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INTRODUCTION

Blood loss causes anemia by two main mechanisms: (1) by the direct loss of red cells; and (2) if the loss of blood is protracted, it will gradually deplete iron stores, eventually resulting in iron deficiency. The latter type of anemia is covered in Chap. 93; here, we are concerned with the former type, that is, posthemorrhagic anemia, which follows acute blood loss. This can be external (e.g., after trauma or obstetric hemorrhage) or internal (e.g., from bleeding in the gastrointestinal tract, rupture of the spleen, rupture of an ectopic pregnancy, subarachnoid hemorrhage). In any of these cases, after the sudden loss of a large amount of blood, there are three clinical/pathophysiologic stages. (1) At first, the dominant feature is hypovolemia, which poses a threat particularly to organs that normally have a high blood supply, like the brain and the kidneys; therefore, loss of consciousness and acute renal failure are major threats. It is important to note that at this stage an ordinary blood count will not show anemia because the hemoglobin concentration is not affected. (2) Next, as an emergency response, baroreceptors and stretch receptors will cause release of vasopressin and other peptides, and the body will shift fluid from the extravascular to the intravascular compartment, producing hemodilution; thus, the hypovolemia gradually converts to anemia. The degree of anemia will reflect the amount of blood lost. If after 3 days the hemoglobin is, for example, 7 g/dL, it means that about half of the entire blood has been lost. (3) Provided bleeding does not continue, the bone marrow response will gradually ameliorate the anemia. In this phase of the process, the reticulocyte count and erythropoietin levels will be elevated.

The diagnosis of acute posthemorrhagic anemia (APHA) is usually straightforward, although sometimes internal bleeding episodes (e.g., after a traumatic injury), even when large, may not be immediately obvious. Whenever an abrupt fall in hemoglobin has taken place, whatever history is given by the patient, APHA should be suspected. Supplementary history may have to be obtained by asking the appropriate questions, and appropriate investigations (e.g., a sonogram or an endoscopy) may have to be carried out.

TREATMENT

TREATMENT Anemia Due to Acute Blood Loss

With respect to treatment, a two-pronged approach is imperative. (1) In many cases, the blood lost needs to be replaced promptly. Unlike with many chronic anemias, when finding and correcting the cause of the anemia is the first priority and blood transfusion may not be even necessary because the body is adapted to the anemia, with acute blood loss the reverse is true; because the body is not adapted to the anemia, blood transfusion takes priority. (2) While the emergency is being confronted, it is imperative to stop the hemorrhage and to eliminate its source.

In an acute hemorrhage situation, plasma may be preferred to saline for volume expansion since dilution of clotting factors with crystalloid may ...

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