Chapter 24
Hematologic
Emergencies
National 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 Competencies
Hematology
• Anatomy, physiology, pathophysiology,
assessment, and management of:
− Sickle cell crisis
− Clotting disorders
National 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 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
Introduction
• EMS systems rarely respond to hematologic
emergencies.
• Hematologic disorder: any disorder of the
blood
− Hemolytic disorders
− Hemostatic disorders
Introduction
• Hematopoietic system
− Organs and tissues involved in the production of
blood components
Blood and Plasma
• Blood performs the following functions:
− Respiratory
− Nutritional
− Excretory
− Regulatory
− Defensive
Blood and Plasma
• Blood is made of:
− Plasma:
• 92% water
• 55% of total blood
volume
− Formed elements:
• 45% of total blood
volume
• Includes RBCs,
WBCs, and platelets
Blood 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 Plasma
• Three common lab tests:
− RBC count
− Hemoglobin level
− Hematocrit measurement
Blood 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
• The major players
in the hematologic
system are the:
− Bone marrow
− Liver
− Spleen
The 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 System
• Processes protect against pathogens and
other unwanted materials.
− Must distinguish between:
• Body’s own tissue
• Outside organs
The Immune System
• Native immunity
− Nonspecific,
maximal response
− First line of
defense
− Associated with
initial inflammatory
response
• Acquired immunity
− Specific to
vertebrates
− A pathogenspecific response
The Immune System
• Humoral immunity
− Secretion of
immunoglobins
• Recognizes a
specific antigen
• Cell-mediated
immunity
− Macrophages and
T-cells destroy
pathogens.
The 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 System
Blood Classifications
• Developed to prevent medical problems
during replacement
− ABO system
Blood Classifications
• Blood contains a secondary antigen called
the Rh antigen.
− Possible complications in pregnancy
• Hemolytic disease
Hemostasis
• The process of stopping bleeding through:
− Vasoconstriction (immediate response)
− Platelet plugging
− Coagulation
• Clots are made up of fibrin.
Hemostasis
• Clotting cascade
− Can be initiated through:
• Intrinsic pathway
• Extrinsic pathway
− Coagulopathy: process that interferes with the
clotting cascade or hemostasis
Patient Assessment
• Note any lifethreatening signs
or symptoms.
− Ask about
patient’s history
and SAMPLE
history.
− A nonjudgmental
approach is
essential.
Scene Size-Up
• Ensure the scene is safe for entry.
• Consider the mechanism of injury.
• Determine the number of patients.
• Assess for hazards.
Primary Assessment
• An African American or Mediterranean
patient reporting severe pain may have
sickle cell disease.
− Perform cervical spine stabilization if necessary.
Primary 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 Assessment
• Circulation
− Manage life-threatening conditions.
− If hemophilia is suspected, watch for:
• Acute blood loss
• Bleeding of unknown origin
• Hypoxia or shock
Primary Assessment
• Transport decision
− Depends on severity and patient’s wishes
− Transport to the closest facility if:
• Sickle cell crisis
• Uncontrolled bleeding
History 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 Taking
• Look for:
− Changes in LOC
− Vertigo
− Feelings of fatigue
− Syncope
− Dyspnea
− Chest pain
− Changes in pulse
rate and rhythm
− Coughing up blood
− Visual disturbances
− Muscle pain
− Stiffness
History 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 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 Assessment
• Performed on
scene, en route, or
not at all
• Perform a physical
exam, focusing on
major joints.
• Obtain vital signs.
Secondary 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.
Reassessment
• Reassess frequently.
• Administer supplemental oxygen.
• Provide ventilation as appropriate.
• Cover to maintain body temperature.
Reassessment
• According to local protocol, administer:
− IV fluid
− Nitrous oxide
• Prehospital care for hemophilia can include
IV therapy.
Reassessment
• Inform hospital
staff about:
• Document:
− Patient history
− Present situation
− Each assessment
− Your findings
− Treatment
− Assessment
findings
− Interventions and
their results
− Time of
interventions
− Changes in
patient condition
Emergency Medical Care
• Emergency medical care should include:
− Oxygen
− Fluids
− ECG
− Comfort
− Pharmacology
− Support
Sickle 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 Crisis
• Pathophysiology (cont’d)
− Can lead to:
• Aplastic crisis: RBC production temporarily stops.
• Hemolytic crisis: Acute RBC destruction
Sickle Cell Crisis
• Pathophysiology (cont’d)
− May manifest as:
• Vaso-occlusive crisis
• Acute chest syndrome
• Splenic sequestration crisis
Sickle Cell Crisis
• Assessment
− Characterizations may include:
• Shortness of breath
• Inadequate perfusion of the skin
• Jaundice
• Mild dehydration
Sickle 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 Crisis
• Management
− Administer high levels of oxygen.
− Rapidly transport patient.
− Consider IV fluid therapy.
− Maintain patient’s body temperature.
− Recommend that patient rest.
Anemia
• Pathophysiology
− Low hemoglobin or
erythrocyte level
− Usually associated
with an underlying
disease
Anemia
• Iron deficiency anemia
− Most common type
− Causes include:
• Gastrointestinal blood loss
• Menstrual bleeding
• Frequent donations or diagnostic test
Anemia
• Pathophysiology (cont’d)
− May be caused by an inherited hemolytic
disorder or a hematologic disorder
− Can have serious consequences in high
altitudes
Anemia
• Assessment
− Patients may feel:
• Worn down
• Lack of energy
• Overexerted
• Unable to “catch their
breath”
− Patients may have:
• Anginal-type chest
pain
• Leukopenia
• Thrombocytopenia
Anemia
• 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.
Anemia
• Management (cont’d)
− Allow the patient to rest.
− Consider rapid transport for:
• Abrupt change in consciousness
• Hypotension
• Significant perfusion inadequacies
Leukemia
• Pathophysiology
• Anemia
• Thrombocytopenia
• Leukocytosis
Courtesy of Mark C. Ide
− Cancer in the
lymphoid system
− Blood cells
develop
abnormally and/or
excessively,
causing:
Leukemia
• 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
Leukemia
• Pathophysiology (cont’d)
− Survival depends on several factors:
• Stage of detection
• Underlying medical condition
• Response to treatment
− Treated with chemotherapy and radiation
Leukemia
• Assessment
− Patient presentation
depends on:
• Stage of leukemia
• Current treatment
− Patients may
present with:
• Fatigue
• Headaches
• Bone pain
• Unexplained
bleeding
Leukemia
• Management
− As appropriate, provide:
• Airway support
• Oxygen therapy
• IV fluid therapy
• Analgesics
• Positive support
Leukemia
• 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.
Lymphomas
• Pathophysiology
− Group of malignant diseases within the
lymphoid system
− Classified in two categories
Lymphomas
• 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
Lymphomas
• Assessment
− Require chemotherapy or radiation.
− Signs and symptoms may include:
• Pallor
• Feeling hot and then cold or both
• Inadequate perfusion
• Abnormal ECG rhythms
Lymphomas
• Management
− Aggressive pain
management
− Treat inadequate
perfusion and
abnormal heart
rhythms.
− Initiate rapid
transport if
condition does not
improve.
Polycythemia
• Pathophysiology
− Overabundance or overproduction of RBCs
− Multiple causes
− Can lead to other conditions
− Treatment usually includes phlebotomy or
cancer-type therapy
Polycythemia
• Assessment
− Findings may widely vary
− Note the extent and duration of dyspnea.
− Has the patient experienced pruritus or changes
in skin temperature?
Polycythemia
• Management
− Consists of supportive care and transport to the
appropriate facility.
− Administer oxygen and establish IV as needed.
Disseminated Intravascular
Coagulation
• Pathophysiology
− Number of causes
− Two stages:
• Defibrination
• Uncontrolled
hemorrhage
− High mortality rate
Disseminated Intravascular
Coagulation
• Assessment
− Identify associated signs and symptoms.
− Patients may have:
• Respiratory difficulty
• Signs of shock
• Skin changes
Disseminated Intravascular
Coagulation
• Management
− Identify underlying cause and establish
treatment early.
− Maintain an airway.
− Treat for shock.
Hemophilia
• Pathophysiology
− A bleeding disorder in which clotting:
• Does not occur
• Occurs insufficiently
− Two primary types: A and B
Hemophilia
• Pathophysiology (cont’d)
− Signs and symptoms may include:
• Acute and chronic bleeding
− Patients may require:
• Hospitalization for transfusion
• Infusion of factors VIII and IX
Hemophilia
• 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.
Hemophilia
• Management
− Patients may need high-flow oxygen.
− Note ECG findings.
− IV therapy may be necessary.
− Analgesics may be appropriate.
Multiple 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 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 Myeloma
• Assessment
− Findings depend on
stage
− Early stage:
• Fatigue
• Mild pain
− Later stage:
•
•
•
•
Hemorrhage
Weight loss
Bone fractures
Pain
Multiple Myeloma
• Management:
− IV therapy
− Pain management
− Supportive care
Transfusion 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 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 Reactions
• Assessment (cont’d)
− Complications include:
• Hemolytic
• Febrile
• Allergic
• Transfusion-related lung injury
• Circulatory overload
• Bacterial infection
Transfusion Reactions
• Management
− Immediately stop the transfusion.
− Provide hemodynamic supportive care.
− Maximize kidney perfusion.
Transfusion Reactions
• Management (cont’d)
− A hemodynamically unstable patient requires:
• Early invasive monitoring
• Vasopressors
• Promotion of diuresis
− Administer high-flow oxygen.
Summary
• 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.
Summary
• 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.
Summary
• 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.
Summary
• Hematologic disorders include sickle cell
crisis, anemia, leucopenia,
thrombocytopenia, leukemia, lymphomas,
polycythemia, DIC, hemophilia, multiple
myeloma, and complications of blood
transfusions.
Summary
• 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.
Summary
• 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.
Summary
• 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.
Credits
• 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.