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heme.dic.v1PRODUCTION
heme.dic.v1

Disseminated intravascular coagulation (DIC)

hematologyacutesubacutesyndromeadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
4
Actions
0
Advance rule
Set
Advance when

ISTH score calculated; differential narrowed

Patient inputs (16)

Risk profile + cause vary by age (ISTH 2009)

Obstetric DIC pathway different (ISTH 2009)

Septic shock common precipitant (SSC 2021)

Septic precipitant (SSC 2021)

Sepsis, trauma, malignancy, obstetric, pancreatitis, transfusion, snake bite, hepatic (ISTH 2009)

Anticoag baseline; chemo (APL on ATRA) (ISTH 2009; ELN APL 2019)

Platelets + schistocytes (TTP/HUS DDx) (ISTH 2009)

ISTH score; coagulopathy magnitude (ISTH 2009)

ISTH score component; replacement target (ISTH 2009; BSH 2020)

ISTH score component (ISTH 2009)

Sepsis severity (SSC 2021)

Liver failure DDx; renal involvement (ISTH 2009)

Source identification (SSC 2021)

Exclude TTP (ISTH 2024)

Exclude HIT (ISTH 2024)

CT for abscess / hematoma / placental (ISTH 2009)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningapl_with_bleeding_diathesis (ELN APL 2019)
    AML M3 / APL with thrombocytopenia + coagulopathy + Auer rods / faggot cells / t(15;17) (ELN APL 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpurpura_fulminans_meningococcemia (ISTH 2009; SSC 2021)
    Purpura fulminans + sepsis (often meningococcal) + DIC (ISTH 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningobstetric_dic (ISTH 2009)
    Obstetric emergency (HELLP, AFE, abruption, retained fetus) with DIC (ISTH 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_hemorrhage_with_dic (BSH 2020)
    Active hemorrhage requiring ≥10 units RBC in 24 h (BSH 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereisth_score_overt_dic (ISTH 2009)
    ISTH 2001 score ≥5 = overt DIC (ISTH 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethrombotic_phenotype_dic_microthrombi (ISTH 2009; BSH 2020)
    Thrombotic / chronic phenotype DIC (microthrombi, digital ischemia, cancer-associated) (ISTH 2009; BSH 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverettp_or_hit_overlap_concern (ISTH 2024)
    Schistocytes prominent (TTP DDx) OR recent heparin + thrombocytopenia (HIT DDx) (ISTH 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Supportive blood-product replacement for bleeding phenotype
axis: dic_supportive_replacement
Selected axis "Supportive blood-product replacement for bleeding phenotype" by default fallback (first axis)
  • fresh frozen plasma (FFP)
    first line
    blood_product
    10-15 mL/kg • IV • reassess after each unit
    triggers: active_bleeding_with_INR_>1.5_or_aPTT_>1.5x, major_invasive_procedure_planned
    Replace coag factors; aim INR <1.5
    rxcui 2539171
  • cryoprecipitate
    first line
    blood_product
    1 unit/10 kg (or 10 units pooled) • IV • reassess
    triggers: fibrinogen_lt_150_with_active_bleeding, OB_emergency_low_fibrinogen
    Target fibrinogen >150 mg/dL in active bleed; >200 in OB
  • platelets
    first line
    blood_product
    1 apheresis unit • IV • target ≥50 K (≥100 K CNS or active bleed)
    triggers: platelets_lt_50_with_active_bleeding, platelets_lt_20_severe_DIC
    Maintain platelet count for hemostasis
  • prothrombin complex concentrate (PCC)
    rescue
    prothrombin_complex
    25-50 IU/kg • IV • single dose
    triggers: warfarin_or_FXa_inhibitor_overlay, massive_hemorrhage_with_factor_depletion
    Rapid factor replacement; preferred over FFP for warfarin
    rxcui 1670383
  • vitamin K (phytonadione)
    add on
    vitamin_K
    5-10 mg IV/PO • IV/PO • single
    triggers: warfarin_or_VKD_deficiency
    Reverse warfarin / liver vitamin K deficiency
    rxcui 8308
  • tranexamic_acid
    rescue
    antifibrinolytic
    1 g IV over 10 min then 1 g over 8 h • IV • short course
    triggers: proven_hyperfibrinolysis_post_CPB_or_AML_M3_with_hyperfibrinolysis_or_snake_bite
    NOT routine in DIC — only when hyperfibrinolytic phenotype documented; risk of thrombosis
    rxcui 10691

inpatient playbook — drug actions (5)

  1. 1. source-specific therapy
    per cause (abx, surgical, OB delivery, ATRA, etc.) • varies • protocol
    trigger: Identified cause
    Source control is cardinal
  2. 2. replacement for bleeding
    FFP 10-15 mL/kg + cryo + platelets per axis • IV • titrated
    trigger: Active bleeding + abnormal coags
    Maintain hemostasis
  3. 3. PCC for warfarin / FXa overlay
    25-50 IU/kg • IV • single
    trigger: Anticoag overlay
    Rapid reversal
  4. 4. heparin for thrombotic phenotype
    5-8 U/kg/h IV no bolus • IV • continuous
    trigger: Microthrombi or cancer-associated chronic DIC without bleed
    Levi
  5. 5. ATRA + ATO for APL
    per axis • PO/IV • daily
    trigger: Suspected APL
    ELN APL 2019

Auto-drafted A&P note

inpatient

Subjective

- Possible entry pathways: Thrombocytopenia + abnormal PT/aPTT in critically ill patient (ISTH 2009); Bleeding from ≥2 sites (line, mucosal, surgical, wound) (ISTH 2009); Digital ischemia, purpura fulminans, organ dysfunction with consumptive coagulopathy (ISTH 2009).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Disseminated intravascular coagulation (DIC)** (heme.dic.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Supportive blood-product replacement for bleeding phenotype**.
1. fresh frozen plasma (FFP) 10-15 mL/kg IV reassess after each unit (blood_product, first line) — Replace coag factors; aim INR <1.5
2. cryoprecipitate 1 unit/10 kg (or 10 units pooled) IV reassess (blood_product, first line) — Target fibrinogen >150 mg/dL in active bleed; >200 in OB
3. platelets 1 apheresis unit IV target ≥50 K (≥100 K CNS or active bleed) (blood_product, first line) — Maintain platelet count for hemostasis
4. prothrombin complex concentrate (PCC) 25-50 IU/kg IV single dose (prothrombin_complex, rescue) — Rapid factor replacement; preferred over FFP for warfarin
5. vitamin K (phytonadione) 5-10 mg IV/PO IV/PO single (vitamin_K, add on) — Reverse warfarin / liver vitamin K deficiency
6. tranexamic_acid 1 g IV over 10 min then 1 g over 8 h IV short course (antifibrinolytic, rescue) — NOT routine in DIC — only when hyperfibrinolytic phenotype documented; risk of thrombosis

Setting playbook (inpatient) — Identify cause + treat it; provide phenotype-directed supportive care; monitor coags closely (ISTH 2009; BSH 2020)
7. source-specific therapy per cause (abx, surgical, OB delivery, ATRA, etc.) varies protocol — Identified cause (Source control is cardinal)
8. replacement for bleeding FFP 10-15 mL/kg + cryo + platelets per axis IV titrated — Active bleeding + abnormal coags (Maintain hemostasis)
9. PCC for warfarin / FXa overlay 25-50 IU/kg IV single — Anticoag overlay (Rapid reversal)
10. heparin for thrombotic phenotype 5-8 U/kg/h IV no bolus IV continuous — Microthrombi or cancer-associated chronic DIC without bleed (Levi)
11. ATRA + ATO for APL per axis PO/IV daily — Suspected APL (ELN APL 2019)

Non-pharmacologic actions:
- Hematology consult (BSH 2020)
- Source-specific consult (ID, OB, surgery, oncology) (ISTH 2009)
- Avoid invasive procedures unless essential (BSH 2020)
- Compression dressings for line / wound bleeding (BSH 2020)

AVOID / contraindication checks:
- Treat_underlying_cause_first (ISTH 2009; BSH 2020)
- No_routine_TXA_thrombosis_risk (ISTH 2024; BSH 2020)
- Platelet_target_higher_in_CNS_bleed (BSH 2020)
- Fibrinogen_target_higher_in_OB_bleeding (BSH 2020)
- Reassess_coags_after_each_replacement (ISTH 2009; BSH 2020)

Monitoring

Regimen monitoring:
- PT INR aPTT q6 to 12 h (ISTH 2009)
- fibrinogen q6 to 12 h (ISTH 2009; BSH 2020)
- platelets q6 to 12 h (ISTH 2009)
- D dimer serial (ISTH 2009)
- ISTH score serial (ISTH 2009)
- source response (SSC 2021)

Setting (inpatient) monitoring:
- Coags + fibrinogen + platelets q6-12 h (ISTH 2009; BSH 2020)
- Source response (cultures, lactate) (SSC 2021)
- Vitals q1-4 h (SSC 2021)

Follow-up plan: Hematology, oncology, OB, ID per cause; thromboprophylaxis once safe
- Close-out criterion: Follow-up scheduled

Monitoring phase: Coags + fibrinogen + platelets q6-12 h, ISTH score serial, source response

Disposition

Current setting: inpatient — Identify cause + treat it; provide phenotype-directed supportive care; monitor coags closely (ISTH 2009; BSH 2020)

Disposition criteria:
- ICU: severe bleeding, hemodynamic instability, source intervention (ISTH 2009; BSH 2020)
- Step-down: ISTH score declining, source controlled, stable hemostasis (ISTH 2009)

Escalation triggers (move to higher acuity):
- Hemodynamic instability → ICU (SSC 2021)
- CNS bleeding → neurology / neurosurgery (BSH 2020)
- Refractory DIC → hematology + ICU (ISTH 2009; BSH 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] AML M3 / APL with thrombocytopenia + coagulopathy + Auer rods / faggot cells / t(15;17) (ELN APL 2019)
- [LIFE_THREATENING] Purpura fulminans + sepsis (often meningococcal) + DIC (ISTH 2009)
- [LIFE_THREATENING] Obstetric emergency (HELLP, AFE, abruption, retained fetus) with DIC (ISTH 2009)

Citations

- ISTH 2001 Taylor DIC score + Wada DIC harmonization (JTH 2013) + Levi NEJM 1999 review + SCARLET JAMA 2019 + ELN APL 2019 [PMID:11816725](https://pubmed.ncbi.nlm.nih.gov/11816725/)
- Cited evidence (PMID 23379279) [PMID:23379279](https://pubmed.ncbi.nlm.nih.gov/23379279/)
- Cited evidence (PMID 10451465) [PMID:10451465](https://pubmed.ncbi.nlm.nih.gov/10451465/)
- Cited evidence (PMID 31104069) [PMID:31104069](https://pubmed.ncbi.nlm.nih.gov/31104069/)
- Cited evidence (PMID 30803991) [PMID:30803991](https://pubmed.ncbi.nlm.nih.gov/30803991/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ISTH 2001 Taylor DIC score + Wada DIC harmonization (JTH 2013) + Levi NEJM 1999 review + SCARLET JAMA 2019 + ELN APL 2019 — PMID:11816725
  • Cited evidence (PMID 23379279) — PMID:23379279
  • Cited evidence (PMID 10451465) — PMID:10451465
  • Cited evidence (PMID 31104069) — PMID:31104069
  • Cited evidence (PMID 30803991) — PMID:30803991