Why it matters
Fatigue is one of the most common ED complaints — and one of the easiest to dismiss. But sometimes “just tired” hides life-threatening pathology. Severe anemia can masquerade as vague fatigue until the patient tips into shock, arrhythmia, or myocardial ischemia. Rookies must learn to dig deeper when the story doesn’t fit.
1) The 30-second story
- Patient presents with weakness, fatigue, or “can’t get out of bed.”
- May have pallor, tachycardia, or dyspnea on exertion.
- History often vague: “just not myself.”
- Can be the tip of the iceberg for GI bleed, malignancy, chronic disease, or hemolysis.
2) Quick differential
- Severe anemia (bleeding, hemolysis, chronic disease, malignancy).
- Cardiac: CHF, arrhythmia, ACS.
- Pulmonary: COPD, pneumonia.
- Endocrine/metabolic: hypothyroidism, electrolyte disorders, adrenal insufficiency.
- Psychiatric: depression, burnout, functional causes.
3) Red flags 🚨
- HR >110, RR >20, SpO₂ <94%.
- Syncope, chest pain, dyspnea at rest.
- Pallor, conjunctival pallor.
- Orthostatic hypotension.
- Melena, hematochezia, hematemesis.
- Known cancer or recent chemo.
- Anticoagulant use.
4) Bedside exam & first steps
- Vitals: tachycardia, hypotension, tachypnea.
- General appearance: pale, fatigued, dyspneic.
- Cardiac exam: flow murmur from anemia.
- Abdominal exam: tenderness, hepatosplenomegaly, melena on rectal exam.
- Skin: pallor, petechiae, bruising.
5) Investigations
- CBC: Hb/Hct, MCV, reticulocyte count.
- BMP/LFTs: renal/liver disease.
- Coagulation panel: if bleeding risk.
- Iron studies, B12, folate: if chronic process suspected.
- Type and cross: prepare for transfusion.
- Stool occult blood or GI workup if bleed suspected.
6) Management in the ED
- Symptomatic or unstable (Hb <7 g/dL, or <8 g/dL with CAD/CHF):
- Transfuse packed RBCs (1 unit → ~1 g/dL rise in Hb).
- Correct underlying cause (bleeding source, hemolysis, nutritional deficiency).
- Stable with chronic anemia:
- May not require transfusion; admit or arrange close follow-up for workup.
- Massive bleed suspected:
- Activate massive transfusion protocol, consult GI/surgery.
7) Disposition
- Admit: symptomatic anemia, Hb <7, ongoing bleeding, hemodynamic instability, unclear source, elderly/comorbid.
- Discharge: stable mild/moderate anemia, reliable outpatient follow-up, no red flags.
Rookie pearls
- Never dismiss “just tired” in elderly — check Hb.
- Always look for the source: GI bleed is most common hidden culprit.
- Transfusion threshold: 7 g/dL (unless cardiac disease, then 8).
- Flow murmur in a pale patient = think anemia.
- Don’t forget rectal exam — melena/hematochezia can clinch the diagnosis.
Common pitfalls
- Discharging without labs because complaint is vague.
- Anchoring on “psych fatigue” and missing severe anemia.
- Forgetting to type & cross before transfusion.
- Over-transfusing chronically anemic but stable patients.
- Missing GI bleed in patients on anticoagulation.
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