Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 9 Hematology

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy, Physiology, and Pathophysiology General Assessment and Management Managing Specific Patient Problems

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction The Study of Blood and Blood-Forming Organs –Includes study of blood disorders: Red blood cell disorders White blood cell disorders Platelet disorders Coagulation problems –Some hematological diseases are genetic in origin

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy, Physiology, and Pathophysiology

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy, Physiology, and Pathophysiology Components –Blood, bone marrow, liver, spleen, kidneys Hematopoiesis –Pluripotent stem cell –Erythropoietin Blood Volume –Red cell mass and plasma volume

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood Plasma –Water 90–92% by volume –Proteins 6–7% by volume –Other 2–3% by volume Fats, carbohydrates, electrolytes, gases, and chemical messengers

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood Red Blood Cells –Hemoglobin –Oxygen transport Bohr effect 2,3- biphosphoglycerate (2,3-BPG) Oxygen– hemoglobin dissociation curve

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Red Blood Cells –Production Erythropoiesis Hemolysis Sequestration –Laboratory analysis of red blood cells Red blood cell count Hematocrit Hemoglobin Components of Blood

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood White Blood Cells –Provide protection from foreign invasion –Cells are widely distributed throughout bloodstream Margination Cells are attached to vessel walls Demargination Cells release from wall in response to stressors Diapedesis Marginated blood cells that are adhered to vessel wall leave the blood vessel Follow chemical message (chemotaxis)

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood White blood cells (cont.) –Phagocytosis Cells may engulf and destroy an invader –White cell count 5-9,000 cells per microliter of blood

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood White Blood Cells –Leukopoiesis Granulocytes Neutrophil Basophil Eosinophil Lymphocytes Beta T cells Monocytes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood White Blood Cells –Immunity Subpopulation of lymphocytes known as T cells and B cells T cells develop cellular immunity B cells produce humoral immunity –Autoimmune disease –Alterations in the immune process –Inflammatory process

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Immune Response

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of Blood Platelets –Fragments of megakaryocytes –Normal number of platelets ranges from 150,000 to 450,000 per microliter of blood –Thrombocytopenia Excessive bleeding occurs –Thrombocytosis May cause abnormal clotting, plugs in vessels, and emboli

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hemostasis Controlling Blood Loss –Vascular spasms –Platelet plugs –Stable fibrin blood clots

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood vessels spasm reducing amount of blood flow Platelets aggregate Formation of a stable fibrin clot Hemostasis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Damage to vessel initiates the coagulation cascade –Intrinsic pathway activated by turbulent blood flow –Extrinsic pathway activated by trauma Hemostasis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hemostasis Fibrinolysis –Dismantling, or lysing of a clot –Plasminogin Thrombosis –Clot formation in the coronary or cerebral arteries Leads to stroke or myocardial infarctions –Fibrinolytic agents May speed dissolution of clots

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hemostasis Patients who lack certain clotting factors or take medications may complicate your assessment –Medications that decrease the effectiveness of platelets or the coagulation cascade: Aspirin, dipyridamole (Persantine), and ticlopidine (Ticlid) –Medications that cause changes within the clotting cascade that prevent clot formation: Heparin, Warfarin –Glycoprotein IIb/IIIa inhibitors: Abciximab (ReoPro), Eptifibatide (Integrilin),Tirofiban (Aggrastat) Vitamin K (AquaMEPHYTON)

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Products and Blood Typing Blood Types –Antigens A, B, AB, O –Universal donors –Rh factor © Getty Images, Inc.—Image Bank

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Products and Blood Typing

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Transfusion Reactions Hemolytic Reactions –Signs and Symptoms Facial flushing, hyperventilation, tachycardia, hives, chest pain, wheezing, fever, chills, and cyanosis –Treatment Stop transfusion, change all IV tubing, and initiate IV therapy with normal saline or lactated Ringer’s Consider furosemide, dopamine, and diphenhydramine

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Transfusion Reactions Febrile Non-hemolytic Reactions –Signs and Symptoms Headache, fever, and chills –Treatment Stop transfusion, change all IV tubing, and initiate IV therapy with normal saline or lactated Ringer’s Consider diphenhydramine and an antipyretic Observe closely to ensure reaction is nonhemolytic

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Assessment and Management

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Assessment and Management Scene Size-up Initial Assessment Focused History and Physical Exam –SAMPLE history Hematological disorders are rarely the chief complaint –Physical exam Evaluate nervous system function

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical exam –Skin signs –Lymphatic signs –Gastrointestinal signs –Musculoskeletal signs –Cardiorespiratory signs –Genitourinary signs © John Callan/Shout Picture Library General Assessment and Management

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Assessment and Management General Treatment Guidelines –Maintain ABCs Provide high-flow, high-concentration oxygen or assist ventilations as indicated Consider volume replacement –Monitor cardiac rhythm and vital signs Treat rhythm disturbances –Provide reassurance, comfort care, and transport

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Managing Specific Patient Problems

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Managing Specific Patient Problems Diseases of the Red Blood Cells Diseases of the White Blood Cells Diseases of the Platelets/Blood Clotting Abnormalities Other Hematopoietic Disorders

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the Red Blood Cells Anemias –Anemia is a sign, not a separate disease process Hematocrit of less than 37 percent in women or less than 40 percent in men Signs and symptoms may not be present until the body is stressed Differentiate chronic anemia from acute episode –Treat signs and symptoms Maximize oxygenation and limit blood loss Establish IV therapy if indicated

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Types of Anemia

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the Red Blood Cells Sickle Cell Disease –Average life span of sickled red blood cells is 10–20 days Compared to 120 days for normal red blood cells –Sickle cell crises Vaso-occlusive Hematological Infectious –Management Follow general treatment guidelines Consider analgesics © Photo Researchers, Inc.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the Red Blood Cells Polycythemia –Overproduction of erythrocytes –Occurs in patients >50 years old or with secondary dehydration –Results in bleeding abnormalities Epistaxis, spontaneous bruising, GI bleeding –Management Follow general treatment guidelines

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the White Blood Cells Leukopenia/Neutropenia –Too few white blood cells or neutrophils –Follow general treatment guidelines and provide supportive care Leukocytosis –An increase in the number of circulating white blood cells, often due to infection Leukemoid reaction

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the White Blood Cells Leukemia –Cancer of hematopoietic cells –Initial presentation Acutely ill, fatigued, febrile and weak, anemic Often have a secondary infection –Management Follow general treatment guidelines Utilize isolation techniques to limit risk of infection for patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the White Blood Cells Lymphomas –Cancers of the lymphatic system Hodgkin’s and Non-Hodgkin’s –Presentation Swelling of the lymph nodes Fever, night sweats, anorexia, weight loss, fatigue, and pruritis –Management Follow general treatment guidelines Utilize isolation techniques to limit risk of infection for patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diseases of the Platelets Thrombocytosis and Thrombocytopenia –Thrombocytosis An abnormal increase in the number of platelets –Thrombocytopenia An abnormal decrease in the number of platelets –Management Provide supportive care and follow general treatment guidelines

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hemophilia –Deficiency or absence of a blood clotting factor Deficiency of factor VIII causes hemophilia A Deficiency of factor IX causes hemophilia B Deficiency is a sex-linked, inherited disorder Defective gene is carried on the X chromosome –Signs and Symptoms Numerous bruises, deep muscle bleeding, and joint bleeding Blood Clotting Abnormalities

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Clotting Abnormalities Hemophilia –Management Treat the patient similarly to others Administer supplemental oxygen Establish IV access Be alert for recurrent or prolonged bleeding, and prevent additional trauma Von Willebrand’s Disease –Deficient component of factor VIII Generally results in excessive bleeding Generally is not serious; provide supportive care

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Hematopoietic Disorders Disseminated Intravascular Coagulation –System activation of coagulation cascade –Results from sepsis, hypotension, OB complications, severe tissue or brain injury, cancer, and major hemolytic reactions Multiple Myeloma –Cancerous disorder of plasma cells –Pathologic fractures common

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy, Physiology, and Pathophysiology General Assessment and Management Managing Specific Patient Problems