What is the most appropriate next step for a patient experiencing chest tightness, fever, and vomiting shortly after a blood transfusion is initiated?

Immediate Management of Acute Transfusion Reaction

Stop the transfusion immediately and maintain IV access with normal saline—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1

First Actions (Within Seconds)

• Discontinue the blood product immediately at the first sign of any suspected transfusion reaction 1, 2, 3
• Keep the IV line open with normal saline to maintain vascular access for medication administration and fluid resuscitation 1
• Do not remove the blood bag or tubing—these will be needed for investigation 1

Immediate Assessment and Monitoring (Within 5 Minutes)

• Monitor vital signs every 5-15 minutes: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1
• Administer high-flow oxygen (high FiO2) to address potential hypoxemia 4, 1
• Double-check all documentation for administration errors, particularly patient identification and blood component compatibility 1

Notification and Reporting (Within 15 Minutes)

• Contact the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation 1, 2, 3
• Alert the critical care team as this patient may require ICU-level monitoring given the constellation of symptoms 1
• Notify the patient's attending physician for further management decisions 1

Differential Diagnosis Considerations

The triad of chest tightness, fever, and vomiting within minutes suggests several serious possibilities:

Most Likely: Acute Hemolytic Transfusion Reaction (AHTR)

• Caused by ABO incompatibility from human error in patient/blood identification 1, 5
• Presents with fever, chest/back pain, dyspnea, nausea/vomiting within minutes 3
• This is a medical emergency with high mortality risk 3

Also Consider: Bacterial Contamination

• Can present with similar symptoms to other acute reactions 1
• Fever, rigors, hypotension, vomiting occur rapidly 1, 3
• Requires immediate broad-spectrum antibiotics and blood cultures 3

Less Likely Given Timing: TRALI or TACO

• TRALI typically presents 1-2 hours after transfusion with respiratory distress 1
• TACO occurs during or up to 12 hours after transfusion 1
• Both would be less likely to present "within minutes" 1

Critical Laboratory Workup

• Send baseline labs immediately: complete blood count, PT, aPTT, Clauss fibrinogen, direct antiglobulin test (DAT), and repeat cross-match 4, 1
• Return the blood bag and tubing to the blood bank for investigation 1, 2
• Obtain blood and urine samples for hemolysis evaluation (free hemoglobin, haptoglobin, bilirubin) 3
• Blood cultures from the patient and the blood bag if bacterial contamination suspected 3

Common Pitfalls to Avoid

• Never continue the transfusion "just to finish the unit"—even brief additional exposure can worsen outcomes 1, 2
• Do not assume this is a minor allergic reaction based on vomiting alone—the combination with chest tightness and fever suggests a more serious reaction 1, 3
• Do not delay stopping the transfusion to "gather more information"—stop first, investigate second 1, 2, 3
• Avoid discarding the blood bag or tubing before the blood bank can analyze them 1

Supportive Care While Awaiting Further Evaluation

• Maintain adequate blood pressure for organ perfusion (MAP >65-70 mmHg) with IV fluids 4
• Prepare for potential escalation: have vasopressors, intubation equipment, and resuscitation medications readily available 4
• Monitor urine output closely as acute hemolysis can cause acute kidney injury 3
• Consider early ICU transfer given the severity of presentation 1