Teaching Rounds Day 3
Anemia - Part 1
Neighbors and Time Zones...
Join us #medtwitter & #medstudenttwitter
Anemia - Part 1
Neighbors and Time Zones...
Join us #medtwitter & #medstudenttwitter
Claim:
It's nearly impossible to have an approach to anemia.
Yup, impossible.
It's as tough as having an approach to altered mental status?
Wait, what?
Wasn't that the VERY first @cpsovlers episode?
And...what about this schema??
It's nearly impossible to have an approach to anemia.
Yup, impossible.
It's as tough as having an approach to altered mental status?
Wait, what?
Wasn't that the VERY first @cpsovlers episode?
And...what about this schema??
Well, we lied.
Sort of.
That's an approach to ACUTE altered mental status.
Not just any old altered mental status....
Sort of.
That's an approach to ACUTE altered mental status.
Not just any old altered mental status....
The time course changes everything....
An approach to anemia?
Impossible.
An approach to acute anemia?
For sure. Coming your way momentarily.
An approach to chronic anemia?
You go it!
You can't really efficiently tackle ANY problem without the "When"....
Impossible.
An approach to acute anemia?
For sure. Coming your way momentarily.
An approach to chronic anemia?
You go it!
You can't really efficiently tackle ANY problem without the "When"....
The time zone...acute or chronic?
So, how do we figure this out?
Sometimes we get lucky and there is a recent HgB on file.
Plenty of other tools that are a little bit less precise...
So, how do we figure this out?
Sometimes we get lucky and there is a recent HgB on file.
Plenty of other tools that are a little bit less precise...
Yup.
All these other clues are imperfect...
including the reticulocyte index.
More on this concept here - bit.ly/2uP5B5H
Let's zoom out to the big picture:
A lot of reticulocytes mean the bone marrow is alive, well, healthy and NOT the cause of anemia
All these other clues are imperfect...
including the reticulocyte index.
More on this concept here - bit.ly/2uP5B5H
Let's zoom out to the big picture:
A lot of reticulocytes mean the bone marrow is alive, well, healthy and NOT the cause of anemia
So:
Reticulocytosis --> bone marrow is fine -->
LOSS of of RBCs, not production, is on the hook for the anemia.
HgB LOSS usually results in an ACUTE anemia.
Are there exceptions to this retic story?
You bet:
1. It's too soon.
2. There's no EPO.
Reticulocytosis --> bone marrow is fine -->
LOSS of of RBCs, not production, is on the hook for the anemia.
HgB LOSS usually results in an ACUTE anemia.
Are there exceptions to this retic story?
You bet:
1. It's too soon.
2. There's no EPO.
1. Too soon - it takes retics a couple of days to ramp up...
2. No EPO - patients with advanced CKD don't have the EPO required to ramp up retic production if they experience HgB loss
Other reasons for a falsely low retic count, #medtwitter?
2. No EPO - patients with advanced CKD don't have the EPO required to ramp up retic production if they experience HgB loss
Other reasons for a falsely low retic count, #medtwitter?
It's tough to be 100% sure but these clues usually give us a robust working hypothesis re: acute versus chronic
If you are on the fence, assume ACUTE anemia..
That's a good general rule of thumb for any disease process-
Acute disease often has more morbidity than chronic.
If you are on the fence, assume ACUTE anemia..
That's a good general rule of thumb for any disease process-
Acute disease often has more morbidity than chronic.
A notable exception?
Hyponatremia
As @medrants would remind us, if you don't know the time course of hyponatremia, assume it's chronic and correct it slowly...
So many tangents, Rabih.
Ok..Ok....
Reeling myself in...
Let's set our sights on Acute Anemia.
Hyponatremia
As @medrants would remind us, if you don't know the time course of hyponatremia, assume it's chronic and correct it slowly...
So many tangents, Rabih.
Ok..Ok....
Reeling myself in...
Let's set our sights on Acute Anemia.
Acute Anemia...
From the 10,000 foot view...a pretty simple DDx.
1. Bleeding
2. Hemolysis &
3. Acute bone marrow disease -
e.g., acute myeloid leukemia
From the 10,000 foot view...a pretty simple DDx.
1. Bleeding
2. Hemolysis &
3. Acute bone marrow disease -
e.g., acute myeloid leukemia
Bleeding gets immediate priority....
And as @sargsyanz and @EM_RESUS would remind us, the HgB can be completely NORMAL in the setting of hyperacute blood loss
And as @sargsyanz and @EM_RESUS would remind us, the HgB can be completely NORMAL in the setting of hyperacute blood loss
No evidence of bleeding?
The LDH, bilirubin, AST: ALT ratio, & haptoglobin help us zero in on acute hemolysis.
Don't forget to examine the scene of the crime, the peripheral smear.
@CPSolvers approach here:
bit.ly/3ctxHV2
The LDH, bilirubin, AST: ALT ratio, & haptoglobin help us zero in on acute hemolysis.
Don't forget to examine the scene of the crime, the peripheral smear.
@CPSolvers approach here:
bit.ly/3ctxHV2
Within the hemolytic anemias, pay particular attention to the MAHAs - microangiopathic hemolytic anemia.
Untreated, they are incredibly morbid.
And @Sharminzi has got your back.
Check out her @CPSolvers schema video here -
bit.ly/2x6DXC4
Untreated, they are incredibly morbid.
And @Sharminzi has got your back.
Check out her @CPSolvers schema video here -
bit.ly/2x6DXC4
So, we've thought about bleeding & hemolysis.
Time to chat about acute bone marrow disease....
Ever ordered JUST a hemoglobin?
Yes...just a HgB.
Probably not.
Use the WBC and Platelet count to your advantage.
If they are are also low...
Time to chat about acute bone marrow disease....
Ever ordered JUST a hemoglobin?
Yes...just a HgB.
Probably not.
Use the WBC and Platelet count to your advantage.
If they are are also low...
We've just entered the world of pancytopenia..
Side note: I can't WAIT to chat about that.
But, yes, no tangents. No tangents, Rabih.
If your patient has acute pancytopenia, worry about the bone marrow...
The smear is a window into the bone marrow, don't forget to peak.
Side note: I can't WAIT to chat about that.
But, yes, no tangents. No tangents, Rabih.
If your patient has acute pancytopenia, worry about the bone marrow...
The smear is a window into the bone marrow, don't forget to peak.
OK seriously....that was a ton of info!
Time for a break before we recap...
Time for a break before we recap...
1. An approach to anemia?
Impossible.
You need a time course.
2. A prior HgB is super helpful. If we don't have it,
many imperfect clues point us to acute or chronic.
If you aren't sure, assume ACUTE disease.
3. Acute anemia =
Bleeding
Hemolysis or
Acute marrow disease
Impossible.
You need a time course.
2. A prior HgB is super helpful. If we don't have it,
many imperfect clues point us to acute or chronic.
If you aren't sure, assume ACUTE disease.
3. Acute anemia =
Bleeding
Hemolysis or
Acute marrow disease
Alright team...enough for today.
We'll have plenty of #spacedlearning opportunities to lock in some of these concepts.
Expect no more than 20% retention on round 1.
Join us tomorrow, where we shift gears and talk about chronic anemia and wonders of the bone marrow factory...
We'll have plenty of #spacedlearning opportunities to lock in some of these concepts.
Expect no more than 20% retention on round 1.
Join us tomorrow, where we shift gears and talk about chronic anemia and wonders of the bone marrow factory...
Part 2 - here!
