Pediatric emergency medicine trisk 2182 2182

BLOOD LOSS
CLINICAL PEARLS AND PITFALLS
In acute hemorrhage, measured hemoglobin changes may lag behind blood
loss, and normal values should not provide reassurance against clinically
significant blood loss.

Clinical Considerations
Clinical Recognition
Anemia due to blood loss occurs from a variety of causes ( Fig. 93.1 ). Overall, these
conditions are divided into traumatic or atraumatic bleeding. The possibility of occult
nonaccidental trauma must always be considered, particularly in younger children.
Gastrointestinal hemorrhage is the most common cause of atraumatic blood loss, but
postsurgical (e.g., posttonsillectomy hemorrhage), renal, gynecologic, and other
etiologies may also present. In some cases, an anatomic lesion or process may combine
with a congenital or acquired coagulopathy to precipitate significant anemia. For
example, adolescent girls with unrecognized von Willebrand disease (VWD) may
present with anemia due to both acute and chronic blood loss during menses.
Assessment for anemia should be considered in any patient with pallor, jaundice, or
unexplained tachycardia. Asymptomatic chronic anemia may be detected as an
incidental finding that requires further evaluation.
Triage
Known or suspected anemia due to blood loss, hypotension, hypoxia, or evidence of
end-organ dysfunction is a medical emergency and warrants immediate intervention to
prevent progression to cardiopulmonary collapse. Patients with both acute and chronic
blood loss may become unstable. The chronicity of symptoms should not reassure the
clinician, as it may be the exhaustion of physiologic compensatory mechanisms that
prompts the patient to present to medical attention.
Initial Assessment
Initial assessment of a patient presenting with anemia secondary to blood loss includes a
focused history targeted at symptoms of compromise related to anemia/hypoxia as well
as potential etiologies. In suspected blood loss, the clinician must assess for evidence of

trauma including nonaccidental injury, postprocedure bleeding, symptoms of upper or
lower gastrointestinal bleeding, medication use that could precipitate gastrointestinal
bleeding, reports of epistaxis, hematuria or menorrhagia, and any concern for
complications of pregnancy or hemorrhagic ovarian cyst. Inquiries in the history related
to symptomatic anemia should include fatigue, exercise intolerance, syncope,