Disseminated intravascular coagulation

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Target exams

Red flags

• A child with sepsis or trauma who bleeds from venepuncture sites, mucosa, or lines, while also showing skin and digital ischaemia, has disseminated intravascular coagulation until the score and the cause are addressed
• Purpura fulminans, the large stellate purpuric lesions with skin and digital necrosis in meningococcal or pneumococcal sepsis, signals thrombosis-dominated disseminated intravascular coagulation and demands urgent plasma, heparin, and critical care
• A normal fibrinogen in a child with severe sepsis is not reassuring, because fibrinogen is an acute-phase reactant and an inappropriately normal value may hide consumption; a falling trend matters more than a single value
• Disseminated intravascular coagulation in acute promyelocytic leukaemia can precede the leukaemia diagnosis and is managed with all-trans retinoic acid started immediately, not delayed for the bone marrow result
• Do not give platelets, plasma, or cryoprecipitate prophylactically to a child who is not bleeding; treat the cause and reserve components for active bleeding or a high bleeding risk before procedures

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines disseminated intravascular coagulation as an acquired syndrome of systemic intravascular coagulation arising from a trigger
• States the ISTH overt-disseminated intravascular coagulation score of five points or more
• Names sepsis, malignancy, trauma, and obstetric causes as the triggers
• Explains the bleeding-and-thrombosis paradox of microvascular fibrin with platelet and factor consumption
• Coordinates critical care, haematology, and the component and anticoagulant strategy
• Appraises the ISTH score, the sepsis-induced coagulopathy score, and the thrombomodulin and antithrombin evidence
• The ISTH overt-disseminated intravascular coagulation score totals platelets, fibrinogen, D-dimer, and prothrombin time, and five points or more defines overt disease
• Fresh-frozen plasma is ten to fifteen millilitres per kilogram, platelets are given for the bleeding child under fifty times ten to the nine per litre
• The central principle is to treat the underlying cause; components treat bleeding, not the score
• Builds the resuscitation around the cause, the bleeding, and the organ failure
• Counsels the family on the high mortality and the multisystem course
• Distinguishes the bleeding-dominated from the thrombosis-dominated picture and adjusts the plan
• Level 1: Recognition of the sick child with sepsis and the abnormal coagulation screen
• Level 2: The ISTH score, the cause-driven management, and the component thresholds
• Level 3: The purpura fulminans strategy and the multidisciplinary critical care
• The ISTH overt-disseminated intravascular coagulation score of five points or more
• The sepsis-induced coagulopathy score of four points or more as the precursor
• The component and anticoagulant doses and the causes including acute promyelocytic leukaemia
• Recognition of the bleeding-and-thrombosis paradox and the sick child
• Communication of the diagnosis, the severity, and the plan
• Recognition of purpura fulminans and the thrombosis-dominated course
• Disseminated intravascular coagulation as the consumptive coagulopathy of severe sepsis, malignancy, and trauma
• The ISTH score and the cause-driven management
• Acute promyelocytic leukaemia as the malignancy with the highest disseminated intravascular coagulation risk
• Recognition of the consumptive coagulopathy and the multisystem failure
• The ISTH score and the component and anticoagulant strategy
• The principle that treating the cause is the definitive treatment
• The sepsis-induced coagulopathy score and the thrombomodulin evidence
• The paediatric triggers including meningococcal sepsis and acute promyelocytic leukaemia