1. 24
Hematologic and Renal Emergencies

2. Multimedia Directory
Slide 15 Sickle Cell Anemia Video Slide 40 Information About Renal Failure Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

3. Topics The Hematologic System The Renal System
Planning Your Time: Plan 40 minutes for this chapter.
The Hematologic System (20 minutes)
The Renal System (20 minutes)
Note: The total teaching time recommended is only a guideline.
Core Concepts
Disorders of the hematologic system
Disorders of the renal system

4. The Hematologic System
Teaching Time: 20 minutes
Teaching Tips: Relate this lesson to prior discussions about the circulatory system. Consider the blood's role in perfusion and waste removal. Use multimedia graphics to illustrate anemia. Microscopic images will enhance comprehension. Use real-life examples to enhance an otherwise technical discussion. Relate blood disorders to actual symptoms.

5. The Hematologic System
Blood
Represents its own organ system
Has specific functions
Control of bleeding by clotting
Delivery of oxygen to cells
Removal of carbon dioxide from cells
Removal and delivery of other waste products to organs that filtrate and remove them
Covers Objective: 24.2
Point to Emphasize: Control of bleeding, delivery of oxygen to the cells, and removal of carbon dioxide and other waste products are all functions of the blood.
Discussion Topic: Discuss the role of the blood. What specific functions does it serve?
continued on next slide

6. The Hematologic System
Blood
Made up of solid components
Red blood cells
White blood cells
Platelets
Suspended in plasma
Medications can affect some components of blood.
Covers Objectives: 24.2 and 24.3
Discussion Topic: Describe the components of blood. What are the roles of each component?
Knowledge Application: List the components of blood. Ask students to discuss the role that each component plays with regard to body function. Discuss the dysfunction associated with deficits of any component.

7. Blood Clotting
Aggregation of platelets is body's most rapid and initial response to stop bleeding.
Clotting factors are a group of proteins produced in liver and released into the bloodstream.
Once activated, clotting factors form clots through clotting cascades.
Covers Objective: 24.2

8. Coagulopathies Abnormal clotting of blood
Can occur when body forms clots too readily or patient clots too slowly
Certain diseases make patients prone to poor clotting:
Advanced liver disease
Hemophilia
von Willebrand disease
Covers Objective: 24.2

9. Identifying Patients with Coagulopathies
Certain medical conditions, medications in which the normal ability to form clots can worsen patient's disease
Patients with prescribed "blood thinners"
Patients more prone to have life-threatening bleeding when injured than patients not on these medications
Covers Objective: 24.2

10. Anemia Lack of normal amount of red blood cells Acute anemia
Sudden blood loss
Chronic anemia
Excessive menstrual periods
Slow gastrointestinal bleeding
Diseases affecting bone marrow
Covers Objective: 24.4
Point to Emphasize: A lack of a normal number of red blood cells in the circulation is called anemia. This condition can be either chronic or acute.
Discussion Topic: Define anemia. Describe the pathophysiology of the disorder.
Critical Thinking: How might anemia complicate other injuries and illnesses? Consider the following problems: blood loss, acute asthma attack.

11. Sickle Cell Anemia Genetic disease affecting RBCs
More prevalent in certain ethnicities
African Americans
Indian or Middle Eastern descent
Defective shape resembles a sickle
Cells have a short life span leading to anemia
Covers Objective: 24.4
Point to Emphasize: Sickle cell anemia is an inherited disease in which patients have a genetic defect that results in an abnormal structure of the red blood cells.
Discussion Topic: Describe the specific pathophysiology of sickle cell anemia. Discuss the complications associated with this pathophysiology.
Class Activity: Have students research sickle cell anemia. Discuss prevalence, morbidity and mortality rates, pathophysiology, and complications.
continued on next slide

12. Sickle Cell Anemia Complications Destruction of spleen
Sickle pain crisis
Acute chest syndrome
Priapism
Stroke
Jaundice
Covers Objective: 24.4
Class Activity: Have students research sickle cell anemia. Discuss prevalence, morbidity and mortality rates, pathophysiology, and complications.

13. Sickle Cell Anemia
One in twelve African Americans has the sickle cell trait.
Sickle cell trait doesn't always lead to complications.
Possible to lead a normal life with sickle cell trait
Covers Objective: 24.4

14. Patient Care Administer supplemental oxygen.
Monitor for inadequate respiration.
Monitor for signs of hypoperfusion.
Transport to stroke center if stroke is suspected.
Covers Objective: 24.5

15. Sickle Cell Anemia Video
Covers Objective: 24.4
Video Clip
Sickle Cell Anemia
What is sickle cell anemia?
Where are red blood cells made?
How do cells become sickle shaped?
What problems can be caused by sickled cells?
What treatments are available for sickle cell anemia?
Transcript.
Sickle cell anemia is a genetically transmitted disorder marked by a severe reduction in circulating red blood cells. Red blood cells are produced in the red marrow of bones such as the vertebrae, ribs and body of the sternum. Red blood cells are filled with hemoglobin that enables them to carry the oxygen from the lungs to all of the body tissues. In sickle cell anemia, red blood cells contain an abnormal form of hemoglobin. As the red blood cell deoxygenates, the hemoglobin forms crosslinks with other hemoglobin molecules and long crystals develop. Crystals continue to form as oxygen is released and the red cells assume a sickle shape. Sickled red blood cells are inflexible and rigid and cause mechanical obstruction of small arterioles and capillaries leading to pain and ischemia. Sickled cells are also more fragile than normal leading to hemolysis, tissue death secondary to ischemia progresses to organ failure with repeated occlusive episodes. Sickle cell anemia cannot be cured. Treatment is aimed at preventing sickle cell crisis, controlling the anemia and relieving pain. Blood transfusions and fluid replacement expand blood volume and oxygen exchange needed for reperfusion of occluded vessels.
Click on the screenshot to view a video on the topic of sickle cell anemia.
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16. The Renal System Teaching Time: 20 minutes
Teaching Tips: Use anatomical models and multimedia graphics to demonstrate the renal system. Tour a local dialysis center. Demonstrate dialysis equipment and interview dialysis patients. Emphasize that renal problems can be a primary problem or can complicate other illnesses or injuries.

17. The Renal System Components
Two kidneys
Two ureters
One urethra
Responsible for filtering blood and removing waste
Maintains fluid balance
Maintains acid/base balance
Covers Objective: 24.6
Point to Emphasize: The renal system is made up of two kidneys, two ureters, and a single urethra. It is responsible for the filtration of the blood and the removal of certain waste products, excessive salts, and excessive fluid from the body.
Discussion Topic: Describe the components and function of the renal system.
Knowledge Application: Have students label the components of the renal system on a blank illustration.

18. Diseases of the Renal System
Affect many different portions
Range from minor to life-threatening
Covers Objective: 24.6
Point to Emphasize: The renal system is made up of two kidneys, two ureters, and a single urethra. It is responsible for the filtration of the blood and the removal of certain waste products, excessive salts, and excessive fluid from the body.
Discussion Topic: Describe the components and function of the renal system.
Knowledge Application: Have students label the components of the renal system on a blank illustration.

19. Urinary Tract Infections
Most common disease that afflicts renal and urinary system
Caused by bacteria
Usually limited to the bladder
Cause pain and frequent urination
If left untreated, can result in pyelonephritis
UTI ascends up ureter into kidney.
Covers Objective: 24.6

20. Kidney Stones Usually made of calcium and formed within the kidney
When in the kidney, they cause no symptoms.
When they become dislodged, can cause unilateral flank pain that radiates to the groin area.
Patients may report nausea and vomiting.
Covers Objective: 24.6

21. Patients with Urinary Catheters
As a result of:
Renal obstruction of bladder outflow
Neurological disorder
Use urinary catheters to drain urine
Commonly inserted in urethra
May be placed through skin
Complications of UTI and local trauma at site of catheter insertion
Covers Objective: 24.6

22. Renal Failure
Occurs when kidneys lose ability to adequately filter and remove toxins
Acute failure typically results from shock or toxic ingestion.
Chronic failure may be inherited or secondary to damage from uncontrolled diabetes or hypertension.
Covers Objective: 24.7
Point to Emphasize: Renal failure can occur acutely or chronically. It is characterized by the kidneys' losing their ability to filter the blood adequately and to remove toxins and excess fluid from the body.
Discussion Topic: Define renal failure. Discuss the ramifications of failure of this system.
continued on next slide

23. Renal Failure End-stage renal disease (ESRD)
Irreversible renal failure
Requires dialysis
Hemodialysis
Peritoneal dialysis
90% receive hemodialysis in specialized centers.
Covers Objective: 24.7
Point to Emphasize: Patients with end-stage renal disease usually require an external medical system to remove toxins and excess fluid from their body.
Discussion Topic: Describe the two types of dialysis.

24. Renal Failure
More than 400,000 Americans on dialysis who are treated in dialysis centers undergo three treatments a week, each lasting three to four hours.
Only 8% treat themselves at home.
ESRD patients often rely on EMS for transport to and from dialysis.
Covers Objective: 24.7
Talking Points: At some point in your career, you will transport an ESRD patient and deal with the complications of kidney failure.

25. Hemodialysis
Patient connected to a dialysis machine that pumps blood through specialized membranes
Treatments last several hours, multiple times a week.
Covers Objective: 24.8
Talking Points: A two-port catheter is inserted into a major vein in the torso. An A-V fistula is surgically created and connects arterial and venous blood flow.

26. Hemodialysis
Covers Objective: 24.8
Talking Points: A two-port catheter is inserted into a major vein in the torso. An A-V fistula is surgically created and connects arterial and venous blood flow.
How hemodialysis works. Adapted from Treatment Methods for Kidney Failure, National Institute of Diabetes and Digestive and Kidney Diseases; U.S. Centers for Disease Control and Prevention.

27. Hemodialysis Two types of access to blood circulation
Two-port catheter
A-V fistula
Characteristic thrill when palpated
Covers Objective: 24.8
Critical Thinking: What are the side effects of hemodialysis? How might these side effects impact EMS?

28. Hemodialysis
Covers Objective: 24.8
Critical Thinking: What are the side effects of hemodialysis? How might these side effects impact EMS?
A two-port catheter for hemodialysis inserted into a major vein of the torso. © Edward T. Dickinson, MD

29. Hemodialysis
Covers Objective: 24.8
Critical Thinking: What are the side effects of hemodialysis? How might these side effects impact EMS?
A fistula surgically connects an artery and a vein in an extremity. © Edward T. Dickinson, MD

30. Peritoneal Dialysis Uses peritoneal cavity's large surface area
Special fluid infused into abdominal cavity and left for several hours to absorb waste and excess fluid
Fluid is removed and discarded.
Covers Objective: 24.8
Knowledge Application: Have students work in small groups. Ask each group to describe a specific type of dialysis. Include a discussion about how filtration is achieved.
continued on next slide

31. Peritoneal Dialysis Continuous ambulatory peritoneal dialysis (CAPD)
Gravity exchange process repeated several times a day
Continuous cycler-assisted peritoneal dialysis (CCPD)
Machine used to fill and empty abdominal cavity while person sleeps
Covers Objective: 24.8
Knowledge Application: Have students work in small groups. Ask each group to describe a specific type of dialysis. Include a discussion about how filtration is achieved.

32. Peritoneal dialysis catheter. © Edward T. Dickinson, MD
Covers Objective: 24.8
Knowledge Application: Have students work in small groups. Ask each group to describe a specific type of dialysis. Include a discussion about how filtration is achieved.
Peritoneal dialysis catheter. © Edward T. Dickinson, MD

33. Medical Emergencies in ESRD
Two broad groups
Loss of normal kidney function
Complication of dialysis treatments
Most dialysis patients have underlying medical factors.
Diabetes
Hypertension
Covers Objective: 24.9

34. Complications of ESRD Usually relate to patient missing dialysis
Present with signs and symptoms similar to congestive heart failure
Shortness of breath
Edema
Electrolyte disturbances
Covers Objective: 24.9

35. Patient Care For the ESRD patient who has missed dialysis Assess ABCs.
Obtain vital signs and be aware of fistulas.
Administer oxygen.
Monitor vital signs closely and have AED ready.
Transport to facility capable of dialysis.
Covers Objective: 24.9
Talking Points: Be certain not to take a blood pressure on the same arm containing a fistula, as you will damage it. Patients are usually very aware of this, but if your patient is obtunded, you will have to assess this for yourself.

36. Complications of Dialysis
Bleeding from A-V fistula site
Clotting and loss of function of the A-V fistula
Bacterial infection of blood due to contamination at A-V fistula or dialysis catheter site
Peritonitis
Covers Objective: 24.9
Point to Emphasize: Advanced life support will be an important resource for complications associated with dialysis patients.
Discussion Topic: Discuss common complications associated with dialysis.
Class Activities: Tour a dialysis center. Discuss dialysis equipment. Interview a dialysis patient. Discuss how dialysis is accomplished and whether the patient regularly experiences any complications.
Knowledge Application: Brainstorm common complications of dialysis. Discuss potential treatment options.

37. Patient Care ESRD patient with complications of dialysis Assess ABCs.
Control bleeding.
Use direct pressure, elevation, and hemostatic dressings as needed.
If bleeding cannot be controlled by other means, a tourniquet should be applied.
Administer oxygen.
Covers Objective: 24.10
Knowledge Application: Invite a paramedic to class to discuss the role of advanced life support in the treatment of a dialysis complication.
continued on next slide

38. Patient Care ESRD patient with complications of dialysis
Treat for shock.
Keep patient supine and warm.
If peritonitis is suspected, transport dialysis fluid for confirmation.
Covers Objective: 24.10

39. Kidney Transplant Patients
Kidneys are the most commonly transplanted organs.
Approximately 16,000 transplants per year
Patients spend their lives on special class of drugs.
Help prevent organ rejection
Increased susceptibility to infections
Covers Objective: 24.11

40. Information About Renal Failure Video
Covers Objective: 24.7
Video Clip
Information About Renal Failure
Discuss the different types of renal failure.
What are the most common causes of chronic renal failure?
What are the signs and symptoms associated with acute renal failure?
Discuss the stages of chronic renal failure.
Why is dialysis used for renal failure?
What is the mortality rate for patients with acute renal failure?
Transcript.
There are two types of renal or kidney failure acute and chronic.
Acute renal failure is the sudden loss of kidney function that develops as a result of an injury or damage to the body in general or the kidneys in particular.
Acute renal failure is caused by a blockage of urine flow out of the kidneys and into the bladder, exposure to certain drugs and/or toxic substances or significant loss of blood or a sudden drop in blood flow to the kidneys. Kidneys that had preexisting disease or damage are at higher risk for acute renal failure.
Signs and symptoms include confusion, drowsiness, decreased urine output, Kussmaul breathing, dyspnea, tachypnea, and coma. Acute renal failure is a very serious condition with a mortality rate in excess of 50 percent. Chronic renal failure develops over a much longer period of time. Its nephrons lose their ability to function and are replaced by scar tissue. Usually this takes place over the course of many years.
In the early stages, there may be no symptoms and progression may be so gradual that symptoms do not occur until kidney function is less than one tenth of normal. Diabetes and hypertension are the 2 most common causes and account for approximately two thirds of the cases of chronic renal failure. The goal of treatment for all renal failure is to identify and treat any reversible causes as well as preventing excess accumulation of fluids and wastes while allowing the kidneys to heal and gradually resume their normal function. In some cases, dialysis may be necessary. Dialysis is a method of removing toxic substances from the blood when the kidneys are unable to do so. Some patients may require a renal transplant to implant a healthy kidney into a patient with kidney disease or kidney failure.
Click on the screenshot to view a video on the topic of renal failure.
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41. Chapter Review

42. Chapter Review
Blood delivers oxygen to the cells, removes carbon dioxide from the cells, and controls bleeding by clotting.
Blood consists of red cells, white cells, and plasma.
Anemia is lack of red blood cells in circulation.
continued on next slide

43. Chapter Review
Sickle cell anemia is an inherited disease in which a defect in the hemoglobin results in sickle shape to red blood cells. This misshaping inhibits movement of red blood cells through capillaries, causing "sludging" and blockages in smaller blood vessels.
continued on next slide

44. Chapter Review
The renal system is comprised of the kidneys, the ureters, the bladder, and the urethra.
The kidneys perform vital filtering of the blood to remove waste products. They also help maintain water balance within the body.
continued on next slide

45. Chapter Review
Problems with the renal system include infection, kidney stones, and renal failure.
Renal failure is a condition in which the kidneys are unable to filter waste and provide a balance of fluids and electrolytes in the body.
continued on next slide

46. Chapter Review
Dialysis removes excess fluid and electrolytes from the body by filtration. Dialysis may be performed in either of two ways: hemodialysis or peritoneal dialysis. Hemodialysis at dialysis centers is generally performed three times per week. Peritoneal dialysis is done at home and is usually done several times daily.
continued on next slide

47. Chapter Review
Major complications in patients with end-stage renal disease can occur after the patient has missed a dialysis appointment, from infections, or as a result of bleeding from hemodialysis access sites.

48. Remember Blood has specific cellular components.
Abnormal blood cells can significantly affect patients.
The renal system is critical to maintaining homeostasis.
Renal failure can be chronic or acute.
End stage renal disease is managed through dialysis.

49. Questions to Consider
Does my patient have a history of sickle cell disease or ESRD?
Does my patient have an A-V fistula?
Will I need to make an early request for ALS because of complications from a missed dialysis appointment?
Talking Points: Discuss how an EMT would handle these type of patients. What special precautions are needed?

50. Critical Thinking
You have a patient who is transported routinely for dialysis three times per week. She was sick and canceled the trip yesterday. Now she calls saying she can't breathe and feels like she is going to die. Is it possible that she has a legitimate complaint after missing dialysis by only one day?
Talking Points: Dialysis is a critical function for patients in ESRD. Missing even one appointment can be a life-threatening emergency. The kidneys are essential to eliminate toxins and regulate water in our bodies. Without dialysis to replace the lost function, this patient's body has no way to rid itself of dangerous toxins.