Clinical Commander

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heme.dic.v1

Disseminated intravascular coagulation (DIC)

hematologyacutesubacutesyndromeadultinpatientacute
Start encounter →Print handoutPRODUCTION

STEP 3 deepened 2026-05-16; citations re-verified 2026-05-22: §5.5.1 effect sizes wired (ISTH overt-DIC score >=5 threshold + mortality correlation Taylor/Wada; SCARLET rTM 28-day mortality 26.8% vs 29.4% NS PMID 31104069; APL early DIC-hemorrhagic death ~5-10% despite CR >90% ELN APL PMID 30803991; sepsis-DIC ~2x mortality Levi PMID 10451465). §5.5.2 Factor-VIII pivot (DIC vs liver), TTP/HIT/VKDC/dilutional/acquired-haemophilia pivots, cross-routing (heme.ttp, workup.acute_leukemia, sepsis bundle). 2026-05-22 PMID remediation: replaced mis-attributed Wada 23889640->23379279, Levi 24847960->10451465 (NEJM 1999 DIC review), SCARLET 31573641->31104069, Sanz/APL 19740935->30803991 (ELN APL 2019); last_reconciled 2026-05-22. NEW dossier — manifest repointed. NEXT STEPS: (1) author manifest at prisma/seed/manifests/heme.dic.v1.ts; (2) RxCUI validation for heparin (UFH), enoxaparin, vitamin K, PCC, tranexamic acid, ATRA, arsenic trioxide (blood products lack reliable RxCUIs); (3) calculator gaps — ISTH DIC score may be in panel.coag; verify exposure. Treat-cause-first principle explicit; phenotype-directed therapy (bleeding vs thrombotic vs APL) captured. Sibling differentiation from heme.ttp.core.v1 covers 5 features + PLASMIC routing.

Entry points (5)

  • lab_abnormality
    Thrombocytopenia + abnormal PT/aPTT in critically ill patient (ISTH 2009)
    thrombocytopenia_with_coag_abnormality
  • symptom
    Bleeding from ≥2 sites (line, mucosal, surgical, wound) (ISTH 2009)
    bleeding_from_multiple_sites
  • symptom
    Digital ischemia, purpura fulminans, organ dysfunction with consumptive coagulopathy (ISTH 2009)
    microthrombosis_digital_ischemia_or_purpura_fulminans
  • history
    AML M3 / APL with bleeding diathesis (ELN APL 2019)
    apl_with_bleeding
  • history
    Obstetric emergency (HELLP, AFE, abruption, retained fetus) with coagulopathy (ISTH 2009)
    obstetric_emergency_dic

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Risk profile + cause vary by age (ISTH 2009)
  • sex_pregnancy_statusrequired
    demographic • used at CONTEXT
    Obstetric DIC pathway different (ISTH 2009)
  • sbprequired
    vital • used at CONTEXT
    Septic shock common precipitant (SSC 2021)
  • temperaturerequired
    vital • used at CONTEXT
    Septic precipitant (SSC 2021)
  • cbc_with_smearrequired
    lab • used at INITIAL_WORKUP
    Platelets + schistocytes (TTP/HUS DDx) (ISTH 2009)
  • pt_inr_apttrequired
    lab • used at INITIAL_WORKUP
    ISTH score; coagulopathy magnitude (ISTH 2009)
  • fibrinogenrequired
    lab • used at INITIAL_WORKUP
    ISTH score component; replacement target (ISTH 2009; BSH 2020)
  • d_dimer_or_fdprequired
    lab • used at INITIAL_WORKUP
    ISTH score component (ISTH 2009)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Sepsis severity (SSC 2021)
  • lft_creatininerequired
    lab • used at INITIAL_WORKUP
    Liver failure DDx; renal involvement (ISTH 2009)
  • adamts13
    lab • used at BRANCHING_WORKUP
    Exclude TTP (ISTH 2024)
  • hit_4ts_pf4_assay
    lab • used at BRANCHING_WORKUP
    Exclude HIT (ISTH 2024)
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    Source identification (SSC 2021)
  • precipitant_knownrequired
    history • used at CONTEXT
    Sepsis, trauma, malignancy, obstetric, pancreatitis, transfusion, snake bite, hepatic (ISTH 2009)
  • current_medsrequired
    medication • used at CONTEXT
    Anticoag baseline; chemo (APL on ATRA) (ISTH 2009; ELN APL 2019)
  • imaging_for_source
    imaging • used at BRANCHING_WORKUP
    CT for abscess / hematoma / placental (ISTH 2009)

12-phase flow (12)

  1. 1FRAME
    Confirm DIC via ISTH 2001 overt-DIC score — Bayesian threshold ≥5 = overt DIC (validated, high sensitivity/specificity vs reference standard; each point correlates with rising ICU mortality — Taylor ISTH 2001 PMID 11816725, Wada DIC harmonization PMID 23379279); <5 = non-overt → serial re-scoring (DIC is dynamic). Rule out look-alikes (liver, ITP, TTP, HIT, dilutional)
    inputs: cbc_with_smear, pt_inr_aptt, fibrinogen, d_dimer_or_fdp
    advance: ISTH score calculated; differential narrowed
  2. 2ENTRY
    Abnormal coags + thrombocytopenia in critically ill, bleeding multiple sites, microthrombi, purpura fulminans, suspected APL, OB emergency
    inputs: age
    advance: Entry trigger captured
  3. 3CONTEXT
    Precipitant, baseline coags, transfusion, pregnancy, malignancy
    inputs: precipitant_known, sex_pregnancy_status, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Life-threatening bleeding, purpura fulminans (esp meningococcemia), APL with bleeding, ICH, OB emergency
    inputs: sbp
    actions: workup.bacterial_meningitis, workup.acute_leukemia
    advance: Acute red flags addressed
  5. 5INITIAL_WORKUP
    CBC + smear, PT/INR/aPTT, fibrinogen, D-dimer/FDP, LFT, CMP, lactate, source cultures + imaging
    inputs: cbc_with_smear, pt_inr_aptt, fibrinogen, d_dimer_or_fdp, lft_creatinine, lactate, blood_cultures
    actions: panel.cbc, panel.coag, panel.lft, panel.renal, workup.dic
    advance: Stage-1 returned + ISTH score
  6. 6BRANCHING_WORKUP
    Schistocyte review for TTP/HUS, ADAMTS13, HIT 4Ts + PF4 assay, fibrinogen trends, source workup (CT for abscess, OB ultrasound)
    inputs: adamts13, hit_4ts_pf4_assay, imaging_for_source
    actions: workup.endocarditis, workup.ttp_standalone, 4ts
    advance: Differential refined
  7. 7DIFFERENTIAL
    Named Bayesian pivots — Factor VIII is the load-bearing discriminator: normal/HIGH in DIC (acute-phase) vs LOW in hepatic synthetic failure when PT/fibrinogen abnormal in both. TTP: schistocytes ++, ADAMTS13 <10%, NORMAL PT/fibrinogen (DIC has abnormal coags) → route heme.ttp.core.v1. HIT: heparin day 5-10 + thrombosis + 4Ts, normal fibrinogen. Vitamin-K deficiency: isolated PT, corrects with vitamin K. Dilutional: massive-transfusion history. Acquired haemophilia: isolated aPTT + abnormal mixing study — Levi NEJM 1999 (PMID 10451465); Wada DIC harmonization (PMID 23379279)
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    ISTH overt vs non-overt; phenotype (bleeding / thrombotic / mixed); SOFA if ICU
    inputs: cbc_with_smear, pt_inr_aptt, fibrinogen, d_dimer_or_fdp
    actions: calc.sofa, calc.qsofa
    advance: Phenotype + severity tier documented
  9. 9TREATMENT
    TREAT UNDERLYING CAUSE first (sepsis source control + abx; surgical / OB delivery; ATRA + ATO for APL); supportive replacement for active bleeding (FFP 10-15 mL/kg, cryoprecipitate 1 unit/10 kg target fibrinogen >150, platelets target ≥50 or ≥100 in CNS bleed, PCC for VKDC); heparin in chronic/thrombotic phenotype; AVOID TXA unless proven hyperfibrinolysis (APL/obstetric — otherwise catastrophic thrombosis risk); recombinant thrombomodulin did NOT significantly reduce 28-day mortality in sepsis-associated coagulopathy (~26.8% vs 29.4%, SCARLET JAMA 2019 PMID 31104069) — region-specific use only; APL: start ATRA at first suspicion (before genetic confirmation) — early DIC-driven hemorrhagic death is the leading induction-mortality cause (~5-10%) despite CR >90% with ATRA+ATO (ELN APL 2019 PMID 30803991); sepsis-DIC ~2x mortality vs sepsis alone (Levi NEJM 1999 PMID 10451465)
    inputs: precipitant_known, fibrinogen
    advance: Treat-cause + phenotype-directed plan documented
  10. 10DISPOSITION
    ICU for severe bleeding / hemodynamic instability / source needing urgent intervention
    advance: Disposition documented
  11. 11MONITORING
    Coags + fibrinogen + platelets q6-12 h, ISTH score serial, source response
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Hematology, oncology, OB, ID per cause; thromboprophylaxis once safe
    advance: Follow-up scheduled