dr Bipul Borthakur

1. DISSEMINATED COAGULATION
CASCADE AND ITS
ABNORMALITIES
Dr BIPUL BORTHAKUR
PROF Orthopaedics, SILCHAR ,ASSAM,INDIA

2. SEQUENCE OF DISCUSSION
• Definition
• Etiology
• Classification
• Pathophysiology
• Signs and symptoms
• Laboratory diagnosis
• Differential diagnosis
• Treatment
• Complications
• prognosis

3. DEFINITION
• Disseminated intravascular coagulation(DIC) is a syndrome
characterized by the systematic activation of blood
coagulation which generates intravascular thrombin and
fibrin resulting in the thrombosis of small to medium sized
vessels and ultimately organ dysfunction and severe
bleeding

4. Normal coagulation cascade

5. ETIOLOGY
• DIC is not a primary disease but a disorder secondary to
many triggering events
• Some of the common causes are-
• Infections
• Trauma
• Malignancy
• Toxic reactions
• Drug reactions

6. CLASSIFICATION
• Acute DIC-Acute DIC occurs when large procoagulant factors enter
into circulation in a brief period of time ,thereby over running
compensatory hemostatic mechanisms ,predisposing patients to
haemorrhage
• Chronic DIC-chronic DIC occurs when small amount of procoagulant
factors enter into circulation over a period of time and are well
compensated by compensated haemostatic mechanisms

7. VARIOUS TYPES OF DIC

8. PATHOPHYSIOLOGY

10. SIGNS AND SYMPTOMS OF DIC
• Signs of deep venous or arterial thrombus or embolus
• Superficial venous thrombosis especially without varicose vein
• Multiple thrombotic events at the same site
• Serial thrombotic episodes
• Bleeding such as-upper GI bleed,petechiae,ecchymosis,iv lines and
catheters bleed, bleeding from surgical sites,drains,within serous cavities,
tracheostomies
• Renal failure
• Pulmonary symptoms such as haemoptysis,dysponea ,cough
• jaundice

11. Laboratory parameters and their significance

12. Algorithm for the diagnosis of DIC

13. Various scoring systems to diagnose DIC
• ISTH CRITERIA
• JMHW CRITERIA
• JAAM CRITERIA

14. ISTH criteria
• Underlying clinical condition predisposing to DIC-essential
• Clinical symptom-not used
• Platelet count -50000-1lac-1 point
• Fibrin related marker-moderate increase-2 points
marked increase-3 points
Fibrinogen<1 -1 point
PT-Prolongation3-6 sec-1point
prolongation>6 sec-2 point
DIC diagnosis >/5 points

15. JMWH criteria
• Underlying clinical condition predisposing to DIC-1 point
• Clinical symptom-bleeding-1 point, organ failure 1point
• Platelet count-80,000-120,000-1 point
50,000-80,000-2 point
<50,000-3 point
FDP-10-20ug/ml=1 point
20-40ug/ml=2 point
>40ug/ml= 3point
Fibrinogen-1-1.5 -1 point
<1-2 points
PT-PT ratio1.25-1.67-1point
>1.67-2 points
DIC diagnosis>= 7 points

16. JAAM criteria
• Underlying clinical condition predisposing to DIC-essential
• Clinical symptom Sirs score>=3-1 point
• Platelet count -80,000-120,000or >30% reduction 1 point
<80,000 or >50% reduction 2 points
Fibrin related marker-FDP 10-25gm/ml-1 point
FDP>25gm/ml=3 point
Fibrinogen-not used
PT ratio >=1.2 -1 point
DIC diagnosis>=4 points

17. Treatment
• The prime stone of management of DIC is to treat the underlying
cause or correct initiating factors or excessive coagulation. In number
of instances ,immediate management of underlying cause may not be
possible or take long time
• Therefore measures to breach vicious cycles of thrombosis and
hemorrhage are required
• So the main treatment options for DIC include replacement therapy
and anticoagulation therapy

18. Recommendation for treatment
• Transfusion of platelets is recommended in the following condition-
• Active bleeding and platelet count less than 50,000/cumm
• Platelet count of less than 50000 in those with high risk of bleeding
• An absolute platelet count of less than 20,000
• Administration of FFP may be useful in patients with active bleeding
with either prolonged PT (>6 above normal) or activated aPTT(>1.5
times above normal)or decreased fibrinogen (<1.5gm/dl)
• It should be considered in DIC patients requiring invasive procedures
with similar laboratory abnormalities

19. • Administration of fibrinogen concentrate or cryoprecipitate
may be recommended in actively bleeding Patients with
persistent severe hypofibrinogaemia (<1.5gm/dl) despite FFP
replacement
• Prothrombin Complex concentrate (pcc) may be considered in
actively bleeding patients where FFP transfusion is not possible
• Therapeutic doses of heparin should be considered in cases of
DIC where thrombosis predominates. The use of LMWH is
preferred over unfractionated heparin in such cases
• Antifibrinolytics are generally avoided in case of DIC

20. COMPLICATIONS
• SEVERE BLEEDING
• STROKE
• ISCHAEMIA OF INTERNAL ORGANS
• MODS

21. Differential diagniosis
• Atypical haemolytic-uraemic syndrome
• Haemolytic uraemic syndrome
• Heparin induced thrombocytopenia and thrombosis syndrome
• Idipopathic thrombocytopenic purpura
• Liver disease
• Primary haemostatic disorder
• Thrombotic thtrombocytopenic purpura

22. Skin manifestation of DIC

23. PROGNOSIS
• SINCE DIC is as a result of acute medical illness, prognosis depends
almost entirely upon the speed of handling the patient as well as
treating the underlying disorder
• The underlying disease that causes the disorder predicts the outcome

24. Conclusion
• Prompt diagnosis of DIC by identifying the underlying disorder is
essential
• Scoring system should be used for diagnosis and assessing the
prognosis of treatment
• Treatment strategy is likely to involve multidispinary approach which
should be tailored with individual patient

25. तमुवाच हृषीके श: प्रहसन्निव भारत |
सेियोरुभयोममध्ये ववषीदनतममदं वच: || 10||
tam-uvācha hṛiṣhīkeśhaḥ prahasanniva bhārata
senayorubhayor-madhye viṣhīdantam-idaṁ vachaḥ
meaning-O Dhritarashtra, thereafter, in the midst of both
the armies, Shree Krishna smilingly spoke the following
words to the grief-stricken Arjun.