Approach to the Critical Patient

Immediate priorities

Hemorrhagic emergency triggers

ABCs and resuscitation

Monitoring and targets

Hemodynamic monitoring

Serial coagulation monitoring

Critical decision points

Identify and treat the underlying cause — single most important intervention

Phenotype determination

Escalation triggers

PITFALLS

Diagnostic and management pitfalls

History

Presenting symptoms

Bleeding manifestations

Organ dysfunction symptoms

Trigger identification

Sepsis context

Obstetric context

Trauma and tissue injury

Malignancy context

Risk factors and past history

Medical history

Medications and exposures

Family history

Physical Exam

Vital signs

Hemodynamic stability assessment

Skin and mucous membranes

Bleeding and skin lesions

Active bleeding sites

Organ-specific examination

Neurologic

Abdominal examination

Extremities

Focused exam for underlying cause

Differential Diagnosis

Life-threatening mimics

Thrombotic microangiopathies

Heparin-induced thrombocytopenia (HIT)

Coagulopathy mimics

Severe liver disease

Massive transfusion and dilutional coagulopathy

Primary fibrinolysis

Trauma-related coagulopathy

Trauma-induced coagulopathy (TIC)

HELLP syndrome

Laboratory Tests

Core coagulation panel

ISTH DIC scoring labs

Additional hematology labs

Hemolysis assessment

ADAMTS13 activity

Antithrombin activity

Systemic evaluation labs

Infection and organ function

Type and screen

Diagnostic Tests

Scoring Systems

ISTH Overt DIC Score

Sepsis-Induced Coagulopathy (SIC) Score

Quick DIC Score

Viscoelastic Testing (TEG/ROTEM)

MRI

MRI indications in DIC

CT

CT head

CT chest

CT abdomen and pelvis

Ultrasound

Point-of-care ultrasound (POCUS)

Obstetric ultrasound

Abdominal ultrasound

Disposition

ICU admission

Overt DIC (ISTH score >= 5) — all require ICU admission

Early-phase or compensated DIC (SIC score >= 4)

Consult triggers

Specialist consultation indications

Transfer criteria

Transfer to higher level of care

Discharge criteria

Resolution criteria before discharge consideration

Treatment

Treat the underlying cause

Sepsis management

Obstetric causes

Malignancy-associated DIC

Blood product replacement

Platelet transfusion

Fresh frozen plasma (FFP)

Cryoprecipitate

Packed red blood cells

Fibrinogen concentrate (alternative to cryoprecipitate)

Anticoagulation

VTE prophylaxis in non-bleeding DIC

Therapeutic anticoagulation for thrombotic DIC

Antithrombin concentrate

Recombinant thrombomodulin

Medications to avoid

Antifibrinolytics (tranexamic acid)

Activated protein C (drotrecogin alfa)

Long-acting antiplatelet agents

Special Populations

Pregnancy

Obstetric causes of DIC

Blood product considerations in pregnancy

Fetal considerations

Geriatric

Physiologic vulnerability

Medication considerations

Underlying malignancy

Pediatrics

Neonatal DIC

Weight-based blood product dosing

Pediatric DIC triggers

Background

Epidemiology

Incidence and prevalence

Mortality

Classification by cause

Pathophysiology

Core mechanism

Phenotypic spectrum

2025 ISTH phase classification

Immune mechanisms

Therapeutic Considerations

Evidence base for blood product replacement

Anticoagulation evidence

Investigational and adjunctive therapies

Patient Discharge Instructions

copy discharge instructions

Understanding your diagnosis

Signs to return to the emergency department immediately

Follow-up instructions

References

Guidelines and key sources

ISTH SSC 2025 DIC Definition Update

Levi M, Scully M. How I Treat Disseminated Intravascular Coagulation

Hunt BJ. Bleeding and Coagulopathies in Critical Care

Wada H, Thachil J, Di Nisio M, et al. Guidance for Diagnosis and Treatment of DIC

Gando S, Levi M, Toh CH. Disseminated Intravascular Coagulation

Clinical scoring and prognosis

Iba T, Levi M, Thachil J, et al. Sepsis-Induced Coagulopathy Management

Iba T, Maier CL, Tanigawa T, Levy JH. Risk Stratification in Sepsis-Associated DIC

Wada T, et al. DIC Resolution as Surrogate Outcome for Mortality

Squizzato A, Hunt BJ, et al. Supportive Management Strategies for DIC