Alexander ch26 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 26
Hematologic Disorders

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the anatomy and physiology of the hematologic
system.
3. Describe the pathophysiology and complications of sickle
cell disease.
4. Recognize the signs and symptoms of vaso-occlusive
crisis.
5. Describe the etiologies and pathophysiology of anemias.
6. Explain the etiology and pathophysiology of diseases of
the white blood cells, including leukemias and
lymphomas.
Objectives (1 of 2)

7. Describe the etiology and pathophysiology of disorders
of coagulation and hemostasis, including disseminated
intravascular coagulation (DIC) and hemophilia.
8. Discuss the risk factors, signs and symptoms, and
consequences of deep vein thrombosis.
9. Develop a list of differential diagnoses for patients
presenting with signs and symptoms of hematologic
disorders.
10.Provide prehospital treatment appropriate to the needs
of patients with a variety of hematologic disorders.
Objectives (2 of 2)

• Hematology
– Study of blood and blood-forming (hemopoietic)
organs and tissues
• Disorders related to red blood cells (RBCs), white
blood cells (WBCs), platelets, or coagulation
Introduction

Think About It
• How could a history of sickle cell disease relate to
a complaint of abdominal pain?
• What additional information do Cecil and Eliza
need to provide the patient with the best care
possible?
• What prehospital interventions should Cecil and
Eliza anticipate based on the information so far?

Anatomy and Physiology Review (1 of 9)
• Plasma
– Liquid transport medium of the blood
– 55% blood volume; 92% water
• Formed elements of blood
– Eythrocytes (RBCs)
– Leukocytes (WBCs)
– Thrombocytes (platelets)
• How many liters of blood does the average
adult have?

• Liver, spleen, bone marrow: eliminate aged and
damaged blood cells
• Erythropoietin:
– Kidneys and liver secrete hormone that stimulates RBC
production.
• Plasma
– Proteins (albumin, clotting factors, antibodies)
– Carries electrolytes, nutrients, medications, hormones,
other substances throughout body

Figure 26-1
Hypoxia triggers increased release of erythropoietin, a hormone that stimulates the bone
marrow to produce red blood cells (RBCs).
(Bledsoe, Bryan E.; Martini, Frederic H.; Bartholomew, Edwin F.; Ober, William C.;
Garrison, Claire W.; Anatomy & Physiology for Emergency Care, 2nd Edition, © 2008.
Reprinted with permission of Pearson Education, Inc., Upper Saddle River, NJ)

• Red blood cells
– Flattened disks
– Provide surface area for gas exchange; flexible to
squeeze through capillaries
– Limited life span of 120 days
– Erythropoietin increases to stimulate bone marrow to
increase production of RBCs.

• Red blood cells (continued)
– Hematocrit
 Measure of percentage of blood volume composed of
formed elements
– Hemoglobin
 Iron-containing protein that carries oxygen and carbon
dioxide within RBCs

• White blood cells
– Produced in bone marrow
– Signaled by chemical messengers to travel to areas
where they are needed
– Types: neutrophils, eosinophils, basophils, monocytes,
lymphocytes
– Different types of WBCs respond preferentially to
different kinds of antigens.

Figure 26-2
The clotting (coagulation) cascade.

• Platelets
– Fragments of thrombocytes
– Activated by exposed tissue collagen in injured blood
vessels
– Become sticky and adhere to injured tissue and to
each other, creating platelet plug
– Hemostasis process is completed by the activation of
clotting cascade.

• Hemostasis
– Process of stopping bleeding
• Three phases following injury
– Injured vessel constricts to slow flow of blood.
– Platelets are attracted to the area and form platelet
plug.
– Clotting cascade

Table 26-1 (1 of 3)
Medications and Herbal Supplements That Can Affect Blood Clotting
Medication or Supplement Use Complications
alfalfa Used as a tea for arthritis and
multiple other conditions
Contains coumarin and vitamin K; excessive
use can interfere with anticoagulant drug
therapy
aspirin Anti-inflammatory, analgesic,
platelet aggregation inhibitor
Increased bleeding from impaired platelet
function
aspirin plus extended-release
dipyridamole (Aggrenox)
Platelet aggregation inhibitor Increased bleeding from impaired platelet
function
apixaban (Eliquis) Anticoagulant Inhibits blood clotting mechanism; increased
bleeding
borage oil Used as an anti-inflammatory Can prolong bleeding times
clopidogrel (Plavix) Platelet aggregation inhibitor Increased bleeding from impaired platelet
function
dabigagtrin etexilate (Pradaxa) Anticoagulant; used to prevent
blood clots in atrial fibrillation
Inhibits blood clotting mechanism; increases
bleeding
dipyridamole (Persantine Platelet aggregation inhibitor Increased bleeding from impaired platelet
function
enoxaparin (Lovenox) Low-molecular weight heparin used
in injectable form as an
anticoagulant
Inhibits blood clotting mechanism; increased
bleeding
dong quai Taken for several reasons, including
to treat premenstrual symptoms and
menstrual cramps
Contains coumarins and can interact with
warfarin, increasing bleeding risk

Table 26-1 (2 of 3)
feverfew Taken to prevent migraine
headaches
Has antiplatelet and anticoagulant effects
garlic Used in concentrated, capsule form
as an antiinflammatory, as an anti-
infective, and to decrease risk of
heart disease
Can cause increased bleeding when taken in
conjunction with warfarin; decreases platelet
aggregation
ginger Used as an anti-inflammatory,
antinausea, and analgesic
supplement
Decreases platelet aggregation
gingko biloba Taken to improve mental clarity and
memory
Decreases platelet aggregation
guarana Used as a stimulant; found in
energy drinks
Inhibits platelet aggregation
horse chestnut varicose veins Contains coumarin and increases risk of bleeding
nonsteroidal anti-
inflammatories
(ibuprofen, naproxen,
others)
Anti-inflammatory, analgesic Irritates gastrointestinal tract, inhibits platelets
prasugrel (Effient) Platelet aggregation inhibitor Increased bleeding from impaired platelet
function
rivaroxaban (Xaralto) Anticoagulant Inhibits blood clotting mechanism; increased
bleeding

Table 26-1 (3 of 3)
ticlopidine (Ticlid) Platelet aggregation inhibitor Increased bleeding from impaired platelet
function
turmeric Used to treat arthritis and
inflammatory conditions
Antiplatelet effects
vitamin E Antioxidant Inhibits platelet aggregation
vitamin K Dietary intake from green leafy
vegetables
Can block effects of heparin and warfarin,
interfering with their ability to prevent
blood clots
warfarin (Coumadin) Anticoagulant Inhibits portions of the clotting cascade
white willow bark Anti-inflammatory and analgesic;
has properties similar to aspirin
Can inhibit platelet aggregation and cause
gastrointestinal irritation

• Blood groups
– Determined by ABO and Rh antigen systems
– A, B, both A and B, or no (O) antigens
– Type O can only receive type O blood.
• Universal donor
• Universal recipient

• Blood groups (continued)
– Rh-positive: Rh antigen on RBCs; do not have anti-Rh
antibodies in blood
– Rh-negative: do not have Rh antigen on RBCs; do not
initially have anti-Rh antibodies
 If exposed to Rh-positive blood, develop anti-Rh antibodies
 Explains hemolytic disease of newborn

Assessment and Management (1 of 3)
• Complaint depends on exact nature of problem
– Sickle cell
– Warfarin use
– Leukemia
– Excessive platelets

Figure 26-5
Petechiae. (© Dr. P. Marazzi/ Science Source)

• Check for and control significant hemorrhage.
• Look for purpura, petechiae, or lymphadenopathy.
• Treatment:
– Oxygen, fluid replacement, analgesia

Table 26-2
Signs and Symptoms of Hematologic Disorders
• Tachycardia
• Tachypnea
• Dyspnea
• Fatigue, malaise, weakness
• Pallor
• Lymphadenopathy (swollen, tender lymph nodes)
• Fever
• Hematuria
• Petechiae (pinpoint hemorrhages that may appear like a rash)
• Purpura (hemorrhagic area in the skin > 3 mm in diameter)
• Unusual bruising or bleeding
• Pruritus (itching)
• Abdominal pain
• Joint pain and swelling
• Syncope
• Jaundice
• Severe night sweats

• Obtain a set of baseline vital signs and use
monitoring devices according to the situation.
• The patient’s list of medications can be particularly
helpful in determining whether the patient has, or
is at risk for, a hematologic problem.

Blood Transfusion Reactions
• Signs and symptoms of transfusion reaction
– Flushing
– Pain at infusion site
– Chest pain
– Back or flank pain
– Restlessness or anxiety
– Nausea
– Fever, chills
– Renal failure

Red Blood Cell Disorders (1 of 4)
• Anemia
– Abnormally low hematocrit
– Causes:
 Decreased production of RBCs
 Increased destruction of RBCs
 Loss of RBCs (hemorrhage)
– Cells do not receive enough oxygen for energy
production.

• Anemia signs and symptoms
– Fatigue
– Pallor
– Tachycardia
– Shortness of breath, particularly on exertion
– Severe cases could include chest pain/signs of
heart failure
• What are the causes of anemia?

Figure 26-6
In sickle cell disease, abnormal hemoglobin proteins change shape after releasing oxygen,
causing the red blood cells to become sickle shaped. The abnormally shaped red blood
cells can cause vaso-occlusive crisis and have a short life span.

• Sickle cell disease
– Genetic disorder
– Common in people of African, Mediterranean, Middle
Eastern, Caribbean, and South and Central American
origin or descent.
– RBCs take on abnormal curved (sickle-shaped)
appearance.
– RBCs live only 10 to 20 days.

• Sickle cell disease (continued)
– Abnormal shape of sickle cells makes it difficult for
them to move through capillaries.
– More prone to clumping together
– The clumping of sickle cells with subsequent
obstruction of capillary beds is called a vaso-occlusive
crisis.

• Leukemia
– Cancer causes bone marrow to rapidly produce large
numbers of abnormal WBCs.
– Crowd out normal cells, resulting in anemia, bleeding,
infection
– Signs and symptoms:
 Easy bruising, bone pain, enlarged spleen, swollen lymph
nodes, repeated infections, fatigue
White Blood Cell Disorders (1 of 3)

• Lymphoma
– Cancers of lymphocytes (B or T lymphocytes)
localized to lymph nodes
– Either Hodgkin’s or non-Hodgkin’s lymphoma
– Survival rate for Hodgkin’s lymphoma very high;
relatively high for non-Hodgkin’s lymphoma.

• Multiple myeloma
– Cancer of cells in bone marrow
– Abnormal cells multiply and crowd out normal cells.
– Decreased production of blood cells; results in
pathologic fracture of affected bone

Clotting Disorders (1 of 4)
• Platelet disorders
– Thrombocytopenia
 Low number of platelets
– Platelets reduced in number or impaired by leukemia
or bone marrow disorders
– Thrombocytosis
 Increased platelet count results in risks for bleeding and
clotting

• Hemophilia
– Inherited disease
 Deficiencies in certain clotting factors
– Painful, swollen joints; abnormal menstrual bleeding;
bleeding gums; bruising; epistaxis; rash; purpura;
petechiae; prolonged bleeding; gastrointestinal and
urinary tract bleeding
– Treatment
 Replacement of specific clotting factor

• Blood clots and deep vein thrombosis
– Deep vein thrombosis (DVT)
 Blood clots form in deep, large veins of legs, pelvis, arms.
– If DVT breaks loose, can cause pulmonary embolism.
– Anticoagulant medications

• Disseminated intravascular coagulation (DIC)
– Results from systemic overactivation of clotting
mechanisms
 Blood transfusion reactions
 Sepsis
 Surgery
 Severe trauma

Chapter Summary (1 of 3)
• Hematology: study of blood and blood-forming
organs
• Blood comprised of plasma (transport medium)
and formed elements
• Plasma: proteins, antibodies, clotting factors,
electrolytes, nutrients
• RBCs carry oxygen and carbon dioxide bound to
hemoglobin for gas exchange.

• Decrease in RBCs from blood loss, decreased
production, or increased destruction can lead to
tissue hypoxia.
• Abnormal shape of RBCs in sickle cell disease
leads to increased hemolysis and microvascular
occlusion.
• Antigens on RBC surface are the basis of blood
typing.

• Increase in WBCs result of response to infection,
inflammation, or pathologic process.
• Each type of WBC has specific functions.
• Hemostatic process: vasospasm, platelet
aggregation, clotting cascade
• Patient’s list of medications provides information.
• Abnormal localized blood clotting: DVT
• Systemic over activation of clotting mechanisms:
DIC

Alexander ch26 lecture

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