When considering the signs and symptoms characteristic of anemia, it is useful to stratify patients into one of two groups: those with chronic or non-emergent anemia and those with more acute emergent anemia.
Patients with non-emergent anemia may present with vague, non-specific complaints that make diagnosing anemia difficult on clinical grounds alone.
When the progression of anemia is very slow, the patient may be able to adapt via the normal compensatory mechanisms until hemoglobin concentration is very low. Symptoms can include fatigue, weakness, dizziness, lethargy, cold intolerance, decreased exercise tolerance, dyspnea with exertion, headache and chest pain. A patient with a history of angina may report chest pain that is more severe in the presence of anemia.
If questioned, the patient may describe a history of poor nutrition or vegetarianism, both of which can result in vitamin deficiency. Question the patient about any possible chronic bleeding from gastrointestinal (GI) sources, frequent epistaxis, abnormal menses, pregnancies or abortions. Inquire about any episodes of hemoptysis, epistaxis, hematuria or abnormal bruising.
Clinical exam findings include pallor to the skin, nailbeds or conjunctiva. Jaundice can occur secondary to hemolytic causes of anemia as the waste products of RBC metabolism, such as bilirubin, accumulate. In addition to jaundice, an enlarged spleen (splenomegaly) may be palpable in cases of hemolytic anemia as the spleen becomes engorged with RBCs and debris. As a result of the sympathetic response to developing anemia, tachycardia, a bounding pulse and widened pulse pressure may be present.
The most common cause of acute or emergent anemia is blood loss.3 In cases of acute, emergent anemia, all of the signs and symptoms listed above may be present. In cases of trauma or extensive hemorrhage secondary to medical procedures, the source of blood loss may be obvious.
In the absence of obvious sources of hemorrhage, question the patient about any history of GI bleeding evidenced by hematemesis, hematochezia or melena. Be sure to ask females about heavy menses or intercycle vaginal bleeding. Severe weakness, lethargy and dizziness may progress to near-syncope, syncope, altered mental status and loss of consciousness. In addition, dyspnea and chest pain may be present while at rest.
Patients may experience exacerbations of their underlying illnesses such as cardiovascular and respiratory disease, which can also reduce their ability to compensate for acute blood loss. Tachycardia, hypotension and an increased respiratory rate will be present to a degree, dependent on the severity of blood loss and the patient’s ability to compensate. Oxygen saturation may be normal in anemic patients who are without respiratory pathology, as it is only a reflection of the percentage of hemoglobin saturated, not the amount of hemoglobin present.
Prehospital management of the anemic patient varies, depending on the clinical manifestations and complaints present.
The patient should be placed in a position of comfort and be kept warm. For patients with signs or symptoms that suggest possible life-threatening conditions (hypotension, pallor, cyanosis, chest pain, dyspnea, etc.), administer oxygen, initiate IV access and monitor cardiac status during transport.
If the patient complains of chest pain or discomfort, perform a 12-lead ECG and administer an aspirin. Oxygen should be provided via an appropriate delivery device based on the FiO2 desired. Specifics regarding IV access should be determined based on the patient’s hemodynamic status and the etiology of the anemia. For example, hypovolemic anemia secondary to a GI hemorrhage would necessitate large-bore IV access to allow for rapid fluid volume administration in the prehospital environment and possible administration of blood or blood products in the emergency department.