Anemia in the Emergency Department: Evaluation And

November 2013 Anemia In The Emergency Volume 15, Number 11 Department: Evaluation And Authors Timothy G. Janz, MD, FACEP, FCCP Professor, Department of Emergency Medicine, Pulmonary/Critical Treatment Care Division, Department of Internal Medicine, Boonshoft School of Medicine, Wright State University, Dayton, OH Roy L. Johnson, MD, FAAEM Abstract Assistant Professor, Associate Program Director, Integrated Residency in Emergency Medicine, Boonshoft School of Medicine, Wright State University, Dayton, OH Anemia is a common worldwide problem that is associated with Scott D. Rubenstein, MD, MS, EMT-T nonspecific complaints. The initial focus for the emergency evalu- Chief Resident, Wright State University/Wright-Patterson Air Force ation of anemia is to determine whether the problem is acute or Base Combined Emergency Medicine Residency, Dayton, OH chronic. Acute anemia is most commonly associated with blood Peer Reviewers loss, and the patient is usually symptomatic. Chronic anemia is David Cherkas, MD, FACEP usually well tolerated and is often discovered coincidentally. Once Assistant Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY diagnosed, the etiology of anemia can often be determined by Chad Meyers, MD applying a systematic approach to its evaluation. The severity of Director, Emergency Critical Care, Bellevue Hospital Center; the anemia impacts clinical outcomes, particularly in critically ill Assistant Professor of Clinical Emergency Medicine, New York patients; however, the specific threshold to transfuse is uncertain. University School of Medicine, New York, NY Evaluation of the current literature and clinical guidelines does CME Objectives not settle this controversy, but it does help clarify that a restrictive Upon completion of this article, you should be able to: transfusion strategy (ie, for patients with a hemoglobin < 6-8 g/ 1. Differentiate between the 3 categories of anemia when considering a differential diagnosis. dL) is associated with better outcomes than a more liberal transfu- 2. Describe the diagnostic workup for patients presenting to the sion strategy. Certain anemias may have well-defined treatment ED with anemia. options (eg, sickle cell disease), but empiric use of nutritional 3. Summarize the general principles of transfusion therapy. supplements to treat anemia of uncertain etiology is discouraged. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-In-Chief of Medicine at Mount Sinai, New Attending Physician, Massachusetts Icahn School of Medicine at Mount Research Editor Andy Jagoda, MD, FACEP York, NY General Hospital, Boston, MA Sinai, New York, NY Michael Guthrie, MD Professor and Chair, Department of Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, Scott Silvers, MD, FACEP Emergency Medicine Residency, Emergency Medicine, Icahn School Professor and Chair, Department FACEP Chair, Department of Emergency Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical of Emergency Medicine, Carolinas Professor and Chair, Department of Medicine, Mayo Clinic, Jacksonville, FL Sinai, New York, NY Director, Mount Sinai Hospital, New Medical Center, University of North Emergency Medicine, Pennsylvania York, NY Carolina School of Medicine, Chapel Hospital, Perelman School of Corey M. Slovis, MD, FACP, FACEP International Editors Professor and Chair, Department Hill, NC Medicine, University of Pennsylvania, Peter Cameron, MD Associate Editor-In-Chief Philadelphia, PA of Emergency Medicine, Vanderbilt Steven A. Godwin, MD, FACEP University Medical Center; Medical Academic Director, The Alfred Kaushal Shah, MD, FACEP Professor and Chair, Department Michael S. Radeos, MD, MPH Emergency and Trauma Centre, Associate Professor, Department of Director, Nashville Fire Department and of Emergency Medicine, Assistant Assistant Professor of Emergency International Airport, Nashville, TN Monash University, Melbourne, Emergency Medicine, Icahn School Dean, Simulation Education, Medicine, Weill Medical College Australia of Medicine at Mount Sinai, New University of Florida COM- of Cornell University, New York; Stephen H. Thomas, MD, MPH York, NY George Kaiser Family Foundation Giorgio Carbone, MD Jacksonville, Jacksonville, FL Research Director, Department of Chief, Department of Emergency Emergency Medicine, New York Professor & Chair, Department of Gregory L. Henry, MD, FACEP Medicine Ospedale Gradenigo, Editorial Board Hospital Queens, Flushing, NY Emergency Medicine, University of William J. Brady, MD Clinical Professor, Department of Oklahoma School of Community Torino, Italy Professor of Emergency Medicine Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Medicine, Tulsa, OK Amin Antoine Kazzi, MD, FAAEM and Medicine, Chair, Medical of Michigan Medical School; CEO, Director of Network Operations and Ron M. Walls, MD Associate Professor and Vice Chair, Emergency Response Committee, Medical Practice Risk Assessment, Business Development, Department Professor and Chair, Department of Department of Emergency Medicine, Medical Director, Emergency Inc., Ann Arbor, MI of Emergency Medicine, Brigham University of California, Irvine; and Women’s Hospital; Assistant Emergency Medicine, Brigham and Management, University of Virginia John M. Howell, MD, FACEP American University, Beirut, Lebanon Professor, Harvard Medical School, Women’s Hospital, Harvard Medical Medical Center, Charlottesville, VA Clinical Professor of Emergency Boston, MA School, Boston, MA Hugo Peralta, MD Peter DeBlieux, MD Medicine, George Washington Scott D. Weingart, MD, FCCM Chair of Emergency Services, Professor of Clinical Medicine, University, Washington, DC; Director Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Hospital Italiano, Buenos Aires, Interim Public Hospital Director of Academic Affairs, Best Practices, FAAEM, FACP Medicine, Director, Division of Argentina of Emergency Medicine Services, Inc, Inova Fairfax Hospital, Falls Assistant Professor of Emergency ED Critical Care, Icahn School of Dhanadol Rojanasarntikul, MD Louisiana State University Health Church, VA Medicine, The University of Maryland School of Medicine, Medicine at Mount Sinai, New Attending Physician, Emergency Science Center, New Orleans, LA Shkelzen Hoxhaj, MD, MPH, MBA Baltimore, MD York, NY Medicine, King Chulalongkorn Francis M. Fesmire, MD, FACEP Chief of Emergency Medicine, Baylor Memorial Hospital, Thai Red Cross, Professor and Director of Clinical College of Medicine, Houston, TX Alfred Sacchetti, MD, FACEP Senior Research Editors Thailand; Faculty of Medicine, Assistant Clinical Professor, Research, Department of Emergency Eric Legome, MD Chulalongkorn University, Thailand Medicine, UT College of Medicine, Department of Emergency Medicine, James Damilini, PharmD, BCPS Chief of Emergency Medicine, Clinical Pharmacist, Emergency Suzanne Peeters, MD Chattanooga; Director of Chest Pain Thomas Jefferson University, King’s County Hospital; Professor of Room, St. Joseph’s Hospital and Emergency Medicine Residency Center, Erlanger Medical Center, Philadelphia, PA Clinical Emergency Medicine, SUNY Medical Center, Phoenix, AZ Director, Haga Hospital, The Hague, Chattanooga, TN Downstate College of Medicine, Robert Schiller, MD The Netherlands Brooklyn, NY Chair, Department of Family Joseph D. Toscano, MD Nicholas Genes, MD, PhD Medicine, Beth Israel Medical Chairman, Department of Emergency Assistant Professor, Department of Keith A. Marill, MD Center; Senior Faculty, Family Medicine, San Ramon Regional Assistant Professor, Harvard Medical Emergency Medicine, Icahn School Medicine and Community Health, Medical Center, San Ramon, CA School; Emergency Department Case Presentations positive fecal occult blood test on digital rectal examina- tion. The patient’s ECG is consistent with rate-controlled A 54-year-old Hispanic male presents to the ED with the atrial fibrillation and shows ST-segment depression in complaints of fatigue and weakness. The weakness is de- the lateral leads. The CBC reveals a hemoglobin of 4.9 g/ scribed as generalized, and the symptoms have been pres- dL and a hematocrit of 15.2%, with a normal WBC and ent and constant for the last 2 days. The patient denies platelet count, PT, INR, and aPTT. His basic chemistry hematemesis, hematochezia, dark-colored stools, hematu- panel reveals an elevated BUN of 64 mg/dL and a cre- ria, or other evidence of bleeding. He also denies chest or atinine of 2.3 mg/dL. The troponin is within the normal abdominal pain, dyspnea, diaphoresis, fever, or chills. The range. A normal saline bolus of 500 cc is administered. patient has not seen a doctor in the last 15 years and does As you call cardiology, you wonder: what is the optimal not think he has any medical conditions. The only medica- treatment for this patient’s presentation… cardiac cath- tion he has been taking is over-the-counter ibuprofen, eterization or transfusion? which he has been taking daily since he injured his back Just as you think you are getting control of the ED, a at work 2 weeks ago. The patient works as a construction 6-month-old boy is brought in by his parents for conges- laborer and denies past surgeries or allergies. His vital tion, increased work of breathing, and perioral cyanosis. signs are: blood pressure, 110/50 mm Hg; heart rate, 127 The parents state that their child is taking longer to feed beats/min; respirations, 22 breaths/min; and SpO2, 97% because he seems to be out of breath. This has been going on room

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