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Chapter 24Chapter 24
Hematologic Emergencies
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Medicine
Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Hematology
•Anatomy, physiology, pathophysiology, assessment, and management of:
− Sickle cell crisis
− Clotting disorders
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
• Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of common or major hematological diseases and/or emergencies− Sickle cell crisis
− Blood transfusion complications
− Hemostatic disorders
− Lymphomas
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
• Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of common or major hematological diseases and/or emergencies (cont’d)− Red blood cell disorders
− White blood cell disorders
− Coagulopathies
IntroductionIntroduction
• EMS systems rarely respond to hematologic emergencies.
• Hematologic disorder: any disorder of the blood− Hemolytic disorders
− Hemostatic disorders
IntroductionIntroduction
• Hematopoietic system− Organs and tissues involved in the production of
blood components
Blood and PlasmaBlood and Plasma
• Blood performs the following functions:
Blood and PlasmaBlood and Plasma
• Blood is made of:
Blood and PlasmaBlood and Plasma
• The production of RBCs occurs within stem cells.− Stimulated by erythropoietin
− Five days to mature• Average life span: 4 months
− Hemoglobin carries oxygen to the tissues.
Blood and PlasmaBlood and Plasma
• Three common lab tests:− RBC count
− Hemoglobin level
− Hematocrit measurement
Blood and PlasmaBlood and Plasma
• White blood cells− Larger than RBCs
− Immunity against “foreign invaders”
− Derived from stem cells
− Several types
• Platelets− Smallest formed
element
− Clot the blood• Hemostasis
− Two thirds circulate through the blood.
Blood-Forming Organs and RBC Production
Blood-Forming Organs and RBC Production
• The major players in the hematologic system are the:− Bone marrow
− Liver
− Spleen
The Inflammatory ProcessThe Inflammatory Process
• All of the body’s cells and blood contain antigens at birth.− Antigens activate the immune system.
• Autoimmune diseases − Identify the body’s own antigen as foreign
The Immune SystemThe Immune System
• Processes protect against pathogens and other unwanted materials.− Must distinguish between:
• Body’s own tissue
• Outside organs
The Immune SystemThe Immune System
• Native immunity− Nonspecific,
maximal response
− First line of defense
− Associated with initial inflammatory response
• Acquired immunity− Specific to
vertebrates
− A pathogen-specific response
The Immune SystemThe Immune System
• Humoral immunity− Secretion of
immunoglobins• Recognizes a
specific antigen
• Cell-mediated immunity− Macrophages and
T-cells destroy pathogens.
The Immune SystemThe Immune System
• White blood cells− Produced in the bone marrow
− Laboratory values provide information on the immune system.
− Baseline count is normally 5,000–10,000 cells/µL.
The Immune SystemThe Immune System
Blood ClassificationsBlood Classifications
• Developed to prevent medical problems during replacement − ABO system
Blood ClassificationsBlood Classifications
• Blood contains a secondary antigen called the Rh antigen.− Possible complications in pregnancy
• Hemolytic disease
HemostasisHemostasis
• The process of stopping bleeding through:− Vasoconstriction (immediate response)
− Platelet plugging
− Coagulation• Clots are made up of fibrin.
HemostasisHemostasis
• Clotting cascade− Can be initiated through:
• Intrinsic pathway
• Extrinsic pathway
− Coagulopathy: process that interferes with the clotting cascade or hemostasis
Patient AssessmentPatient Assessment
• Note any life-threatening signs or symptoms.− Ask about patient’s
history and SAMPLE history.
− A nonjudgmental approach is essential.
Scene Size-UpScene Size-Up
• Ensure the scene is safe for entry.
• Consider the mechanism of injury.
• Determine the number of patients.
• Assess for hazards.
Primary AssessmentPrimary Assessment
• An African American or Mediterranean patient reporting severe pain may have sickle cell disease. − Perform cervical spine stabilization if necessary.
Primary AssessmentPrimary Assessment
• Form a general impression.− Perform a rapid scan and determine LOC.
• Airway and breathing− Inadequate breathing or altered mental status
should receive high-flow oxygen or ventilation.
Primary AssessmentPrimary Assessment
• Circulation− Manage life-threatening conditions.
− If hemophilia is suspected, watch for:• Acute blood loss
• Bleeding of unknown origin
• Hypoxia or shock
Primary AssessmentPrimary Assessment
• Transport decision− Depends on severity and patient’s wishes
− Transport to the closest facility if:• Sickle cell crisis
• Uncontrolled bleeding
History TakingHistory Taking
• Obtain patient and SAMPLE history.
• Do not take a sickle cell crisis lightly.− Life-threatening situations, characterized by:
• Signs of pneumonia
• Swelling of fingers and toes
• Jaundice
History TakingHistory Taking
History TakingHistory Taking
• Is pain isolated or felt throughout?
• Has the patient experienced:− Skin changes?
− Bleeding?
− History of liver problems?
− Pain for unknown reasons?
− Genitourinary or gastrointestinal problems?
History TakingHistory Taking
• If known sickle cell disease, ask:− Have you had a crisis before?
− When was the last time?
− How did it resolve?
− Have you had any illness, unusual amount of activity, or stress lately?
Secondary AssessmentSecondary Assessment
• Performed on scene, en route, or not at all
• Perform a physical exam, focusing on major joints.
• Obtain vital signs.
Secondary AssessmentSecondary Assessment
• Evaluate and document mental status.
• In patients experiencing a sickle cell crisis:− Respirations are normal to rapid.
− Pulse is weak and rapid.
− Skin is pale and clammy with low blood pressure.
ReassessmentReassessment
• Reassess frequently.
• Administer supplemental oxygen.
• Provide ventilation as appropriate.
• Cover to maintain body temperature.
ReassessmentReassessment
• According to local protocol, administer:− IV fluid
− Nitrous oxide
• Prehospital care for hemophilia can include IV therapy.
ReassessmentReassessment
• Inform hospital staff about:− Patient history
− Present situation
− Assessment findings
− Interventions and their results
• Document:− Each assessment
− Your findings
− Treatment
− Time of interventions
− Changes in patient condition
Emergency Medical Care Emergency Medical Care
• Emergency medical care should include: − Oxygen
− Fluids
− ECG
− Comfort
− Pharmacology
− Support
Sickle Cell CrisisSickle Cell Crisis
• Pathophysiology− Leading inherited
blood disorder
− Gene defect of the adult-type hemoglobin (HbA)
− Defective RBCs have an oblong shape.
Courtesy of Bill Branson/National Cancer Institute
Sickle Cell CrisisSickle Cell Crisis
• Pathophysiology (cont’d)− Can lead to:
• Aplastic crisis: RBC production temporarily stops.
• Hemolytic crisis: Acute RBC destruction
Sickle Cell CrisisSickle Cell Crisis
• Pathophysiology (cont’d)− May manifest as:
• Vaso-occlusive crisis
• Acute chest syndrome
• Splenic sequestration crisis
Sickle Cell CrisisSickle Cell Crisis
• Assessment− Characterizations may include:
• Shortness of breath
• Inadequate perfusion of the skin
• Jaundice
• Mild dehydration
Sickle Cell CrisisSickle Cell Crisis
• Assessment (cont’d)− Patients may have significant pain.
• Pediatric patients typically present with pain in the hands and feet.
• Adults typically report back and proximal extremity pain.
Sickle Cell CrisisSickle Cell Crisis
• Management− Administer high levels of oxygen.
− Rapidly transport patient.
− Consider IV fluid therapy.
− Maintain patient’s body temperature.
− Recommend that patient rest.
AnemiaAnemia
• Pathophysiology− Low hemoglobin or
erythrocyte level
− Usually associated with an underlying disease
AnemiaAnemia
• Iron deficiency anemia− Most common type
− Causes include:• Gastrointestinal blood loss
• Menstrual bleeding
• Frequent donations or diagnostic test
AnemiaAnemia
• Pathophysiology (cont’d)− May be caused by an inherited hemolytic
disorder or a hematologic disorder
− Can have serious consequences in high altitudes
AnemiaAnemia
AnemiaAnemia
• Management− Check and monitor airway breathing.
− Check vital signs frequently.
− For chest pain, apply a cardiac monitor.
− Blood pressure management and fluid replacement may be needed.
AnemiaAnemia
• Management (cont’d)− Allow the patient to rest.
− Consider rapid transport for:• Abrupt change in consciousness
• Hypotension
• Significant perfusion inadequacies
LeukemiaLeukemia
• Pathophysiology− Cancer in the
lymphoid system
− Blood cells develop abnormally and/or excessively, causing:• Anemia
• Thrombocytopenia
• Leukocytosis
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LeukemiaLeukemia
• Pathophysiology (cont’d)− Acute leukemia:
Bone marrow is replaced with abnormal lymphoblasts
− Chronic leukemia: Abnormal cells accumulate in: • Bone marrow
• Lymph nodes
• Spleen
• Peripheral blood
LeukemiaLeukemia
• Pathophysiology (cont’d)− Survival depends on several factors:
• Stage of detection
• Underlying medical condition
• Response to treatment
− Treated with chemotherapy and radiation
LeukemiaLeukemia
LeukemiaLeukemia
• Management− As appropriate, provide:
• Airway support
• Oxygen therapy
• IV fluid therapy
• Analgesics
• Positive support
LeukemiaLeukemia
• Management (cont’d)− You may be called because loved ones are
uncertain about what to do.• Discuss with medical control.
• Document all findings.
• Have a refusal/release form signed.
LymphomasLymphomas
• Pathophysiology− Group of malignant diseases within the
lymphoid system
− Classified in two categories
LymphomasLymphomas
• Non-Hodgkin− Any age
− Can be hereditary
− Characterized by progression• Indolent
• Aggressive
• Highly aggressive
• Hodgkin:− Progressive
enlargement of lymphoid glands
− Highly rare
− Peaks between:• 15–35 years of age
• After age 55–60
LymphomasLymphomas
• Assessment− Require chemotherapy or radiation.
− Signs and symptoms may include:• Pallor
• Feeling hot and then cold or both
• Inadequate perfusion
• Abnormal ECG rhythms
LymphomasLymphomas
• Management− Aggressive pain
management
− Treat inadequate perfusion and abnormal heart rhythms.
− Initiate rapid transport if condition does not improve.
PolycythemiaPolycythemia
• Pathophysiology− Overabundance or overproduction of RBCs
− Multiple causes
− Can lead to other conditions
− Treatment usually includes phlebotomy or cancer-type therapy
PolycythemiaPolycythemia
• Assessment− Findings may widely vary
− Note the extent and duration of dyspnea.
− Has the patient experienced pruritus or changes in skin temperature?
PolycythemiaPolycythemia
• Management− Consists of supportive care and transport to the
appropriate facility.
− Administer oxygen and establish IV as needed.
Disseminated Intravascular Coagulation
Disseminated Intravascular Coagulation
• Pathophysiology− Number of causes
− Two stages:• Defibrination
• Uncontrolled hemorrhage
− High mortality rate
Disseminated Intravascular Coagulation
Disseminated Intravascular Coagulation
• Assessment− Identify associated signs and symptoms.
− Patients may have:• Respiratory difficulty
• Signs of shock
• Skin changes
Disseminated Intravascular Coagulation
Disseminated Intravascular Coagulation
• Management− Identify underlying cause and establish
treatment early.
− Maintain an airway.
− Treat for shock.
HemophiliaHemophilia
• Pathophysiology− A bleeding disorder in which clotting:
• Does not occur
• Occurs insufficiently
− Two primary types: A and B
HemophiliaHemophilia
• Pathophysiology (cont’d)− Signs and symptoms may include:
• Acute and chronic bleeding
− Patients may require:• Hospitalization for transfusion
• Infusion of factors VIII and IX
HemophiliaHemophilia
• Assessment− Take care of the ABCs.
− Be alert for signs of acute blood loss.
− Note any bleeding of unknown origin.
− Patients may show signs of hypoxia.
HemophiliaHemophilia
• Management− Patients may need high-flow oxygen.
− Note ECG findings.
− IV therapy may be necessary.
− Analgesics may be appropriate.
Multiple MyelomaMultiple Myeloma
• Pathophysiology− Number of plasma cells in the bone marrow
increase abnormally• Forms tumors in the bone
• Results in anemia and susceptibility to infection
Multiple MyelomaMultiple Myeloma
• Pathophysiology (cont’d)− Neoplastic cells may accelerate protein
development in the bloodstream.
− Patients may have weakness in the bones.
− Chemotherapy and other anticancer treatment may be given.
Multiple MyelomaMultiple Myeloma
Multiple MyelomaMultiple Myeloma
• Management:− IV therapy
− Pain management
− Supportive care
Transfusion ReactionsTransfusion Reactions
• Pathophysiology− Similar to anaphylactic reaction
− Monitor a patient receiving a blood transfusion very closely for the first 30–60 minutes
− Occurs when a patient receives a blood type different than their own
Transfusion ReactionsTransfusion Reactions
• Assessment− Symptoms can be subtle in patients who are
unresponsive or intubated.
− An acute reaction may include a rapid onset of:• Chills
• Back pain
• Hypotension
Transfusion ReactionsTransfusion Reactions
• Assessment (cont’d)− Complications include:
• Hemolytic
• Febrile
• Allergic
• Transfusion-related lung injury
• Circulatory overload
• Bacterial infection
Transfusion ReactionsTransfusion Reactions
• Management− Immediately stop the transfusion.
− Provide hemodynamic supportive care.
− Maximize kidney perfusion.
Transfusion ReactionsTransfusion Reactions
• Management (cont’d)− A hemodynamically unstable patient requires:
• Early invasive monitoring
• Vasopressors
• Promotion of diuresis
− Administer high-flow oxygen.
SummarySummary
• Most EMS systems rarely respond to hematologic emergencies.
• Blood performs respiratory, nutritional, excretory, regulatory, and defensive functions.
• Blood is made up of plasma and formed elements, including RBCs, WBCs, and platelets.
SummarySummary
• Common lab blood tests are RBC count, hemoglobin level, and hematocrit measurement.
• Blood tests measuring subtypes of WBCs can provide valuable information about the status of the immune system.
• The ABO system is commonly used to classify blood types.
SummarySummary
• During the primary assessment, note any signs and symptoms that may be immediately life threatening.
• While taking a history and during the secondary assessment, look for changes in the level of consciousness.
• General blood disorder management should include oxygen, fluids, ECG, transport, medications, and psychological support.
SummarySummary
• Hematologic disorders include sickle cell crisis, anemia, leucopenia, thrombocytopenia, leukemia, lymphomas, polycythemia, DIC, hemophilia, multiple myeloma, and complications of blood transfusions.
SummarySummary
• A patient experiencing a sickle cell crisis will experience significant pain.
• A patient with anemia has a low hemoglobin or RBC level.
• Leukopenia is a reduction in the number of WBCs. Thrombocytopenia is a reduction in the number of platelets.
• Leukemia is a cancer that affects the production of WBCs.
SummarySummary
• Lymphomas are a group of malignant disorders that occur within the lymphoid system. The two types are non-Hodgkin (most common) and Hodgkin lymphoma.
• Polycythemia is an overabundance or overproduction of RBCs.
• Disseminated intravascular coagulation (DIC) may result from a massive injury, sepsis, or obstetric complications.
SummarySummary
• Hemophilia is a bleeding disorder in which clotting does not happen or is insufficient.
• Multiple myeloma is a cancer of the bone marrow caused by malignant plasma cells.
• Complications of blood transfusions are similar to anaphylactic reactions. They are caused by a mismatch of the patient’s blood type to that received, or an allergic reaction to preservatives or agents in the transfused product.
CreditsCredits
• Chapter opener: © Monkey Business Images/ShutterStock, Inc.
• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Blue—Courtesy of Rhonda Beck; Lime—© Photodisc; Purple—Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.