CURRENT Essentials of Critical Care.pdf

Chapter 18 Dermatology 261■■■Disseminated Intravascular Coagulation (DIC) &Purpura FulminansEssentials of Diagnosis• Ranges from mild bruising and oozing at venipuncture sites tomassive hemorrhage and necrosis accompanying abnormalbleeding or clotting as result of uncontrolled activation of coagulationand fibrinolysis• Purpura fulminans characterized by acute, rapidly enlarging,tender, irregular areas of purpura, especially over extremities;may evolve into hemorrhagic bullae with necrosis and escharformation• Excessive generation of thrombin, formation of intravascular fibrinclots, consumption of platelets and coagulation factors• Laboratory findings: thrombocytopenia, anemia, prolonged prothrombinand partial thromboplastin times, low fibrinogen, increasedfibrin degradation products• May be accompanied by pulmonary, hepatic, or renal failure,gastrointestinal bleeding, and hemorrhagic adrenal infarctionDifferential Diagnosis• Severe liver disease• Thrombotic thrombocytopenic purpura• Vitamin K deficiency• Heparin-induced thrombocytopenia• Congenital or acquired protein S or C deficiency• Microangiopathic hemolytic anemias• Acute promyelocytic leukemia (M3 variant)Treatment• Hemodynamic stabilization• Treatment of underlying infection/disorder• Transfusion of fresh frozen plasma, cryoprecipitate• Heparin rarely indicated■ PearlClinically overt disseminated intravascular coagulopathy (DIC) is ascommon in patients with gram-positive sepsis as in those with gramnegativesepsis.ReferenceLevi M et al: Disseminated intravascular coagulation. N Engl J Med1999;341:586. [PMID: 1045465]