Anemia in the ED: Running on Empty

-Case-
A 52-year-old woman with a history of heavy menstrual bleeding presents to the ED with progressive fatigue, dizziness, and dyspnea on exertion. She denies chest pain or syncope. Vitals show HR 105, BP 110/70, RR 18, and SpO2 97% on room air. Her CBC reveals a hemoglobin of 5.8 g/dL. 

-Evaluation-
Anemia is a common ED finding and can range from an incidental lab result to a life-threatening emergency.

  • By definition anemia is a hemoglobin <13.0 g/dL (men) or <12.0 g/dL (women)
  • Classification by MCV:
    • Microcytic (<80): often due to iron deficiency, thalassemia
    • Normocytic (80-100): think acute blood loss, anemia of chronic disease
    • Macrocytic (>100): clue in on B12/folate deficiency, liver disease, alcoholism
  • Key Symptoms:
    • Fatigue, weakness, dizziness
    • Dyspnea, palpitations, chest pain
    • Pallor, tachycardia, orthostasis
  • Key Labs:
    • CBC with differential
    • Reticulocyte count (elevated = compensation)
    • Iron studies, B12/folate levels if indicated based on MCV
    • Hemolysis labs: LDH, haptoglobin, bilirubin

Diagnosis in the ED:

  • Determine acuity: chronic vs acute
  • Evaluate hemodynamic status: tachycardia, hypotension, hypoxia
  • Identify cause: bleeding source (GI, vaginal, trauma), hemolysis, malignancy

-Management-

  • Transfuse if unstable or Hgb <7 g/dL (or <8 g/dL in cardiac patients)
  • Type and screen, crossmatch
  • Address underlying cause: GI bleeding, menorrhagia, trauma, etc.
  • Iron, folate, or B12 supplementation if deficiency suspected and stable
  • Consider admission for ongoing transfusion or diagnostic workup

-Fast Facts-

  • Anemia is a sign, not a diagnosis—always investigate the cause
  • Acute anemia from blood loss can cause normal initial Hgb
  • Beware subtle signs of hemodynamic compromise in the elderly
  • Hemolysis or malignancy should be considered in normocytic anemia with elevated LDH and indirect bilirubin

Patients may come in for fatigue, but it isn’t just burnout. In the ED, anemia is common, but your job is to identify who’s stable and who’s crashing. Understand the classification, hunt for the source, treat the numbers – but more importantly, treat the patient!

Want to learn more? Listen to our in-depth podcasts and read our high-yield study guides on other EM topics!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol. 2014;89(1):88–96. doi:10.1002/ajh.23598
  2. Musallam KM, Tamim HM, Richards T, et al. Preoperative anemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. 2011;378(9800):1396–1407. doi:10.1016/S0140-6736(11)61381-0
  3. Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood. 2004;104(8):2263–2268. doi:10.1182/blood-2004-05-1812
  4. Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005;352(10):1011–1023. doi:10.1056/NEJMra041809
  5. Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2016;10(10):CD002042. doi:10.1002/14651858.CD002042.pub4
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