After the second time she passed out, her children decided to call 9-1-1. You and your partner arrive to find Mrs. Harper lying on the couch in the front room. She appears to be sleeping but opens her eyes as you approach. Her children are quick to tell you they’re home from college and are concerned about their mother. Since they’ve been home, they’ve noticed their mother has been tired and listless. They tell you she seems to be short of breath with minimal exertion; after the second time she passed out, they decided to call for help even though their mother denies any complaint.
Your initial assessment reveals a female who’s in her late 40s and is awake and oriented but slow with her responses stating she’s “just tired.” Her pulse is strong, and her skin is warm but appears pale. She admits to being mildly dyspneic with exertion and very tired, attributing this to being busy with work and home. After obtaining vital signs, your partner reports the patient’s pulse is 96 and occasionally irregular. Blood pressure is 138/90 and respirations are 18. Breath sounds are clear and pulse oximetry reads 98% on room air.
Your partner asks you, “What are you thinking? Stroke, heart attack, blood loss?”
With further questioning, the patient continues to deny other complaints—no nausea, vomiting, dark or bloody stools, and no recent traumatic events. She laughs at you when you ask whether there’s a chance she’s pregnant, stating she’s divorced and not sexually active. She denies any significant medical history and doesn’t take any medications. Physical assessment reveals a soft, non-tender abdomen and no chest-wall tenderness or pain with respirations. The cardiac monitor shows sinus with an occasional premature atrial contraction. A Cincinnati Stroke test is negative, and her dizziness doesn’t seem to be positional. Your significant findings are limited to pale skin, being weak and tired and non-specific air hunger.
Mrs. Harper agrees to be transported. You apply oxygen at 4 liters per minute and establish an IV set at KVO. The oxygen makes Mrs. Harper feel “better,” and other than that, there are no changes during transport. Calling for a follow-up on the patient several hours later, you learn that Mrs. Harper had a low red blood cell (RBC) count. She was anemic.
Red Blood Cells
The body uses the RBC, also known as an erythrocyte, to transport oxygen to cells. RBCs are the most abundant cell in the blood accounting for about 99% of all formed elements in the blood. The average adult male will have about 5.4 million RBC for each cubic millimeter of blood, and the adult female has about 4.8 million RBC per cubic millimeter of blood. The measurement of total RBCs in the blood is expressed as hematocrit with 40–52% being a normal value for the adult male and 35–47% being normal for the adult female.1
The RBC is a biconcave disk that has no nucleus. The protein hemoglobin in the RBC gives the blood its red color and is responsible for transporting the oxygen. The approximately 280 million hemoglobin molecules on each RBC carry oxygen, and because the RBC doesn’t have a nucleus, it uses none of the oxygen it carries—the perfect pack mule. The RBC has a life span of about 120 days. Thus, RBCs are rapidly reproduced in the bone marrow, triggered by a substance known as erythropoietin. When the total number of RBCs is decreased, the patient is anemic.2
Anemia is a sign of an underlying condition. One of the more common causes of anemia, especially in women and children, is iron deficiency. Other causes include blood loss, liver disease, vitamin B12 deficiency and cancer. Anemia occurs because of a slow or altered production of RBCs, destruction of RBCs or loss of RBCs as with hemorrhage. The signs of anemia may be subtle and in some cases will be the first sign of an underlying condition. In other words, a patient may meet with their physician because of weakness and discover they’re anemic. Further evaluation may reveal the root cause to be leukemia. Common signs and symptoms include chest pain, weakness, dyspnea and pallor.
Unless the underlying cause is hemorrhage, the blood pressure should be within a normal range. Pulse oximetry may read high even though the body is hypoxic because pulse oximetry measures the percent of RBC bound with oxygen. The problem in anemia is that there isn’t enough RBC even though they may all be bound with oxygen. In the case of sickle cell anemia, the RBC structurally changes to a rigid sickle shape, which can block blood supply to distal tissues and organs. Patients with sickle cell crisis present with systemic pain and are at risk for myocardial infarction and stroke.
Treatment for anemic patients includes maximizing oxygenation and making the patient comfortable. Remember one of the underlying causes is undiagnosed bleeding, so the patient may require fluid resuscitation. Make the patient comfortable as allowed within your protocols, including the administration of pain medications as warranted. Transport to the emergency department keeping in mind that what’s presenting as just weak and tired may actually be the signs of a life-threatening illness.
1. Marx J, Hockberger R, Walls R: Rosen’s Emergency Medicine Concepts and Clinical Practice, Sixth Edition. Elsevier: St. Louis, 2006.
2. Tortora G: Principles of Anatomy and Physiology. Harper Collins: New York, 1996.