disseminated intravascular coagulation

Disseminated Intravascular Coagulation

Paramedic ProgramChemeketa Community College

Stage 1Vasoconstriction

• Anaerobic metabolism replaces aerobic metabolism

• Lactate and hydrogen ion production increases

• Leaky capillary syndrome occurs

Stage 2Capillary and Venule Opening• Precapillary sphincter relaxes

– Vascular space expands• Postcapillary sphincters remain

closed• Blood pools in capillary system• Blood flow through arterioles is less• Additional capillaries and venules

open– Increased hypoxemia and acidosis

• Cardiac output falls!• Viscera (lungs, liver, kidneys,

GI mucosa congested• Anaerobic metabolism, lactic

acid increases• Respirations increase• Rouleaux formation occurs• Clotting mechanisms are

affected

Stage 3Disseminated Intravascular

Coagulation• A complication of severe injury,

trauma, or disease• May occur in 30-50% of

patients with sepsis

Mortality/morbidity

• In general: 18%• Septic abortion: 50%• Major trauma: DIC approximately

doubles mortality rate

• Resistant to treatment• Still irreversible• Blood coagulates in microcirculation• Capillaries are clogged• Lactic acid production increases

• Wash out phase occurs– Water, sodium leak into cell– Potassium leaks out

• Microinfarcts develop in viscera• Pulmonary capillaries are permeable• Pulmonary edema occurs• ARDS occurs

Two phases of DIC

• 1) • free thrombin in blood• Fibrin deposits• Aggregation of platelets

• 2)• Hemorrhage caused by depletion of

clotting factors• Multiple – system organ failure results

– Loss of platelets and clotting factors– Fibrinolysis– Fibrin degradation interference– Small vessel obstruction, tissue ischemia,

RBC injury, anemia from fibrin deposits

Common causes of DIC• Trauma• Complications of OB• Infection (gram-negative sepsis, gram-

positive infections) • HIV, hepatitis• Malignancy; leukemias, metastatic • Snake-bite• Hypoxia

Other causes

• Liver disease• Infant and adult RDS• Thermal injury: Burns• Massive transfusion• MI• Crohn’s disease• Aortic aneurysms

Risk factors

• Pregnancy• Prostatic surgery• Head injury• Inflammatory states

DDX

• Massive hepatic necrosis• Vitamin K deficiency• Thrombocytopenia purpura• Hemolytic-uremic syndrome• Primary fibrinolysis

S/S of DIC• Epistaxis• Gingival bleeding• Mucosal bleeding• Hemoptysis• Hematemesis• Cough• Dyspnea• Localized rales• Tachypnea• Pleural friction rub• Confusion• Disorientation

• Stool blood• Hematuria• Fever • Petechiae• Purpura• Ecchymosis• Anuria• Thrombosis• Stupor • Peripheral cyanoses

Management of DIC

• Reverse underlying cause• Replace platelets• Replace coagulation factors• Replace blood

Medications

• Heparin (contraindicated in head injury)• Broad-spectrum antibiotics for sepsis

Bye Bye, now