Approach
An underlying disorder is required for consideration of disseminated intravascular coagulation (DIC) and can include major trauma/burns/organ destruction, sepsis/severe infection (including severe coronavirus disease 2019 [COVID-19]), severe obstetric disorders or complications, solid tumors and hematologic malignancies, severe toxic or immunologic reactions, and major vascular disorders (large aortic aneurysms or giant hemangiomas).[2][3]
There is no single diagnostic test for DIC. Risk factors, clinical manifestations, and all available laboratory results must be considered to make the diagnosis.[10]
Clinical evaluation
In addition to the symptoms and signs of the underlying disease, common findings include thrombosis, bleeding, or both. Microvascular thrombosis often results in multiorgan ischemia and failure. Ischemic findings include purpura fulminans/gangrene/acrocyanosis, delirium/coma, oliguria/azotemia, hypotension/tachycardia/circulatory collapse, dyspnea/hypoxia, gastrointestinal ulcers, and adrenal dysfunction. Hemorrhagic findings include petechiae/ecchymosis, oozing, intracranial bleeding, hematuria, and massive gastrointestinal bleeding. In general, ischemic findings are considered earlier signs of DIC, while bleeding findings are late overt signs.[1][2]
Initial laboratory evaluation
Initial laboratory investigations to order in all patients are:[10]
Platelet count: shows thrombocytopenia
Prothrombin time: often prolonged
Fibrinogen: low levels
D-dimer/fibrin degradation products: elevated.
A combination of the results of these four investigations can be used to calculate a diagnostic score.[4]
Activated partial thromboplastin time is useful in monitoring patient progress.
Additional tests
Subsequent tests may show prolonged thrombin time and low levels of coagulation factors (V, VIII, X, XIII). As these tests are not required for diagnosis of DIC, they should not be ordered routinely. However, if specific or multiple coagulation factor deficiencies are suspected, measurement of coagulation factors helps in the selection of a specific replacement therapy.
Imaging studies and other tests
Depending on the underlying disorder and areas of thrombosis and hemorrhage, additional investigations should be ordered to assist in diagnosis of the underlying disorder. For example, computed tomography/magnetic resonance imaging of the pancreas with serum amylase and lipase would help define acute pancreatitis.
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