Type A blood - Advocate Health Care
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Transcript Type A blood - Advocate Health Care
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 #10-7200-E1206
Program revised by:
Sharon Hopkins, RN, BSN
EMS Educator
Objectives
Upon successful completion of this CE
module, the EMS provider should be able to:
discuss
insults to the hematopoietic system
discuss the uniqueness when caring for patients
with special challenges
review acute interventions necessary for the
chronic care patient
discuss medications used in Region X
participate in case scenario review
successfully complete the post quiz with a score
of 80% or better
Hematology
Definition - the study of blood and bloodforming organs collectively known as the
hematopoetic system.
Prehospital care for most patients with
hematological disorders is mainly
supportive.
Understanding some of the hematological
disorders enhances EMS assessment skills
Blood Cells
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:
lymph nodes
spleen
liver
Components of
Blood
Plasma
Platelets
thrombocytes
White
blood cells
leukocytes
Red
blood cells
erythrocytes
Components by Volume
-WBC’s & platelets
together form <5%
of formed elements
- RBC’s
95% of volume of
formed elements
Components of Blood
78%
water
22% solids (plasma, RBC’s, WBC’s, platelets)
Plasma
Clear
fluid part of blood; about 92% water
Plasma contains various cellular materials in
solution and suspension:
proteins (albumin, globulins, fibrinogen)
salts
metals
inorganic compounds
Red Blood Cells (RBC’s) Erythrocytes
Mainly comprised of water and hemoglobin
Hemoglobin (a protein) - oxygen carrying
component of the RBC; gives blood its red
color; carries oxygen
Primary function of RBC:
transport
oxygen from the lungs to various body
tissue
transport carbon dioxide from various tissues to
the lungs
Average life expectancy RBC 90-120 days
Pulse Oximetry
Estimates the amount of oxygen carried in
the bloodstream using infrared technology
across the skin
White Blood Cells (WBC’s) Leukocytes
Helps fight infection and aids in the
immune process
Helps heal wounds by ingesting matter
(dead cells, tissue debris, old RBC’s)
Protects the body from foreign material
(antigens)
Involved in the protection from mutated
cells (ie: cancer)
Includes: lymphocytes, monocytes,
eosinophils, basophils, neutrophils
Platelets - Thrombocytes
Small, sticky cells
Helps in blood clotting
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
Plasma takes up about 55% of the blood
volume
More Blood Components
Fat
globules
Chemical substances
carbohydrates
proteins
hormones
Gases
including
oxygen
carbon
dioxide
nitrogen
Complete Blood Count - CBC
A particular and common blood test
Measures the size, number, and maturity
of different blood cells in a specific volume
of blood
Can be used to determine abnormalities
in
production of blood cells
in destruction of blood cells
Blood Groups
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
Most common blood grouping is ABO and
Rh
A, B, AB, and O blood types
Person can be Rh+ or Rh
Blood Types
Type AB blood- universal recipient
Can receive any of the 4 types of blood
Carries both A & B antigens but does not have
antibodies to A or B blood
Type O blood - universal donor
Can be given to patients regardless of blood type
Has both anti-A & anti-B antibodies but no antigens
Type A blood has A antigens & anti-B antibodies
Can receive type A or O blood only
Type B blood has B antigens & anti-A antibodies
Can receive type B or O blood only
Blood groups
Rh blood groups
Discovered
in the blood of the
rhesus monkey in 1940’s
If the blood has Rh 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
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)
Acquired Factor Deficiencies
Hemolytic disease of the newborn
Arises during pregnancy
Maternal and fetal blood may be incompatible if
Rh factor discrepancy is present
Usually the first born is unaffected
Future problems in pregnancy prevented by
Rhogam injections given after birth to Rhmother 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
Blood Transfusions
Blood is the most easily shared
human tissue
Many lives are saved each year
Most often used to alleviate anemia
An antibody-antigen reaction can
occur causing the transfused blood to
hemolyze or burst
The liberated hemoglobin causes
kidney damage from sludging
Hemostasis
The sequence of clot formation that stops
bleeding
Quick, localized and carefully controlled
Three mechanisms reduce blood loss:
Vascular
spasm - local vasoconstriction
Platelet plug formation
Blood clotting (coagulation)
Failure of these mechanisms could result
in hypoperfusion and shock
Mechanisms of Hemostasis
Vascular
spasm
Contraction of the smooth muscle
around the injured vessel
Plug formation
Platelets stick to the walls (platelet
adhesion)
Platelets physically change to have
projections that hold onto one another
Enzymes released that make other
platelets more sticky in the same area
Mechanisms of Hemostasis
Blood
clotting
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
A gelatinous mass is formed that further
occludes vessel opening
Clot reabsorbed by body when no
longer needed
General Patient Assessment
Most patients with hematological problems
are dealing with a chronic 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
When possible, honor patient requests for
hospital destination
improved
continuity of care
have release signed if necessary (not closest)
Patient Assessment
Scene size-up, BSI precautions, general
impression
Initial assessment
Assess airway, breathing, circulation,
mental status (AVPU)
Check for life threats
common issues could include lifethreatening bleeds and massive
infections with septic shock
Patient Assessment cont’d
Focused history and physical exam
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
Patient Assessment cont’d
SAMPLE history
anemia
- increased heart rate & respirations
poor tissue oxygenation - fatigue, malaise,
apprehension, confusion, change in skin color
clotting problem - excessive bruising, skin
discoloration
infection - lymph node enlargement (swollen
glands), sore throat, pain on swallowing
bleeding abnormalities - nausea, anorexia,
bloody vomiting or diarrhea, bleeding gums
Vital signs, pulse oximetry, pain scale, EKG
Patient Assessment cont’d
Physical exam
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
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
Patient Assessment cont’d
GI
system
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
Pain
system
& swelling in joints
autoimmune diseases (rheumatoid arthritis),
hemophilia (bleeding into joint)
Patient Assessment cont’d
Cardiorespiratory
system
Anemia
dyspnea,
tachycardia, chest pain
Genitourinary system
Hematuria - blood in the urine
Heavy menstrual bleeding
Frank vaginal bleeding
General Treatment
Airway & breathing
Supplemental
oxygen usually with
non-rebreather
Watch for dyspnea and fatigue
Circulation
Fluid
volume replacement with crystalloid
solution (ie: NS or LR) does not carry oxygen
Watch for & treat dysrhythmias
Comfort measures
Morphine,
oxygen, positioning
Psychological support for patient & family
Diseases of Red Blood Cells
Anemias
The
most common disease of RBC’s
Defined as a hematocrit less than 37% in
women; 40% in men
Sickle
cell anemia = sickle cell disease
Disorder
in production of red cells (sickle
shape when oxygen levels become low)
Polycythemia
Excess
production in red blood cells
Anemia
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
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
Females may temporarily decrease RBC
levels during menstruation
Anemia
Signs and symptoms
Fatigue, intolerance of cold, pale skin,
dizziness, irritability, tachycardia, shortness
of breath, chest pain
Many actual types of anemia:
Iron deficiency - inadequate iron intake
Pernicious - poor absorption vitamin B12
Hemolytic - RBC’s destroyed faster than
produced
Aplastic - bone marrow fails to produce
blood cells
Sickle Cell Anemia/Disease
Inherited disorder of red blood cell production
RBC’s have sickle shape when oxygen levels are
low; red blood cells become rigid
Average sickled RBC life span 10-20 days (normal is
120 days)
Generation of new RBC’s can’t keep up with the
hemolysis (destruction)
Blood viscosity increased
sludging of blood
obstruction of capillaries & small blood vessels
blood flow to tissues & organs disrupted
tissues & organs eventually damaged
adults often have multiple organ problems
cardiopulmonary, renal, neurological diseases
Sickle Cell Crisis
Disease not limited to 1 ethnicity but can
affect many including Caucasian
3 presentations of crisis common:
Vasoocclusive crisis
musculoskeletal
abdominal
pain
pain
priapisms
pulmonary
problems
renal crisis (renal infarction)
central nervous system crisis (cerebral infarctions)
Sickle Cell Crisis cont’d
Hematological
Crisis
fall
in hemoglobin level
stagnation of red blood cells in spleen
problems with bone marrow function
Infectious
patient
crisis
functionally immunosuppressed
vulnerable to infection & sepsis
loss of splenic function makes patient
susceptible to massive bacterial infection
Sickle Cell Complications
Sepsis - due to immunosuppression
Acute chest syndrome
infection
or sickled red cells trapped in lungs
dyspnea, coughing, chest pain
Hand-and-foot syndrome
painful
swelling due to severe vascular occlusion
Splenic sequestration crisis
accumulation
of sickled cells in spleen
pale, enlarged spleen, abdominal pain, shock
Sickle Cell Complications cont’d
Aplastic crisis
severe
anemia when bone marrow temporarily
stops producing red blood cells
pale, tired, less active than normal
Stroke
cerebral
vascular occlusion due to sickled cells
can affect any age
extremity weakness, change in level of
consciousness
Painful episode
acute
and severe pain anywhere but most often
hands, arms, chest, legs, feet
Prehospital Care Sickle Cell
Anemia/Disease
Care is primarily supportive
Oxygen via nonrebreather mask to
increase the saturation of the circulating
RBC’s - evaluate pulse oximetry
IV of normal saline to hydrate patient
Pain relief with analgesics
larger
than normal amounts
of morphine are often
required for pain control
involve medical control for
higher dosing
Polycythemia
Abnormally high percentage of RBC’s (high
hematocrit)
Rare disorder; typically in people over 50
No cure but can be treated
Can be caused by:
Unregulated increase in RBC production
Tissue hypoxia
Dehydration
Blood doping - athlete training at high
altitudes to increase RBC production
Makes it harder to pump blood
through the body because it’s thicker
Increases risk of thrombosis
Polycythemia
Signs and symptoms
Bleeding
abnormalities
epistaxis,
Headache,
spontaneous bruising, GI bleeding
dizziness, blurred vision
Itching
Severe
cases with congestive heart failure
Treatment
Supportive
IV
- O2 - monitor
Hospital treatment - phlebotomy (“blood
letting”) to remove excess red blood cells
Diseases of White Blood Cells (WBC’s)
White blood cells are body’s principal
defense system against infection
Problems could include:
Leukopenia/neutropenia
decrease
in number of WBC’s
Leukocytosis
increase
in number of circulating WBC’s
could indicate: bacterial infection, rheumatoid
arthritis, DKA, leukemia, pain, excercise
Leukemia
Lymphomas
Leukemia
Malignant disease (cancer) of blood
forming tissue
Classifications
Acute lymphocytic leukemia (ALL)
primarily of children and young adults
Acute myelogenous leukemia (AML)
primarily of older people in their 60’s and
70’s
Chronic lymphocytic leukemia (CLL)
primarily of older people in their 60’s and
70’s
Chronic myelogenous leukemia (CML)
Leukemia
Common presentations:
moderate
to severe anemia
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
Common complication - infection
primarily
due to low number of circulating
neutrophils (main blood component protecting
against bacterial or fungal infection)
Leukemia & EMS Care
Patient at risk for infection
Isolation
techniques (gloves and masks) to
prevent spread of your germs to the patient
Care primarily supportive
Position of comfort
Oxygen via nonrebreather mask if needed
IV (fluid bolus if patient is dehydrated)
Analgesics (ie: morphine) for pain
Lymphomas
Cancer of the lymphatic system
Most prominent in the lymph nodes
Malignant lyphoma classification:
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
40,000
lymphoma
diagnosed annually in USA
cure rate depends on type of lymphoma identified
Lymphoma
Presenting signs & symptoms
may
report fever, night sweats, anorexia,
weight loss, fatigue, itching
many with Hodgkin’s have no symptoms
non-Hodgkin’s most commonly have swollen
lymph nodes
Field treatment
supportive
consider
IV, O2, pain control
necessary
isolation techniques
gloves
& mask
if
Diseases of Platelets & Blood
Clotting Abnormalities
Thrombocytosis
patients
- increased platelets
usually asymptomatic
Thrombocytopenia
easy
- decrease in platelets
bruising & bleeding
Hemophilia
absence
von
of protein necessary for blood clotting
Willebrand’s disease
inherited
disease affecting both sexes
excessive bleeding after injury or surgery
aspirin contraindicated
Hemophilia
Inherited clotting deficiency
Females are carriers
1 in 10,000 males have the disease
Bleeding may occur spontaneously or after
minor trauma
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
Hemophilia
Signs and symptoms
numerous bruises
deep muscle bruising
joint bleeding - hemarthrosis
Characterized by blood in the urine,
bloody noses and painful, swollen joints
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
Field Treatment Hemophilia
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
IV - O2 via nonrebreather- monitor
Ice application
Superficial injuries - patience & pressure
If joint injury, splinting will reduce pain
Transport to ED necessary for replacement
of deficient factor
Other Hematopoietic Disorders
Disseminated
intravascular coagulation - DIC
Disorder
of coagulation
High mortality rate
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
Simultaneous clotting and bleeding
Patient experiences widespread thrombosis and
end-organ ischemia
DIC
Signs
& symptoms
Oozing blood at
venipuncture and wound sites
Purpuric rash often over chest and abdomen
Minute hemorrhages just under skin
Prehospital care
Supportive and focused on symptoms
IV - O2- monitor
Patient often hemodynamically unstable
Hospital treatment
Fresh frozen plasma & platelets at hospital
Additional Hematopoietic
Disorders
Multiple
Cancer
myeloma
disorder of plasma cells (cells that
produce antibodies)
Rarely found in persons under 40
Approximately 14,000 new cases every year
Cancer plasma cells overcrowd healthy cells
with a reduction in blood cell production
Patient becomes anemic and is prone to
infection
Multiple Myeloma
Signs & symptoms
Pain
in back or ribs
Diseased marrow weakens bones and
pathological fractures occur (fractures with
minimal or no trauma)
Fatigue
Risk for bleeding due to decrease in platelets
Renal failure from elevated calcium levels
Increased risk for infection due to a lack of
certain antibody secretion
Multiple Myeloma Treatment
Prehospital care
Supportive
IV
if signs of dehydration
Pain control - disease can be painful and pain
in presence of pathological fractures
Hospital care
Chemotherapy
Radiation
Bone
marrow transplants
What Is Bone Marrow?
Tissue in the center of large bones where new
blood cells are produced
2 types of stem cells produced
hematopoietic
stem cells - forms blood cells:
WBC’s
- leukocytes
RBC’s - erythrocytes
platelets - thrombocytes
stromal
stem cells - mix of cells to generate:
fat
cartilage
bone
can
differentiate into many kinds of tissue (ie: nervous)
Bone
Marrow
Bone Marrow Transplant
Pioneered in 1970
Transplant of hematopoietic stem cells
Most often done for life-threatening
diseases of blood or bone marrow
acute
lymphocytic leukemia
acute myelogenous leukemia
aplastic anemia
chronic myelogenous leukemia
Hodgkin’s and non-Hodgkin’s diseases
multiple myeloma
radiation poisoning
Types of Bone Marrow Transplant
Autologous bone marrow transplant
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
Allogenic bone marrow transplant
involves
donor & recipient; must match tissue
type
recipient requires immunosuppressant drugs
donor bone marrow harvested under general
anesthesia (>100 needle sticks in large bone)
Bone Marrow Transplant Cont’d
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
recipient gets injection to boost stem cell yield
Cord blood
donation
of umbilical cord & placenta after infant
delivered
cord blood yields higher concentration of stem
cells but limited volume (50 ml - 2 T)
usually transplanted into children, not adults
cord blood can be stored frozen for years
Bone Marrow Infusion
Stem cells (bone marrow transplant) given
IVPB
stem
cells circulate in the blood stream
stem cells migrate into bone marrow spaces
stem cells grow & start to produce new blood
cells
takes several weeks to grow enough new cells
Bone marrow transplant mortality rate is
high - 10%
reserved
for life-threatening conditions
Case Scenario #1
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.
Vital signs: B/P 132/70; P - 96; R - 18
What is the order of the assessment steps
to take?
What interventions are necessary?
Case Scenario #1
Assessment
steps
Scene size-up, BSI, general impression
Initial assessment
ABC’s, AVPU, check for life threats
Focused history & physical exam
trauma without significant
mechanism of injury
perform a head-to-toe
SAMPLE, vital signs, pulse ox, pain scale
Case Scenario #1
Interventions
Manual
c-spine control
Follow SOP “Spinal clearance, In-field”
evaluate mechanism of injury,
signs & symptoms, patient reliability
IV-O2-monitor as applicable
Application of ice
Splinting of injured/swollen extremities
will help with pain control
Direct pressure for bleeding wounds
Case Scenario #2
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?
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)
BSI’s necessary for providers to wear
include
gloves
mask