causes of fever during transfusions, including acute

intravascular hemolysis, sepsis, or TRALI. The differential

for hypotension during transfusion includes ongoing

hemorrhage, hemolytic transfusion reaction, anaphylaxis,

sepsis from bacterial contamination, and TRALI. Shortness

of breath is seen in anaphylaxis, hemolytic transfusion

reaction, volume overload, TRALI, and sepsis. Wheezing

may be noted in anaphylaxis, volume overload, or TRALI.

Anaphylaxis is often associated with urticaria (unlike

acute intravascular hemolysis or sepsis) and usually is not

associated with fever. Volume overload or TRALI may

present with isolated shortness of breath, pulmonary

edema, and/or hypoxia without other systemic findings

such as fever or hypotension. A high index of suspicion

and broad differential is required in all cases, particularly

when the patient experiences any new symptom in the

setting of current or recent transfusion.

TREATMENT

When blood products are being transfused, they should be

administered at a slow rate for the first 30 minutes to allow for

early identification of a possible reaction. If a transfusion reaction is suspected, the first step is to immediately STOP the

transfusion. Check the labels on the blood products and

patient, and send blood samples from both the patient and

the blood products to the blood bank for further analysis.

Treatment modalities for each individual type of reaction

follow.

Acute intravascular hemolysis. Stop the transfusion

immediately. Resuscitate volume aggressively with

crystalloid intravenous (IV) fluid. Administer diuretics to

maintain urine output 1-2 mL/kg/hr. Vasopressors should

be initiated if hypotension is refractory to IV fluids. Send

blood and urine specimens to the lab per hospital protocol.

Anaphylaxis. Stop the transfusion immediately. Rapidly

resuscitate with crystalloid IV fluids and administer

epinephrine 0.3 mg (1:1,000) subcutaneously (SQ)/intramuscularly (IM), methylprednisolone 125 mg IV, diphen ­

hydramine 50 mg IV, famotidine 20 mg IV, and albuterol

5 mg in 3 mL of saline nebulizer. Repeat epinephrine as

needed, and consider starting an epinephrine drip if

necessary.

Sepsis. Stop the transfusion immediately. Pan-culture

the patient and treat with copious crystalloid IV fluids,

broad-spectrum antibiotics, and vasopressors as needed

for refractory hypotension. Follow the appropriate sepsis

protocol at your institution.

TRALI. Stop the transfusion immediately. Administer

oxygen and gently diurese. Many patients require

noninvasive positive pressure ventilation, and severe

cases may require intubation and mechanical ventilation.

Massive transfusion coagulopathy. Administer FFP

and platelets to reverse coagulopathy and thrombocytopenia. Some hospitals have protocols in massive PRBC

transfusion that include platelets and FFP in fixed ratios.

Treat hypothermia by warming all blood products to room

temperature, coadministration of warm crystalloid IV

fluid, and external rewarming measures such as warming

blankets. Treat hypocalcemia with IV calcium gluconate.

Simple febrile reaction. Stop the transfusion. Treat

with antipyretics such as acetaminophen. Restart the

transfusion only after ruling out acute hemolysis or sepsis

from bacterial contamination.

Urticaria. Treat with an antihistamine such as

diphenhydramine, and consider a short course of steroids

if the rash is severe. The transfusion does not need to be

stopped if isolated urticaria occurs, without fever or

anaphylaxis.

Delayed extravascular hemolysis. Usually no specific

treatment is required; often observed as outpatient.

Graft -versus-host disease. Bone marrowtransplantation

is the only effective treatment. Prevention is the most useful

strategy by transfusing leukocyte-reduced blood in immunocompromised or related recipients.

DISPOSITION

� Admission

Patients with persistent vital sign abnormalities or ongoing

hemorrhage require admission to a monitored setting in a

telemetry or intensive care unit. Additionally, any patients

with findings of intravascular hemolysis, anaphylaxis,

sepsis, TRALI, massive transfusion reactions, or volume

overload should be admitted to a monitored setting.

� Discharge

Although many patients receiving blood transfusions in

the ED already require admission, hemodynamically stable

patients without ongoing hemorrhage may be safely

discharged home in the absence of a transfusion reaction.

Patients who experience a simple febrile reaction or

urticarial rash may require a period of observation, but can

still be discharged safely in most circumstances.

SUGGESTED READING

Coil CJ, Santen SA. Transfusion therapy. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine, A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 1 493-1 500.

Emery M. and blood components. In: Marx J A, Hockberger RS,

Walls RN. Rosen's Emergency Medicine, Concepts and Clinical

Practice. 7th ed. Philadelphia, PA: Mosby Elsevier, 201 0, pp.

42-46.

Anticoagu lant Therapy

and Its Comp lications

joanne C. Witsil, PharmD

Key Points

• In the anticoagulated patient, have a low threshold to

obta in imaging studies after trauma.

• When initiating warfarin therapy, coadministration with

heparin or low-molecular-weight heparin (3-5 days) is

necessary to avoid a paradoxical hypercoagulable state.

INTRODUCTION

Use of anticoagulation therapy and complications related

to their usage are frequently encountered in the emergency

department (ED). Anticoagulant therapies commonly

seen include heparin, low-molecular-weight heparin

(LMWH), warfarin, and the direct thrombin inhibitor

dabigatran etexilate. These agents are used frequently

in patients with acute coronary syndrome (ACS), venous

thromboembolism (VTE), valve replacement, and atrial

fibrillation (AF). When administered in the appropriate

clinical setting, anticoagulant medications prevent morbidity and mortality. For example, the risk of stroke in

patients with AF and structural heart disease is 5% a year

but is reduced by 70% with the use of chronic oral anticoagulation therapy.

Anticoagulants are not without complications, however. In patients taking warfarin, up to 1 5% will suffer a

bleeding complication, 4.9% will develop a major bleeding

complication, and approximately 1 o/o will develop a fatal

complication annually. The risk of a bleeding complication

from heparin use is approximately 6% and is no different

than the risk of bleeding from LMWH.

Heparin is a mixture of glycosaminoglycan chains of

varying lengths that binds to antithrombin III, resulting in

inhibition of thrombin and coagulation factors II, IX, X,