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