APPROACH TO ANEMIA

Question 1

Approach to the Critically Ill Anemia

Answer 1

AIRWAY:
Evaluate airway stability
Profound anemia -> hypoxia -> mental status change -> failure to protect airway

BREATHING:
Supplement hypoxia with oxygen until transfusion

Beware TACO or TRALI with transfusion

CIRCULATION:
Type and Cross
OR
Administer 2U O- blood

Massive transfusion:
Apply 1:1:2 FFP:platelets:PRBC

DISABILITY:
FND can occur with anemia and preexisting carotid or CV disease

EXPOSURE:
Identify external signs of hemorrhage
GI bleed

Question 2

Pathophysiology

Answer 2

Hemorrhage
Impaired Production
Hemolysis

Question 3

History & Physical

Answer 3

Ask About:
Bleeding
Trauma
Surgery
B symptoms
Drugs
Recent Illnesses
Diet
Recent Surgery

Medications (NSAIDS, ASA, anticoags)
Alcohol intake

Dyspnea on Exertion
Exertional Chest Pain
Faintness / Light head
Syncope / Presyncope
Palpitations
Fatigue

Look for:

HR: Tachycardia
RR: Tachypnea
BP: HoTN

Pallor Palpebral Conjunctivae >92% sensitive
Koilonychia
Petechiae / Purpura
Jaundice
Murmur
Hyperdynamic precordium
Enlarged lymph nodes
Enlarged spleen (hemolysis)
DRE
Proprioception deficits (Romberg)

Question 4

4 Red Flags

Answer 4

Tachycardia
Hypotension
Hypothermia
Decreased LOC

Question 5

DDx: RBC Loss

Answer 5

Hemorrhage

Question 6

DDx: Microcytic Anemia (MCV < 80)

Answer 6

TAILS
* Thalassemia
* Anemia of Chronic Inflammation
* Iron Deficiency
* Lead Poisoning
* Sideroblastic Anemia

Question 7

D/Dx: normocytic anemia with an elevated reticulocyte count (RBC > 2%)

Answer 7

Hemorrhage
Hemolysis

Question 8

D/Dx: normocytic anemia with a decreased reticulocyte count (RBC < 2%)

Answer 8

CKD
Marrow Disorder (Pure Red Cell Aplasia)
Marrow Suppression (↓WBC, ↓platelets)
Infiltrative (leukemia, infection)
Anemia of chronic disease
Sequestration
Pregnancy
Endocrinopathy

Question 9

D/Dx: hemolytic anemia

Answer 9

Heriditary:
G6PD
sickle cell disease
thalassemia
spherocytosis

Acquired:
MAHA
Autoimmune hemolytic anemia (AHI)
thrombotic thrombocytopenic purpura (TTP)
Hemolytic Uremic Syndrome (HUS)
DIC
PNH

malaria
Babesiosis
Brown Recluse Spider

Question 10

Workup

Answer 10

Serum Hemoglobin
Mean Cell Volume
Consider platelets (r/o pancytopenia)
Reticulocyte Count
Red Cell Districution Width (RDW)

Microcytic:
Serum Ferritin
Serum Iron
Total Iron Binding Capacity

Macrocytic:
B12
Folate

Normocytic Anemia:
Peripheral Blood Smear
Beta-HcG
Hb Electrophoresis
LDH
Bilirubin
Haptoglobin
Consider COOMB’s test
TSH
SPEP
DIC Panel

Question 11

2 specific adjunct investigations

Answer 11

Colonoscopy
Bone Marrow Biopsy

Question 12

4 specific labs when suspecting hemolysis

Answer 12

LDH
Haptoglobin
Indirect Bili
Blood Smear: Red Cell Fragmentation, Tear Drop RBC, Microspherocytes
Fibrinogen

Question 13

Workup: Microcytic anemia with normal ferritin

Answer 13

HGB electrophoresis (Thalasemia)
ESR, CRP (Inflamatory disease)
Smear (sideroblastic

Question 14

Managment: Anemia on a blood thinner

Answer 14

1. Don’t stop if mechanical valve
2. VTE less than three months ago
3. AF with mitral stenosis
4. AF CHADS 1-4
5. VTE more than 3 months ago