1. Hematology
Mohamad H Qari, MD, FRCPA

2. Hematology Cellular Components Components of Blood Blood Typing
Red Blood Cells
White Blood Cells
Inflammatory process
Coagulation
Blood Typing
Clotting disorders

3. Hematology

4. Hematopoeisis Three developmental periods Mesoblastic Hepatic Myeloid
Blood islands of yolk sac
Primarily RBC production
Embryonic hemoglobin produced
Hepatic
At 6 weeks cell production in liver
Fetal hemoglobin produced
Spleen, thymus, lymph nodes also active prod.
Myeloid
At 5th month Bone Marrow becomes site of prod.
Liver & spleen now Extramedullary
Hemoglobin A (22)

5. Requirements For Hematopoiesis
Stem Cells
Growth Factors
Microenviroment

6. Stem Cell theory Pluripotent stem cell originator of all cells
Gives rise to cells committed to specific development
Research supporting the theory
PHSC has self-maintaining ability
Committed cells differentiate continuously/ No Reverse Flow

7. Stem cells in Research Pluripotent cells derived from: Application
Cell mass of embryos at blastocyst stage (IVF)
Fetal tissue from terminated pregnancy
Application
Identification of factors of cellular decision-making
Development and testing of drugs
Generation of cells and tissue for therapy

10. Cytokines & Growth Factors
Cytokines stimulate or inhibit
Prevent apoptosis
Colony-Stimulating Factors produced by many different cells
Interleukins numbered according to discovery

11. Components of Blood Plasma Transport mechanism 90-92% water.
6-7% proteins
2-3%
Fats
Carbohydrates (glucose)
Electrolytes
Gases (O2, CO2)
Chemical messengers

12. Cellular Components
WBC’s
RBC’s
Platelets

13. Components of Blood Red Blood Cells Erythrocyte
Hemoglobin – O2 bearing molecule
Comprised of 4 subunits:
Globin (binds to 1 O2 molecule)
Heme (iron)
100% saturation = 4 globin subunits carrying O2
Each gram of hemoglobin = 1.34 ml O2
Cellsalive.com

14. Blood Products and Blood Typing
Blood Types
Antigens
A, B, AB, O
Rh factor
Rh+ = ~85%
Rh- = ~15%
Blood transfusion

15. Components of Blood Red Blood Cells (cont.) Oxygen Transport
Oxy-hemoglobin dissociation curve
2,3-DPG

16. Components of Blood White Blood Cells (Leukocytes) Margination
Phagocytosis
The macrophage is using its internal cytoskeleton to envelop cells of the fungus Candida albicans.

17. Components of Blood Leukocytes (cont.) White Blood Cell Count
Leukopoiesis
Granulocytes
Neutrophil
Basophil
Eosinophil
Monocytes
Lymphocytes
Human Neutrophil:
Phagocytosis of Strep pyogenes

18. Components of Blood Leukocytes (cont.) Immunity
Subpopulation of lymphocytes known as T cells and B cells
T cells develop cellular immunity.
B cells produce humoral immunity

19. Components of Blood Inflammatory Process MAST CELLS.
Immunoglobulin E antibody IgE,  
Antigens
Antigens stick to the mast cell IgE antibodies, causing granules in the mast cell to fire their contents into the surrounding tissue.
This releases a host of inflammatory materials - leukotrienes, tumor necrosis factor, interleukin-4 and other cytokines that turn on other inflammatory cells.
These materials cause fluid to leak from the capillaries and white cells including neutrophils, T cells and eosinophils to leave the circulation. The end result is a "local inflammatory response", a red, itchy welt.
Cellsalive.com

20. Components of Blood Hemostasis- 3 mechanisms Vascular spasm
Contraction of tunica media
Platelet plug
Platelet aggregation
Coagulation
Formation of fibrin clot

21. Components of Blood Hemostasis (cont.) Fibrinolysis Thrombosis
Lysis of clot (plasmin)
Thrombosis
Thrombolytics
Medications affecting clot formation
Alter the enzyme on the platelet.
Affect the coagulation cascade.
Enhance clotting.

22. Coagulation Cascade - Synopsis

23. This scanning electron micrograph shows the fine structure of a blood clot. Platelets released from the circulation and exposed to the air use fibrinogen from the blood plasma to spin a mesh of fibrin.

24. General Assessment - Management
Focused History and Physical Exam
SAMPLE history
Hematological disorders are rarely the chief complaint.
Physical exam
Evaluate nervous system function.
Skin signs

25. General Assessment - Management
Physical Exam (cont.)
Lymphatic signs
Gastrointestinal signs
Epistaxis
Atraumatic bleeding gums
Thrush
Atraumatic splenic/hepatic pain
Musculoskeletal signs
Arthralgia (rheumatoid arthritis)
Hemarthrosis
Cardiorespiratory signs
Tachycardia, cx pn, dyspnea - CHF
Genitourinary signs
Hematuria
Menorrhagia
Infection

26. Blood Products and Blood Typing
Blood Typing - ABO
Blood type
Antigen present on erythrocyte
Antibody present in serum O AB B A
None
A and B
Anti-A, Anti-B
Anti-A
Anti-B

27. Blood Products and Blood Typing
Compatibility Among ABO Blood Groups
Reaction with serum of Recipient
Donor Cells AB B A O - +
= no reaction
+ = reaction

28. Blood Products and Blood Typing
Brady; Paramedic Care Principles and Practice

29. Diseases of Erythrocytes
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.

30. Diseases of Erythrocytes
Brady; Paramedic Care Principles and Practice

31. Diseases of Erythrocytes
Sickle Cell Disease
Normal red cells maintain their shape as they pass through the capillaries and release oxygen to the peripheral tissues (upper panel). Hemoglobin polymers form in the sickle rell cells with oxygen release, causing them to deform. The deformed cells block the flow of cells and interrupt the delivery of oxygen to the tissues (lower panel).

32. Diseases of Erythrocytes
Sickle Cell Disease (cont.)
Sickle cell crises
Vaso-occlusive
Musculoskeletal/abdominal pain
Priapism
Renal/cerebral infarctions
Hematological
Lowered hemoglobin
Splenic sequestration
Infectious
Management
Follow general treatment guidelines prn.
Consider analgesics.

33. Diseases of Erythrocytes
Polycythemia
Overproduction of erythrocytes.
Occurs in patients > 50 years old or with secondary dehydration.
Most deaths due to thrombosis
Results in bleeding abnormalities:
Epistaxis, spontaneous bruising, GI bleeding.
Management:
Follow general treatment guidelines.

34. Diseases of Leukocytes
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

35. Diseases of Leukocytes
Leukemia
Cancer of hematopoietic cells
Initial presentation
Acutely ill, fatigued, febrile and weak, anemic.
Thrombocytopenia
Often have a secondary infection.
Management
Follow general treatment guidelines.
Utilize isolation techniques to limit risk of infection.

36. Diseases of Leukocytes
Lymphomas
Cancers of the lymphatic system
Hodgkin's
Non-Hodgkins
Presentation
Swelling of the lymph nodes
Fever, night sweats, anorexia, weight loss, fatigue, and pruritis
Management
Follow general treatment guidelines.
Utilize isolation techniques to limit risk of infection.

37. Clotting Disorders Thrombocytosis and Thrombocytopenia Thrombocytosis
An abnormal increase in the number of platelets
Thrombocytopenia
An abnormal decrease in the number of platelets
Sequestration
Destruction (ITP)
Decreased production
Management
Provide supportive care and follow general treatment guidelines.

38. Clotting Disorders Hemophilia
Deficiency or absence of a blood clotting factor
Deficiency 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 & Symptoms
Numerous bruises, deep muscle bleeding, and joint bleeding.

39. Clotting Disorders Hemophilia (cont.) Von Willebrand’s Disease
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.

40. Clotting Disorders
Disseminated Intravascular Coagulation

41. Components of Blood Leukocytes (cont.) Multiple Myeloma
Autoimmune disease
May be specific or general
Alterations in the immune process
Immunosuppression
HIV
Anti-rejection medication
Chemotherapy/Cancer
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 are common.

42. Anticoagulants/Antiplatelets
Classifying agents
Anticoagulants
Block synthesis and activation of clotting factors
Antiplatelets
Interfere with platelet aggregation or activation
Fibrinolytics
Dissolve fibrin component of thrombi

43. Anticoagulants/Antiplatelets
Warfarin
Blocks activation of Vit K
Interferes w/ coagulation factors II, VII, IX, and X
Unfractionated Heparin
Binds antithrombin III (AT-III)
Inhibits coagulation factors IX and X and thrombin
Hirudin (medicinal leech)
Prevents thrombin binding

44. Anticoagulants/Antiplatelets
Aspirin
Prevents platelet activation through cyclooxygenase blockade.
Prevents production of thromboxane A2
Allows prostacyclin synthesis
Ticlodipine
Deforms platelet membrane fibrinogen receptor

45. Anticoagulants/Antiplatelets
Antiplatelets (cont.)
Glycoprotein IIb-IIIa Receptor Inhibitors
G IIb-IIIa = platelet membrane receptor of fibrinogen
Abciximab
Eptifibatide
Tirofiban
Fibrinolytics
Activate plasminogen to plasmin = fibrinolysis
Streptokinase
Anistreplase
Tissue Plasminogen Activator
Reteplase
Urokinase

46. Hemorrhage Class I Class II Class III Class IV Blood Loss (ml)
Up to 750
>2000
Blood Loss (% volume)
Up to 15%
15%-30%
30%-40%
>40%
Pulse
<100
>100
>120
>140 BP
Normal
Decreased
Pulse Pressure
Normal or increased
Resp. Rate
14-20
20-30
30-40
>35
Urine Output (ml/hr)
>30
5-15
Negligible
Mental Status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Fluid Replacement (3:1) rule
Crystalloid
Crystalloid and blood

47. Transfusion Reactions
Hemolytic Reaction
Signs & Symptoms
Facial flushing, hyperventilation, tachycardia, hives, chest pain, wheezing, fever, chills, and cyanosis
Treatment
Stop transfusion, change all IV tubing, and initiate IV therapy with normal saline or lactated Ringer’s.
Consider furosemide, dopamine, and diphenhydramine.

48. Transfusion Reactions
Febrile Non-hemolytic Reactions
Signs & Symptoms
Headache, fever, and chills
Treatment
Stop 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 non-hemolytic.