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Curriculum Update: The Hematopoietic System, Patients with Special Challenges, Interventions For The Patient With Chronic Care Needs Condell Medical Center.

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Presentation on theme: "Curriculum Update: The Hematopoietic System, Patients with Special Challenges, Interventions For The Patient With Chronic Care Needs Condell Medical Center."— Presentation transcript:

1 Curriculum Update: The Hematopoietic System, Patients with Special Challenges, Interventions For The Patient With Chronic Care Needs Condell Medical Center EMS System August 2006 Site Code # E1206 Program revised by: Sharon Hopkins, RN, BSN EMS Educator

2 Objectives Upon successful completion of this CE module, the EMS provider should be able to: Upon successful completion of this CE module, the EMS provider should be able to: discuss insults to the hematopoietic system discuss insults to the hematopoietic system discuss the uniqueness when caring for patients with special challenges discuss the uniqueness when caring for patients with special challenges review acute interventions necessary for the chronic care patient review acute interventions necessary for the chronic care patient discuss medications used in Region X discuss medications used in Region X participate in case scenario review participate in case scenario review successfully complete the post quiz with a score of 80% or better successfully complete the post quiz with a score of 80% or better

3 Hematology Definition - the study of blood and blood- forming organs collectively known as the hematopoetic system. Definition - the study of blood and blood- forming organs collectively known as the hematopoetic system. Prehospital care for most patients with hematological disorders is mainly supportive. Prehospital care for most patients with hematological disorders is mainly supportive. Understanding some of the hematological disorders enhances EMS assessment skills Understanding some of the hematological disorders enhances EMS assessment skills

4 Blood Cells Produced mainly in bone marrow - the spongy material in the center of bone Produced mainly in bone marrow - the spongy material in the center of bone Assistance to regulation of production, destruction and differentiation (development of a specific function) of cells carried out in the: Assistance to regulation of production, destruction and differentiation (development of a specific function) of cells carried out in the: lymph nodes lymph nodes spleen spleen liver liver

5 Components of Blood Plasma Plasma Platelets Platelets thrombocytes thrombocytes White blood cells White blood cells leukocytes leukocytes Red blood cells Red blood cells erythrocytes erythrocytes

6 Components by Volume - RBC’s 95% of volume of formed elements -WBC’s & platelets together form <5% of formed elements

7 Components of Blood 78% water 78% water 22% solids (plasma, RBC’s, WBC’s, platelets) 22% solids (plasma, RBC’s, WBC’s, platelets) Plasma Plasma Clear fluid part of blood; about 92% water Clear fluid part of blood; about 92% water Plasma contains various cellular materials in solution and suspension: Plasma contains various cellular materials in solution and suspension: proteins (albumin, globulins, fibrinogen) proteins (albumin, globulins, fibrinogen) salts salts metals metals inorganic compounds inorganic compounds

8 Red Blood Cells (RBC’s) - Erythrocytes Red Blood Cells (RBC’s) - Erythrocytes Mainly comprised of water and hemoglobin Mainly comprised of water and hemoglobin Hemoglobin (a protein) - oxygen carrying component of the RBC; gives blood its red color; carries oxygen Hemoglobin (a protein) - oxygen carrying component of the RBC; gives blood its red color; carries oxygen Primary function of RBC: Primary function of RBC: transport oxygen from the lungs to various body tissue transport oxygen from the lungs to various body tissue transport carbon dioxide from various tissues to the lungs transport carbon dioxide from various tissues to the lungs Average life expectancy RBC days Average life expectancy RBC days

9 Pulse Oximetry Estimates the amount of oxygen carried in the bloodstream using infrared technology across the skin Estimates the amount of oxygen carried in the bloodstream using infrared technology across the skin

10 White Blood Cells (WBC’s) - Leukocytes White Blood Cells (WBC’s) - Leukocytes Helps fight infection and aids in the immune process Helps fight infection and aids in the immune process Helps heal wounds by ingesting matter (dead cells, tissue debris, old RBC’s) Helps heal wounds by ingesting matter (dead cells, tissue debris, old RBC’s) Protects the body from foreign material (antigens) Protects the body from foreign material (antigens) Involved in the protection from mutated cells (ie: cancer) Involved in the protection from mutated cells (ie: cancer) Includes: lymphocytes, monocytes, eosinophils, basophils, neutrophils Includes: lymphocytes, monocytes, eosinophils, basophils, neutrophils

11 Platelets - Thrombocytes Platelets - Thrombocytes Small, sticky cells Small, sticky cells Helps in blood clotting Helps in blood clotting Groups together to form clumps to plug holes and leaks to stop the bleeding Groups together to form clumps to plug holes and leaks to stop the bleeding WBC’s, RBC’s, and platelets make up about 45% of the blood volume WBC’s, RBC’s, and platelets make up about 45% of the blood volume Plasma takes up about 55% of the blood volume Plasma takes up about 55% of the blood volume

12 More Blood Components Fat globules Fat globules Chemical substances Chemical substances carbohydrates carbohydrates proteins proteins hormones hormones Gases including Gases including oxygen oxygen carbon dioxide carbon dioxide nitrogen nitrogen

13 Complete Blood Count - CBC A particular and common blood test A particular and common blood test Measures the size, number, and maturity of different blood cells in a specific volume of blood Measures the size, number, and maturity of different blood cells in a specific volume of blood Can be used to determine abnormalities Can be used to determine abnormalities in production of blood cells in production of blood cells in destruction of blood cells in destruction of blood cells

14 Blood Groups Surfaces of RBC’s contain glycoproteins and glycolipids Surfaces of RBC’s contain glycoproteins and glycolipids Based on the presence or absence of isoantigens (an antigen substance that can stimulate antibody production), we can classify blood into groups Based on the presence or absence of isoantigens (an antigen substance that can stimulate antibody production), we can classify blood into groups Most common blood grouping is ABO and Rh Most common blood grouping is ABO and Rh A, B, AB, and O blood types A, B, AB, and O blood types Person can be Rh + or Rh - Person can be Rh + or Rh -

15 Blood Types Type AB blood- universal recipient Type AB blood- universal recipient Can receive any of the 4 types of blood Can receive any of the 4 types of blood Carries both A & B antigens but does not have antibodies to A or B blood Carries both A & B antigens but does not have antibodies to A or B blood Type O blood - universal donor Type O blood - universal donor Can be given to patients regardless of blood type Can be given to patients regardless of blood type Has both anti-A & anti-B antibodies but no antigens Has both anti-A & anti-B antibodies but no antigens Type A blood has A antigens & anti-B antibodies Type A blood has A antigens & anti-B antibodies Can receive type A or O blood only Can receive type A or O blood only Type B blood has B antigens & anti-A antibodies Type B blood has B antigens & anti-A antibodies Can receive type B or O blood only Can receive type B or O blood only

16 Blood groups Rh blood groups Rh blood groups Discovered in the blood of the rhesus monkey in 1940’s Discovered in the blood of the rhesus monkey in 1940’s If the blood has Rh antigen they are Rh + If the blood has Rh antigen they are Rh + If the blood lacks the antigen they are Rh - If the blood lacks the antigen they are Rh - Rh + & Rh - blood is incompatible; the immune system makes antibodies if mixed Rh + & Rh - blood is incompatible; the immune system makes antibodies if mixed When a subsequent infusion of Rh + blood is received the immune response causes a severe reaction (hemolysis - breakdown of RBC’s and release of hemoglobin) When a subsequent infusion of Rh + blood is received the immune response causes a severe reaction (hemolysis - breakdown of RBC’s and release of hemoglobin)

17 Acquired Factor Deficiencies Hemolytic disease of the newborn Hemolytic disease of the newborn Arises during pregnancy Arises during pregnancy Maternal and fetal blood may be incompatible if Rh factor discrepancy is present Maternal and fetal blood may be incompatible if Rh factor discrepancy is present Usually the first born is unaffected Usually the first born is unaffected Future problems in pregnancy prevented by Rhogam injections given after birth to Rh - mother delivering an Rh + baby Future problems in pregnancy prevented by Rhogam injections given after birth to Rh - mother delivering an Rh + baby Rhogam given to Rh - mother binds to any Rh + antigens left by the fetus and prevent any production of antibodies by the mother that would affect future pregnancies of Rh + baby Rhogam given to Rh - mother binds to any Rh + antigens left by the fetus and prevent any production of antibodies by the mother that would affect future pregnancies of Rh + baby

18 Blood Transfusions Blood Transfusions Blood is the most easily shared human tissue Blood is the most easily shared human tissue Many lives are saved each year Many lives are saved each year Most often used to alleviate anemia Most often used to alleviate anemia An antibody-antigen reaction can occur causing the transfused blood to hemolyze or burst An antibody-antigen reaction can occur causing the transfused blood to hemolyze or burst The liberated hemoglobin causes kidney damage from sludging The liberated hemoglobin causes kidney damage from sludging

19 Hemostasis The sequence of clot formation that stops bleeding The sequence of clot formation that stops bleeding Quick, localized and carefully controlled Quick, localized and carefully controlled Three mechanisms reduce blood loss: Three mechanisms reduce blood loss: Vascular spasm - local vasoconstriction Vascular spasm - local vasoconstriction Platelet plug formation Platelet plug formation Blood clotting (coagulation) Blood clotting (coagulation) Failure of these mechanisms could result in hypoperfusion and shock Failure of these mechanisms could result in hypoperfusion and shock

20 Mechanisms of Hemostasis Vascular spasm Vascular spasm Contraction of the smooth muscle around the injured vessel Contraction of the smooth muscle around the injured vessel Plug formation Plug formation Platelets stick to the walls (platelet adhesion) Platelets stick to the walls (platelet adhesion) Platelets physically change to have projections that hold onto one another Platelets physically change to have projections that hold onto one another Enzymes released that make other platelets more sticky in the same area Enzymes released that make other platelets more sticky in the same area

21 Mechanisms of Hemostasis Blood clotting Blood clotting A ruptured blood vessel exposes collagen and other structural proteins to the blood A ruptured blood vessel exposes collagen and other structural proteins to the blood Proteins activate an enzyme reaction & certain blood proteins are changed into long fibrin strands Proteins activate an enzyme reaction & certain blood proteins are changed into long fibrin strands A gelatinous mass is formed that further occludes vessel opening A gelatinous mass is formed that further occludes vessel opening Clot reabsorbed by body when no longer needed Clot reabsorbed by body when no longer needed

22 General Patient Assessment Most patients with hematological problems are dealing with a chronic condition Most patients with hematological problems are dealing with a chronic condition Most patients need help due to a change in their baseline condition Most patients need help due to a change in their baseline condition Most care administered by EMS providers will be supportive in nature - treat the symptoms Most care administered by EMS providers will be supportive in nature - treat the symptoms When possible, honor patient requests for hospital destination When possible, honor patient requests for hospital destination improved continuity of care improved continuity of care have release signed if necessary (not closest) have release signed if necessary (not closest)

23 Patient Assessment Scene size-up, BSI precautions, general impression Scene size-up, BSI precautions, general impression Initial assessment Initial assessment Assess airway, breathing, circulation, mental status (AVPU) Assess airway, breathing, circulation, mental status (AVPU) Check for life threats Check for life threats  common issues could include life- threatening bleeds and massive infections with septic shock

24 Patient Assessment cont’d Focused history and physical exam Focused history and physical exam Patient categorized as: Patient categorized as:  responsive or unresponsive medical patient  trauma patient with significant or non-significant mechanism of injury Categorization determines which format is used to complete history and physical Categorization determines which format is used to complete history and physical

25 Patient Assessment cont’d SAMPLE history SAMPLE history anemia - increased heart rate & respirations anemia - increased heart rate & respirations poor tissue oxygenation - fatigue, malaise, apprehension, confusion, change in skin color poor tissue oxygenation - fatigue, malaise, apprehension, confusion, change in skin color clotting problem - excessive bruising, skin discoloration clotting problem - excessive bruising, skin discoloration infection - lymph node enlargement (swollen glands), sore throat, pain on swallowing infection - lymph node enlargement (swollen glands), sore throat, pain on swallowing bleeding abnormalities - nausea, anorexia, bloody vomiting or diarrhea, bleeding gums bleeding abnormalities - nausea, anorexia, bloody vomiting or diarrhea, bleeding gums Vital signs, pulse oximetry, pain scale, EKG Vital signs, pulse oximetry, pain scale, EKG

26 Patient Assessment cont’d Physical exam Physical exam eye problems eye problems. especially with autoimmune disorders (immune system can’t determine which tissues are self and which are not) and sickle cell anemia skin condition skin condition. liver disease or hemolysis of RBC’s - jaundice. polycythemia - reddish tone. anemia - pale. bleeding under the skin - petechia (tiny red dots), purpura (large purple blotches), bruising. pruritis (itching) - excess of bilirubin. prolonged bleeding of relatively minor injuries

27 Patient Assessment cont’d GI system GI system Low platelet counts & blood clot abnormalities Low platelet counts & blood clot abnormalities. epistaxis (nosebleed) is common. may swallow excessive blood causing nausea and loose, dark bowel movements. bleeding of the gums. abdominal pain especially associated with problems of the spleen and/or liver Musculoskeletal system Musculoskeletal system Pain & swelling in joints Pain & swelling in joints. autoimmune diseases (rheumatoid arthritis), hemophilia (bleeding into joint)

28 Patient Assessment cont’d Cardiorespiratory system Cardiorespiratory system Anemia Anemia. dyspnea, tachycardia, chest pain Genitourinary system Genitourinary system Hematuria - blood in the urine Hematuria - blood in the urine Heavy menstrual bleeding Heavy menstrual bleeding Frank vaginal bleeding Frank vaginal bleeding

29 General Treatment Airway & breathing Airway & breathing Supplemental oxygen usually with non-rebreather Supplemental oxygen usually with non-rebreather Watch for dyspnea and fatigue Watch for dyspnea and fatigue Circulation Circulation Fluid volume replacement with crystalloid solution (ie: NS or LR) does not carry oxygen Fluid volume replacement with crystalloid solution (ie: NS or LR) does not carry oxygen Watch for & treat dysrhythmias Watch for & treat dysrhythmias Comfort measures Comfort measures Morphine, oxygen, positioning Morphine, oxygen, positioning Psychological support for patient & family Psychological support for patient & family

30 Diseases of Red Blood Cells Anemias Anemias The most common disease of RBC’s The most common disease of RBC’s Defined as a hematocrit less than 37% in women; 40% in men Defined as a hematocrit less than 37% in women; 40% in men Sickle cell anemia = sickle cell disease Sickle cell anemia = sickle cell disease Disorder in production of red cells (sickle shape when oxygen levels become low) Disorder in production of red cells (sickle shape when oxygen levels become low) Polycythemia Polycythemia Excess production in red blood cells Excess production in red blood cells

31 Anemia A sign and not a disease process A sign and not a disease process Bone marrow must be able to keep up with the destruction of older RBC’s to maintain adequate percentages Bone marrow must be able to keep up with the destruction of older RBC’s to maintain adequate percentages Anemia is a significant drop in the percentage of red blood cells (RBC’s) (low hematocrit) Anemia is a significant drop in the percentage of red blood cells (RBC’s) (low hematocrit) Oxygen carrying capacity of the blood is reduced due to decrease in hemoglobin Oxygen carrying capacity of the blood is reduced due to decrease in hemoglobin Females may temporarily decrease RBC levels during menstruation Females may temporarily decrease RBC levels during menstruation

32 Anemia Signs and symptoms Signs and symptoms Fatigue, intolerance of cold, pale skin, dizziness, irritability, tachycardia, shortness of breath, chest pain Fatigue, intolerance of cold, pale skin, dizziness, irritability, tachycardia, shortness of breath, chest pain Many actual types of anemia: Many actual types of anemia: Iron deficiency - inadequate iron intake Iron deficiency - inadequate iron intake Pernicious - poor absorption vitamin B12 Pernicious - poor absorption vitamin B12 Hemolytic - RBC’s destroyed faster than produced Hemolytic - RBC’s destroyed faster than produced Aplastic - bone marrow fails to produce blood cells Aplastic - bone marrow fails to produce blood cells

33 Sickle Cell Anemia/Disease Inherited disorder of red blood cell production Inherited disorder of red blood cell production RBC’s have sickle shape when oxygen levels are low; red blood cells become rigid RBC’s have sickle shape when oxygen levels are low; red blood cells become rigid Average sickled RBC life span days (normal is 120 days) Average sickled RBC life span days (normal is 120 days) Generation of new RBC’s can’t keep up with the hemolysis (destruction) Generation of new RBC’s can’t keep up with the hemolysis (destruction) Blood viscosity increased Blood viscosity increased sludging of blood sludging of blood obstruction of capillaries & small blood vessels obstruction of capillaries & small blood vessels blood flow to tissues & organs disrupted blood flow to tissues & organs disrupted tissues & organs eventually damaged tissues & organs eventually damaged adults often have multiple organ problems adults often have multiple organ problems  cardiopulmonary, renal, neurological diseases

34 Sickle Cell Crisis Disease not limited to 1 ethnicity but can affect many including Caucasian Disease not limited to 1 ethnicity but can affect many including Caucasian 3 presentations of crisis common: 3 presentations of crisis common: ¬ Vasoocclusive crisis musculoskeletal pain musculoskeletal pain abdominal pain abdominal pain priapisms priapisms pulmonary problems pulmonary problems renal crisis (renal infarction) renal crisis (renal infarction) central nervous system crisis (cerebral infarctions) central nervous system crisis (cerebral infarctions)

35 Sickle Cell Crisis cont’d ­ Hematological Crisis fall in hemoglobin level fall in hemoglobin level stagnation of red blood cells in spleen stagnation of red blood cells in spleen problems with bone marrow function problems with bone marrow function ® Infectious crisis patient functionally immunosuppressed patient functionally immunosuppressed  vulnerable to infection & sepsis loss of splenic function makes patient susceptible to massive bacterial infection loss of splenic function makes patient susceptible to massive bacterial infection

36 Sickle Cell Complications Sepsis - due to immunosuppression Sepsis - due to immunosuppression Acute chest syndrome Acute chest syndrome infection or sickled red cells trapped in lungs infection or sickled red cells trapped in lungs dyspnea, coughing, chest pain dyspnea, coughing, chest pain Hand-and-foot syndrome Hand-and-foot syndrome painful swelling due to severe vascular occlusion painful swelling due to severe vascular occlusion Splenic sequestration crisis Splenic sequestration crisis accumulation of sickled cells in spleen accumulation of sickled cells in spleen pale, enlarged spleen, abdominal pain, shock pale, enlarged spleen, abdominal pain, shock

37 Sickle Cell Complications cont’d Aplastic crisis Aplastic crisis severe anemia when bone marrow temporarily stops producing red blood cells severe anemia when bone marrow temporarily stops producing red blood cells pale, tired, less active than normal pale, tired, less active than normal Stroke Stroke cerebral vascular occlusion due to sickled cells cerebral vascular occlusion due to sickled cells can affect any age can affect any age extremity weakness, change in level of consciousness extremity weakness, change in level of consciousness Painful episode Painful episode acute and severe pain anywhere but most often hands, arms, chest, legs, feet acute and severe pain anywhere but most often hands, arms, chest, legs, feet

38 Prehospital Care Sickle Cell Anemia/Disease Care is primarily supportive Care is primarily supportive Oxygen via nonrebreather mask to increase the saturation of the circulating RBC’s - evaluate pulse oximetry Oxygen via nonrebreather mask to increase the saturation of the circulating RBC’s - evaluate pulse oximetry IV of normal saline to hydrate patient IV of normal saline to hydrate patient Pain relief with analgesics Pain relief with analgesics larger than normal amounts of morphine are often required for pain control larger than normal amounts of morphine are often required for pain control involve medical control for higher dosing involve medical control for higher dosing

39 Polycythemia Abnormally high percentage of RBC’s (high hematocrit) Abnormally high percentage of RBC’s (high hematocrit) Rare disorder; typically in people over 50 Rare disorder; typically in people over 50 No cure but can be treated No cure but can be treated Can be caused by: Can be caused by: Unregulated increase in RBC production Unregulated increase in RBC production Tissue hypoxia Tissue hypoxia Dehydration Dehydration Blood doping - athlete training at high altitudes to increase RBC production Blood doping - athlete training at high altitudes to increase RBC production Makes it harder to pump blood through the body because it’s thicker Makes it harder to pump blood through the body because it’s thicker Increases risk of thrombosis Increases risk of thrombosis

40 Polycythemia Signs and symptoms Signs and symptoms Bleeding abnormalities Bleeding abnormalities. epistaxis, spontaneous bruising, GI bleeding Headache, dizziness, blurred vision Headache, dizziness, blurred vision Itching Itching Severe cases with congestive heart failure Severe cases with congestive heart failure Treatment Treatment Supportive Supportive. IV - O 2 - monitor Hospital treatment - phlebotomy (“blood letting”) to remove excess red blood cells Hospital treatment - phlebotomy (“blood letting”) to remove excess red blood cells

41 Diseases of White Blood Cells (WBC’s) White blood cells are body’s principal defense system against infection White blood cells are body’s principal defense system against infection Problems could include: Problems could include: Leukopenia/neutropenia Leukopenia/neutropenia. decrease in number of WBC’s Leukocytosis Leukocytosis. increase in number of circulating WBC’s. could indicate: bacterial infection, rheumatoid arthritis, DKA, leukemia, pain, excercise Leukemia Leukemia Lymphomas Lymphomas

42 Leukemia Malignant disease (cancer) of blood forming tissue Malignant disease (cancer) of blood forming tissue Classifications Classifications Acute lymphocytic leukemia (ALL) Acute lymphocytic leukemia (ALL). primarily of children and young adults Acute myelogenous leukemia (AML) Acute myelogenous leukemia (AML). primarily of older people in their 60’s and 70’s Chronic lymphocytic leukemia (CLL) Chronic lymphocytic leukemia (CLL). primarily of older people in their 60’s and 70’s Chronic myelogenous leukemia (CML) Chronic myelogenous leukemia (CML). occurs in children and adults

43 Leukemia Common presentations: Common presentations: moderate to severe anemia moderate to severe anemia abnormal decrease in platelets abnormal decrease in platelets patient appears acutely ill; febrile, weak, & fatigued; lymph node enlargement; history of weight loss & anorexia; enlarged liver & spleen with abdominal tenderness; tender sternum patient appears acutely ill; febrile, weak, & fatigued; lymph node enlargement; history of weight loss & anorexia; enlarged liver & spleen with abdominal tenderness; tender sternum Common complication - infection Common complication - infection primarily due to low number of circulating neutrophils (main blood component protecting against bacterial or fungal infection) primarily due to low number of circulating neutrophils (main blood component protecting against bacterial or fungal infection)

44 Leukemia & EMS Care Patient at risk for infection Patient at risk for infection Isolation techniques (gloves and masks) to prevent spread of your germs to the patient Isolation techniques (gloves and masks) to prevent spread of your germs to the patient Care primarily supportive Care primarily supportive Position of comfort Position of comfort Oxygen via nonrebreather mask if needed Oxygen via nonrebreather mask if needed IV (fluid bolus if patient is dehydrated) IV (fluid bolus if patient is dehydrated) Analgesics (ie: morphine) for pain Analgesics (ie: morphine) for pain

45 Lymphomas Cancer of the lymphatic system Cancer of the lymphatic system Most prominent in the lymph nodes Most prominent in the lymph nodes Malignant lyphoma classification: Malignant lyphoma classification: Hodgkin’s lymphoma Hodgkin’s lymphoma. 7,500 diagnosed annually in USA. long-term survival better. treatable with radiation, chemotherapy, or both. can be curable Non-Hodgkin’s lymphoma Non-Hodgkin’s lymphoma. 40,000 diagnosed annually in USA. cure rate depends on type of lymphoma identified

46 Lymphoma Presenting signs & symptoms Presenting signs & symptoms may report fever, night sweats, anorexia, weight loss, fatigue, itching may report fever, night sweats, anorexia, weight loss, fatigue, itching many with Hodgkin’s have no symptoms many with Hodgkin’s have no symptoms non-Hodgkin’s most commonly have swollen lymph nodes non-Hodgkin’s most commonly have swollen lymph nodes Field treatment Field treatment supportive supportive consider IV, O 2, pain control if necessary consider IV, O 2, pain control if necessary isolation techniques isolation techniques gloves & mask gloves & mask

47 Diseases of Platelets & Blood Clotting Abnormalities Thrombocytosis - increased platelets Thrombocytosis - increased platelets patients usually asymptomatic patients usually asymptomatic Thrombocytopenia - decrease in platelets Thrombocytopenia - decrease in platelets easy bruising & bleeding easy bruising & bleeding Hemophilia Hemophilia absence of protein necessary for blood clotting absence of protein necessary for blood clotting von Willebrand’s disease von Willebrand’s disease inherited disease affecting both sexes inherited disease affecting both sexes excessive bleeding after injury or surgery excessive bleeding after injury or surgery aspirin contraindicated aspirin contraindicated

48 Hemophilia Inherited clotting deficiency Inherited clotting deficiency Females are carriers Females are carriers 1 in 10,000 males have the disease 1 in 10,000 males have the disease Bleeding may occur spontaneously or after minor trauma Bleeding may occur spontaneously or after minor trauma Can be caused by deficiency of different clotting factors - factor VIII or factor IX Can be caused by deficiency of different clotting factors - factor VIII or factor IX Bleeding takes longer to stop because body cannot form stable fibrin clots Bleeding takes longer to stop because body cannot form stable fibrin clots

49 Hemophilia Signs and symptoms Signs and symptoms numerous bruises numerous bruises deep muscle bruising deep muscle bruising joint bleeding - hemarthrosis joint bleeding - hemarthrosis Characterized by blood in the urine, bloody noses and painful, swollen joints Characterized by blood in the urine, bloody noses and painful, swollen joints Permanent joint damage with repeated bleeding Permanent joint damage with repeated bleeding Transfusion of specific clotting factor near time of injury may lessen the bleeding but will never make the disease go away Transfusion of specific clotting factor near time of injury may lessen the bleeding but will never make the disease go away

50 Field Treatment Hemophilia The platelet plug is not stable but the mechanisms of vasoconstriction and platelet aggregation will still occur The platelet plug is not stable but the mechanisms of vasoconstriction and platelet aggregation will still occur Patients may have prolonged bleeding and possible rebleeding Patients may have prolonged bleeding and possible rebleeding IV - O 2 via nonrebreather- monitor IV - O 2 via nonrebreather- monitor Ice application Ice application Superficial injuries - patience & pressure Superficial injuries - patience & pressure If joint injury, splinting will reduce pain If joint injury, splinting will reduce pain Transport to ED necessary for replacement of deficient factor Transport to ED necessary for replacement of deficient factor

51 Other Hematopoietic Disorders Disseminated intravascular coagulation - DIC Disseminated intravascular coagulation - DIC Disorder of coagulation Disorder of coagulation High mortality rate High mortality rate Most commonly results from: Most commonly results from:. sepsis, hypotension, obstetric complications, severe tissue injury, brain injury, cancer, major hemolytic blood transfusion reactions Fibrin clots formed throughout circulation instead of just at the affected area of need Fibrin clots formed throughout circulation instead of just at the affected area of need Simultaneous clotting and bleeding Simultaneous clotting and bleeding Patient experiences widespread thrombosis and end-organ ischemia Patient experiences widespread thrombosis and end-organ ischemia

52 DIC Signs & symptoms Signs & symptoms Oozing blood at venipuncture and wound sites Oozing blood at venipuncture and wound sites Purpuric rash often over chest and abdomen Purpuric rash often over chest and abdomen Minute hemorrhages just under skin Minute hemorrhages just under skin Prehospital care Prehospital care Supportive and focused on symptoms Supportive and focused on symptoms IV - O 2 - monitor IV - O 2 - monitor Patient often hemodynamically unstable Patient often hemodynamically unstable Hospital treatment Hospital treatment Fresh frozen plasma & platelets at hospital Fresh frozen plasma & platelets at hospital

53 Additional Hematopoietic Disorders Multiple myeloma Multiple myeloma Cancer disorder of plasma cells (cells that produce antibodies) Cancer disorder of plasma cells (cells that produce antibodies) Rarely found in persons under 40 Rarely found in persons under 40 Approximately 14,000 new cases every year Approximately 14,000 new cases every year Cancer plasma cells overcrowd healthy cells with a reduction in blood cell production Cancer plasma cells overcrowd healthy cells with a reduction in blood cell production Patient becomes anemic and is prone to infection Patient becomes anemic and is prone to infection

54 Multiple Myeloma Signs & symptoms Signs & symptoms Pain in back or ribs Pain in back or ribs Diseased marrow weakens bones and pathological fractures occur (fractures with minimal or no trauma) Diseased marrow weakens bones and pathological fractures occur (fractures with minimal or no trauma) Fatigue Fatigue Risk for bleeding due to decrease in platelets Risk for bleeding due to decrease in platelets Renal failure from elevated calcium levels Renal failure from elevated calcium levels Increased risk for infection due to a lack of certain antibody secretion Increased risk for infection due to a lack of certain antibody secretion

55 Multiple Myeloma Treatment Prehospital care Prehospital care Supportive Supportive IV if signs of dehydration IV if signs of dehydration Pain control - disease can be painful and pain in presence of pathological fractures Pain control - disease can be painful and pain in presence of pathological fractures Hospital care Hospital care Chemotherapy Chemotherapy Radiation Radiation Bone marrow transplants Bone marrow transplants

56 What Is Bone Marrow? Tissue in the center of large bones where new blood cells are produced Tissue in the center of large bones where new blood cells are produced 2 types of stem cells produced 2 types of stem cells produced hematopoietic stem cells - forms blood cells: hematopoietic stem cells - forms blood cells:. WBC’s - leukocytes. RBC’s - erythrocytes. platelets - thrombocytes stromal stem cells - mix of cells to generate: stromal stem cells - mix of cells to generate:. fat. cartilage. bone. can differentiate into many kinds of tissue (ie: nervous)

57 Bone Marrow

58 Bone Marrow Transplant Pioneered in 1970 Pioneered in 1970 Transplant of hematopoietic stem cells Transplant of hematopoietic stem cells Most often done for life-threatening diseases of blood or bone marrow Most often done for life-threatening diseases of blood or bone marrow acute lymphocytic leukemia acute lymphocytic leukemia acute myelogenous leukemia acute myelogenous leukemia aplastic anemia aplastic anemia chronic myelogenous leukemia chronic myelogenous leukemia Hodgkin’s and non-Hodgkin’s diseases Hodgkin’s and non-Hodgkin’s diseases multiple myeloma multiple myeloma radiation poisoning radiation poisoning

59 Types of Bone Marrow Transplant Autologous bone marrow transplant Autologous bone marrow transplant stem cells obtained months in advance of use stem cells obtained months in advance of use stem cells isolated from patient; stored in freezer; patient treated to destroy remaining stem cells; harvested stem cells reinfused stem cells isolated from patient; stored in freezer; patient treated to destroy remaining stem cells; harvested stem cells reinfused Allogenic bone marrow transplant Allogenic bone marrow transplant involves donor & recipient; must match tissue type involves donor & recipient; must match tissue type recipient requires immunosuppressant drugs recipient requires immunosuppressant drugs donor bone marrow harvested under general anesthesia (>100 needle sticks in large bone) donor bone marrow harvested under general anesthesia (>100 needle sticks in large bone)

60 Bone Marrow Transplant Cont’d Peripheral blood stem cell process - apheresis Peripheral blood stem cell process - apheresis donor blood withdrawn via needle; blood passes thru machine to remove WBC’s; RBC’s returned to donor; WBC stem cells can be stored frozen donor blood withdrawn via needle; blood passes thru machine to remove WBC’s; RBC’s returned to donor; WBC stem cells can be stored frozen recipient gets injection to boost stem cell yield recipient gets injection to boost stem cell yield Cord blood Cord blood donation of umbilical cord & placenta after infant delivered donation of umbilical cord & placenta after infant delivered cord blood yields higher concentration of stem cells but limited volume (50 ml - 2 T) cord blood yields higher concentration of stem cells but limited volume (50 ml - 2 T) usually transplanted into children, not adults usually transplanted into children, not adults cord blood can be stored frozen for years cord blood can be stored frozen for years

61 Bone Marrow Infusion Stem cells (bone marrow transplant) given IVPB Stem cells (bone marrow transplant) given IVPB stem cells circulate in the blood stream stem cells circulate in the blood stream stem cells migrate into bone marrow spaces stem cells migrate into bone marrow spaces stem cells grow & start to produce new blood cells stem cells grow & start to produce new blood cells takes several weeks to grow enough new cells takes several weeks to grow enough new cells Bone marrow transplant mortality rate is high - 10% Bone marrow transplant mortality rate is high - 10% reserved for life-threatening conditions reserved for life-threatening conditions

62 Case Scenario #1 Your 22 year-old patient with hemophilia presents after falling off his motorcycle at low speed. Your 22 year-old patient with hemophilia presents after falling off his motorcycle at low speed. There are some minor abrasions over the extremities and the patient complains of pain and swelling to the left elbow. There are some minor abrasions over the extremities and the patient complains of pain and swelling to the left elbow. Vital signs: B/P 132/70; P - 96; R - 18 Vital signs: B/P 132/70; P - 96; R - 18 ¬ What is the order of the assessment steps to take? ­ What interventions are necessary?

63 Case Scenario #1 ¬ Assessment steps Scene size-up, BSI, general impression Scene size-up, BSI, general impression Initial assessment Initial assessment. ABC’s, AVPU, check for life threats Focused history & physical exam Focused history & physical exam. trauma without significant mechanism of injury. perform a head-to-toe SAMPLE, vital signs, pulse ox, pain scale SAMPLE, vital signs, pulse ox, pain scale

64 Case Scenario #1 ­ Interventions Manual c-spine control Manual c-spine control Follow SOP “Spinal clearance, In-field” Follow SOP “Spinal clearance, In-field”. evaluate  mechanism of injury,  signs & symptoms,  patient reliability IV-O 2 -monitor as applicable IV-O 2 -monitor as applicable Application of ice Application of ice Splinting of injured/swollen extremities will help with pain control Splinting of injured/swollen extremities will help with pain control Direct pressure for bleeding wounds Direct pressure for bleeding wounds

65 Case Scenario #2 Your 65 year old patient undergoing treatment for leukemia calls for transport. Your 65 year old patient undergoing treatment for leukemia calls for transport. ¬ What is a common complication for this group of patients? ­ What method of infectious control needs to be exercised by the EMS responders?

66 Case Scenario #2 ¬ A common complication for patients with leukemia is infection primarily due to the low number of circulating neutrophils (WBC component responsible for protecting against bacterial and fungal infection) primarily due to the low number of circulating neutrophils (WBC component responsible for protecting against bacterial and fungal infection) ­ BSI’s necessary for providers to wear include gloves gloves mask mask


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