, no flossing, soft toothbrush, and no knives with meals.

E: How do you EDUCATE the patient/family?

The biggest education component for patients/families is around bleeding precautions. Make sure they understand what these are and when to call the MD (or, if in the hospital, when to press that call light to get some help!).

Some patients may be prescribed long-term anticoagulant medication (heparin). They need to understand how to take it, any routine lab tests they’ll need to undergo, and any lifestyle changes such as avoiding activities that could lead to injury (no contact sports, for example).

Ensure the family and patient understand that there is no one specific treatment for DIC. Instead, the goal of treatment is to pinpoint and treat the underlying cause. For example, if the underlying cause is infection, the DIC should resolve once the infection is controlled.

KEY TAKEAWAY: Bleeding precautions and anticoagulant medication

Do you enjoy learning using the LATTE method? Get the LATTE concept map template here.

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REFERENCES:

Hematology-Oncology Associates of CNY. (n.d.). Disseminated Intravascular Coagulation. Hematology-Oncology Associates of CNY. https://www.hoacny.com/patient-resources/blood-disorders/disseminated-intravascular-coagulation/what-are-signs-and-symptoms

Medline Plus. (n.d.). Disseminated intravascular coagulation (DIC). Medline Plus; U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000573.htm

Moake, J. (n.d.). Disseminated Intravascular Coagulation (DIC). Merck Manual Consumer Version; Merck Sharp & Dohme Corp. https://www.merckmanuals.com/home/blood-disorders/bleeding-due-to-clotting-disorders/disseminated-intravascular-coagulation-dic

National Heart Lung & Blood Institute. (n.d.). Disseminated Intravascular Coagulation. National Institute of Health. https://www.nhlbi.nih.gov/health-topics/disseminated-intravascular-coagulation

Simmons, M. A. (2007). Factor xa. In S. J. Enna & D. B. Bylund (Eds.), XPharm: The Comprehensive Pharmacology Reference (pp. 1–2). Elsevier. https://doi.org/10.1016/B978-008055232-3.61736-2