Recognizing Coagulation Disorders in Sepsis in the Emergency Room: A Narrative Review

Sepsis remains a leading cause of global mortality, and early management in the emergency department (ED) is a key determinant of clinical outcomes. Among the earliest physiological derangements in sepsis are abnormalities in coagulation, which represent not merely laboratory disturbances but fundamental reflections of dysregulated host response, endothelial injury, and evolving microvascular thrombosis. Sepsis-induced coagulopathy (SIC) and disseminated intravascular coagulation (DIC) form a dynamic continuum that frequently begins before shock is clinically apparent. Despite their prognostic value and pathophysiologic significance, these abnormalities are often underrecognized in the ED, where coagulation tests are still commonly interpreted through the narrow lens of bleeding risk rather than as markers of systemic thromboinflammation. This narrative review synthesizes current understanding of the mechanisms linking sepsis, endothelial dysfunction, and coagulation abnormalities; outlines the distinction between SIC and overt DIC; and highlights why early identification of coagulopathy in the ED is essential. We discuss practical bedside approaches, including recommended laboratory testing, pattern recognition, and application of validated scores such as the SIC and ISTH DIC criteria. System-level strategies, such as embedding coagulation testing into sepsis bundles, automating score calculation, and enhancing communication between the ED and ICU teams, are explored as avenues to improve early detection. Evidence suggests that ED recognition of SIC/DIC may refine risk stratification, guide triage decisions, and identify patients who may benefit from targeted anticoagulant strategies once stabilized. Ultimately, recognizing coagulation disorders in the ED reframes sepsis not solely as a hemodynamic crisis but as a complex, thromboinflammatory syndrome in which early intervention may alter trajectory and improve outcomes.