Page 71 - JSOM Summer 2022

Prehospital Anemia Care

A Review of Symptoms, Evaluation, and Management

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Cody J. Rankin, CCP-C, FP-C, NRP, SO-ATP ; Thomas Fetherston ;
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Cory D. Ballentine, 18D, CCP-C, FP-C, TP-C, NRP, SO-ATP ;
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Brit S. Adams, 4N091, FP-C, NRP ; Brit Long, MD ; Brandon M. Carius, DSc, MPAS *

ABSTRACT
The ongoing evolution of prehospital medical care continues just walked 100 meters to your aid station. As your junior
to advance beyond immediate triage care. Prehospital care is medic prepares to draw a small sample of blood, you try to re-
even more important to consider in theaters with extended member which important laboratory cut-offs are relevant for
evacuation times and limited local medical assets. Although this patient and how you might provide treatment.
blood loss is often associated with settings of acute traumatic
hemorrhage in military medicine, the possibility for other he- Anemia broadly describes a variety of conditions with de-
matologic compromise necessitating urgent action requires creased proportions of functional erythrocytes, more often
medics operating in these environments to have a fundamental referred to as red blood cells (RBCs). This is diagnostically
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knowledge of the pathophysiology, manifestations, and stabi- measured by hemoglobin concentration in blood samples.
lization measures of anemia to aid their patients prior to, or in Although the World Health Organization criteria provide a
lieu of, evacuation. Continued development of and access to diagnostic threshold for anemia with a hemoglobin level of
point-of-care testing in increasingly forward-deployed settings <12g/dL in adult females and of <13g/dL in adult males, this
further enable medics to perform these tasks. Here, we provide definition is not used consistently throughout the literature
a brief review of hemoglobin function and composition, and and is inconsistent between demographic groups. 3–10 These
presentation and management considerations of anemia, to as- variations demonstrate the need for anemia to be viewed as
sist medics in their treatment efforts. We also address specific part of a broader patient assessment for optimal care.
concerns for battlefield and atraumatic presentations.
Anemia affects up to one-third of the global population, al-
Keywords: hemoglobin; anemia; prehospital care; blood loss, though prevalence may vary significantly because of geog-
hemorrhage; military; laboratory; malaria; hemolysis; bleeding; raphy, age, and gender. 3,4,6–8,11–13 Civilian frequencies range
transfusion widely from 9% in pediatric populations to as high as 47% in
geriatric patients, whereas military studies find rates between
12% and 20% in active-duty personnel. 6,11,14–17
Introduction
Stimulated by increased demand for oxygenation, renal tubular
Scenarios to consider: A 30-year-old male is carried into your cells secrete erythropoietin to drive RBC development. 2,3,18,19
aid station in remote Africa by his teammates concerned by This signal triggers bone marrow differentiation, with normo-
his complaints of dizziness throughout the day. They state that blasts expelling their nuclei during maturation to become re-
he has been sick recently and was telling people he has been ticulocytes, then losing their ribosomal networks to ultimately
sweating more than usual at night. There has been a signifi- become functional RBCs approximately 3–4 days later. 1,2,20
cant increase in mosquitos because of increased rain 1 week A healthy RBC averages a circulation of approximately 120
ago. You have an i-STAT handheld blood analyzer (Abbott) days, after which a natural degradation cycle occurs, eventu-
at your disposal among some other basic laboratory testing ally leading to destruction by the immune system via the liver
equipment. What are your concerns? What tests would help and spleen. 1,18–21 Approximately 0.8% of all circulating RBCs
you evaluate this patient? are destroyed in this process every day, releasing biliverdin
(later converted into bilirubin) and free iron. 2,9,18,19 Inside each
A 26-year-old female comes into your aid station complaining healthy RBC, four hemoglobin chains bind, exchange, and
of ongoing vaginal bleeding, with a longer and heavier than transport oxygen and carbon dioxide via the iron-containing
usual menstrual cycle that is now on its ninth day. She denies heme ring complex. 1–3,22
any history of similar events or known bleeding disorders. She
is pale, and you notice that her heart rate of 120 beats per Both hereditary and environmental factors can affect the
minute is not appropriate for an otherwise healthy female who normal function of hemoglobin and subsequently impair the
*Correspondence to brandon.m.carius.mil@mail.mil
1 SGT Cody J. Rankin is affiliated with the United States Army Special Operations Command, Fort Campbell, KY. 2LT Thomas Fetherston is
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affiliated with the Icahn School of Medicine, Mount Sinai, New York, NY. SFC Cory D. Ballentine is affiliated with Special Forces Operational
Detachment Alpha 3331, 3rd Special Forces Group (Airborne), Fort Bragg, NC. SMSgt Brit S. Adams is affiliated with the Defense Health
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Agency (J3), Combat Support /Joint Trauma System, Washington, DC. MAJ Brit Long is affiliated with Brooke Army Medical Center, Joint
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Base San Antonio–Fort Sam Houston, TX. MAJ Brandon M. Carius is affiliated with the Department of Emergency Medicine, Madigan Army
Medical Center, JBLM, WA.
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