Acute anemia can be caused by hemorrhage or hemolysis, resulting in a precipitous drop in red blood cells. Common causes seen in the emergency department include traumatic injury, gastrointestinal bleeding, or ruptured aneurysm. Physical exam may reveal signs of blood loss or organ damage. Treatment involves fluid resuscitation, blood transfusions tailored to the cause of anemia, and treating any underlying condition causing bleeding. Goals are to restore hemodynamics and replace lost red blood cells.

1. Acute anemia
Flemin Thomas, Pharm-D

2. • Acute anemia denotes a precipitous drop in the RBC
population due to hemolysis or acute hemorrhage. In the
emergency department (ED), acute hemorrhage is by far
the most common etiology.

4. Etiology
• Depending on the etiology, this may occur with or without
reduction in the intravascular volume. It is generally
accepted that an acute drop in hemoglobin to a level of 7-
8 g/dL is symptomatic, whereas levels of 4-5 g/dL may be
tolerated in chronic anemia, as the body is able to
gradually replace the loss of intravascular volume.

5. Blood loss
• Seen in the emergency department (ED)
• Iron deficiency anemia is due to chronic slow bleeding
and nutritional deficits
• Traumatic injury, massive upper or lower gastrointestinal
(GI) hemorrhage, ruptured ectopic pregnancy, ruptured
aneurysm.

6. Hemoglobinopathy
Sickle cell anemia- In mild
sickle syndromes, the
hemoglobin level is 9-11
g/dL.
Aplastic anemia
Thalassemias

7. Red blood cell enzyme abnormality
• Glucose-6-phosphate dehydrogenase (G6PD) and
pyruvate kinase (PK) deficiency are the 2 most common
enzyme defects that cause hemolytic anemia.
• G6PD deficiency affects the pentose phosphate pathway,
and PK deficiency affects the glycolytic pathway.

8. Congenital coagulopathy
• Von Willebrand disease is the most common congenital
bleeding disorder. The disease is characterized by
deficient or defective von Willebrand factor (vWF), which
is essential for platelet adhesion.
• Hemophilia A (classic hemophilia) is caused by factor
VIII deficiency. Severe bleeding is common.
• Hemophilia B (Christmas disease) is due to a factor IX
deficiency.

9. Autoimmune hemolytic anemia
• life threatening
• The disorder is seen in association with autoimmune
diseases (eg, lupus, certain types of lymphomas and
leukemias), or it may be drug induced.

10. Acquired platelet disorder
• Thrombotic thrombocytopenic purpura (TTP)
• Idiopathic thrombocytopenic purpura (ITP)

11. Physical examination
• Assessing ongoing hemorrhage
• In patients with multiple traumas, presume that every body cavity
contains blood until investigation otherwise. The chest, abdomen,
pelvis, and extremities must undergo thorough physical
examination with imaging, as clinically indicated.
• Flank ecchymosis (GreyTurner sign) suggests retroperitoneal
hemorrhage, whereas umbilical ecchymosis (Cullen sign) suggests
intraperitoneal or retroperitoneal bleeding. Both are rare findings in
acute states.

12. • Patients with jaundice may have liver disease,
hemoglobinopathies, or other forms of hemolysis. Purpura and
petechiae suggest platelet disorders, and hemarthrosis may be due
to hemophilia. In patients with alcoholic liver disease, spider
angiomata, caput medusae, umbilical hernias, and hemorrhoids
may be prone to have reduced blood count.
• Agitation may present secondary to acute blood loss. When blood
loss exceeds 40% of total volume, the patient may lose
consciousness.

13. Advanced trauma life support classifies shock into 4 levels; particular
findings are associated with each level, as follows.
• Class I (< 15% blood loss), mild tachycardia may be present, but
blood pressure is normal.
• Class II (15-30% blood loss), tachycardia, tachypnea, and a
decreased pulse pressure are seen.
• Class III (30-40% blood loss) always leads to a measurable
decrease in blood pressure as well as a significant tachycardia and a
narrow pulse pressure.
• Class IV (≥40% blood loss) leads to patient demise unless prompt
resuscitative measures are taken. Marked tachycardia and
significantly decreased blood pressure are common findings.

14. • Organomegaly is a common finding in patients with chronic
blood disorders. A palpable spleen and an enlarged hepatic
inferior border (more than 3 cm below the right midclavicular
costal margin) may suggest chronic anemia.

15. Principles of Therapy
• Therapeutic approaches to treat anemia include blood and blood
products, immunotherapies, hormonal/nutritional therapies, and
adjunctive therapies.
• The goal of therapy in acute anemia is to restore the hemodynamics of
the vascular system and to replace lost red blood cells (RBCs). To
achieve this, the practitioner may use mineral and vitamin
supplements, blood transfusions, vasopressors, histamine (H2)
antagonists, and glucocorticosteroids.

16. Use of blood and blood products
• Correction of acute anemia often requires blood, blood
products, or both. With significant ongoing hemorrhage
or hemolysis, transfusion of blood alone is insufficient,
but providing timely transfusion to restore hemoglobin
to safe levels can prevent major complications of acute
anemia.
• RBC transfusion is the quickest way to raise the
hemoglobin concentration, that benefit must be balanced
against the significant complications associated with
transfusion.

17. Whole blood contains RBCs, platelets, and coagulation factors;
however, it is rarely used as a treatment option.
• Packed red blood cells (PRBCs) are the remaining
components of whole blood after the plasma and platelets are
removed. One unit of PRBCs is the product of 1 unit of whole
blood and has a volume of 250-300 mL(10 g/dl) . Each unit of
PRBCs is expected to raise the hematocrit level by 3 points.
• Platelet transfusion: Each unit of platelets contains 50 mL of
plasma and has normal amounts of fibrinogen and coagulation
factors. Some decrease in factors V and VII is noted in
comparison with whole blood.
• Each unit of platelets raises the platelet count by approximately
10,000/μL. The usual adult dose is 1 U/10 kg.

18. • Fresh frozen plasma (FFP) is a blood product made from the
liquid portion of whole blood. It is used to treat conditions in
which there low blood clotting factors (INR >1.5) or low
levels of other blood proteins.
• The coagulation factors are diluted. Patients with factor V and
XI deficiency and those with coagulopathies due to liver
disease.
• Cryoprecipitate is derived from the precipitate collected from
liquid FFP. It contains fibrinogen, factor VIII, von Willebrand
factor (vWF), and factor XIII. It is ideal for treatment of mild
hemophilia A and conditions that lead to afibrinogenemiae are
the best candidates for FFP administration

19. Administration of drugs and
supplements
• Gastric acid inhibitors (eg, H2receptor antagonists) are of
limited benefit for actively bleeding patients. They are
effective in promoting the healing of gastric and duodenal
ulcers and in preventing their recurrence. Some controversial
evidence exists about the utility of proton pump inhibitors
(PPIs) in preventing recurrent acute bleeding from ulcers.
• Glucocorticoids (eg, prednisone) are used to treat idiopathic
and acquired autoimmune hemolytic anemias.
• Vitamin K deficiency causes elevation of the prothrombin
time (PT) and is commonly seen in patients with liver disease.
The preferred route of administration is subcutaneous.
Intravenous administration of vitamin K should be avoided:
rapid infusions can cause dyspnea, chest pain, and even death.

20. • Propranolol and isosorbide, dinitrate are used in
combination to decrease the incidence of bleeding in some
groups of patients with esophageal varices. This combination
is not useful with acute bleeding.

21. Management Of Acute Anemia With
Etiology
• Acute anemia due to blood loss:
• Monitor with pulse oximetry, cardiac monitor, and a
sphygmomanometer. Provide supplemental oxygen via nasal
cannula or face mask. Establish 2 large-bore intravenous (IV)
lines, and rapidly infuse 12 L of crystalloid while monitoring
the patient carefully for signs and symptoms of iatrogenic
congestive heart failure.
• Consider type O or type specific blood transfusion for patients
who remain hypotensive after 2 L of crystalloid.
Ninfusion(normal saline)0.9% conc. nacl. for young healthy
patients with a hematocrit level below 20% or for elderly
patients with a hematocrit level below 30%.

22. • Vasopressors are relatively contraindicated in the treatment of
hypovolemic shock.
• Obtain fresh frozen plasma (FFP), coagulation factors, and
platelets, if indicated. Patients with hemophilia should have
samples of the deficient factors sent for measurement.
• Once the patient is stabilized, begin specific measures to treat
the underlying cause of bleeding.

23. Acute anemia due to hemoglobinopathy
• The decision to transfuse depends on the rate of fall of the
hemoglobin and the patient’s clinical condition.
• In sickle cell anemia, correction of simple anemia alone by
transfusion is adequate. Hydroxyurea can be used to reduce
sickle cell crisis. Gene therapy and bone marrow transplant are
considered potentially curative.

24. Acute anemia due to acquired platelet disorder
• Patients with thrombocytopenia who have clinical evidence of
bleeding should receive a platelet transfusion. Patients with
platelet counts lower than 10,000/μL are at risk for
spontaneous cerebral hemorrhage and require a prophylactic
transfusion.
• The preferred treatment for thrombotic thrombocytopenic
purpura (TTP) and hemolytic uremic syndrome (HUS) is large
volume plasmapheresis with FFP replacement. Many patients
require daily plasmapheresis.
• Increasing platelet count, decreasing lactate dehydrogenase
(LDH), and decreasing red blood cell (RBC) fragments
indicate a positive response to treatment.

25. Acute anemia due to congenital bleeding disorder
• Treat von Willebrand disease with cryoprecipitate. Each unit
of cryoprecipitate will raise vWF by 3%. Treat hemophilia A
with factor VIII concentrate. Treat hemophilia B with factor
IX concentrate.
• The dosage is based on the site of the bleeding.

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