Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 9Hematology

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hematology

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

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 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

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (1 of 6)

Plasma– Water

90–92% by volume

– Proteins6–7% by volume

– Other2–3% by volume

Fats, carbohydrates, electrolytes, gases, and chemical messengers

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (2 of 6)

Red Blood Cells– Hemoglobin– Oxygen transport– Bohr effect– 2,3 DPG– Oxygen–hemoglobin

dissociation curve

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (3 of 6)

Red Blood Cells– Production

Erythropoiesis

Hemolysis

Sequestration

– Laboratory analysis of red blood cells

Red blood cell count

Hematocrit

Hemoglobin

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (4 of 6)

White Blood Cells– Margination– Phagocytosis– White blood cell count

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (5 of 6)

White Blood Cells– Leukopoiesis

GranulocytesNeutrophilBasophilEosinophil

LymphocytesMonocytes

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood (6 of 6)

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Immune Response

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of Blood

Platelets– Megakaryocytes– Thrombocytopenia– Thrombocytosis

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemostasis (1 of 3)

Controlling Blood Loss– Vascular spasms– Platelet plugs– Stable fibrin blood clots

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemostasis (2 of 3)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemostasis (3 of 3)

FibrinolysisThrombosis– Fibrinolytics– Medications

affecting clot formation

Alter the enzyme on the plateletAffect the coagulation cascadeEnhance clotting

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Products and Blood Typing (1 of 2)

Blood Types– Antigens

A, B, AB, O

– Universal donors– Rh factor

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Products and Blood Typing (2 of 2)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Transfusion Reactions (1 of 2)

Hemolytic Reactions– Signs and Symptoms

Facial flushing, hyperventilation, tachycardia, hives, chest pain, wheezing, fever, chills, and cyanosis.

– TreatmentStop 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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Transfusion Reactions (2 of 2)

Febrile Nonhemolytic Reactions– Signs and Symptoms

Headache, fever, and chills.

– TreatmentStop 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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Assessment and Management (1 of 3)

Scene Size-up

Initial Assessment

Focused History and Physical Exam– SAMPLE history

Hematological disorders are rarely the chief complaint.

– Physical examEvaluate nervous system function.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physical exam– Skin signs– Lymphatic signs– Gastrointestinal

signs– Musculoskeletal

signs– Cardiorespiratory

signs– Genitourinary signs

General Assessment and Management (2 of 3)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Assessment and Management (3 of 3)

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© 2006 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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the Red Blood Cells (1 of 4)

Anemias– Anemia is a sign, not a separate disease

process.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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the Red Blood Cells (2 of 4)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the Red Blood Cells (3 of 4)

Sickle Cell Disease– Sickle cell crises

Vaso-occlusive

Hematological

Infectious

– ManagementFollow general treatment guidelines.

Consider analgesics.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the Red Blood Cells (4 of 4)

Polycythemia– Overproduction of erythrocytes– Occurs in patients >50 years old or with

secondary dehydration.– Results in bleeding abnormalities

Epistaxis, spontaneous bruising, GI bleeding

– ManagementFollow general treatment guidelines.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the White Blood Cells (1 of 3)

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the White Blood Cells (2 of 3)

Leukemia– Cancer of hematopoietic cells– Initial presentation

Acutely ill, fatigued, febrile and weak, anemic

Often have a secondary infection

– ManagementFollow general treatment guidelines.

Utilize isolation techniques to limit risk of infection.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the White Blood Cells (3 of 3)

Lymphomas– Cancers of the lymphatic system– Presentation

Swelling of the lymph nodesFever, night sweats, anorexia, weight loss, fatigue, and pruritis

– ManagementFollow general treatment guidelines.Utilize isolation techniques to limit risk of infection.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diseases of the Platelets

Thrombocytosis and Thrombocytopenia– Thrombocytosis

An abnormal increase in the number of platelets

– ThrombocytopeniaAn abnormal decrease in the number of platelets

– ManagementProvide supportive care and follow general treatment guidelines.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Clotting Abnormalities (1 of 2)

Hemophilia– Deficiency or absence of a blood clotting

factorDeficiency 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 SymptomsNumerous bruises, deep muscle bleeding, and joint bleeding.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Clotting Abnormalities (2 of 2)

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© 2006 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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

Anatomy, Physiology, and Pathophysiology

General Assessment and Management

Managing Specific Patient Problems