Hematologic Complications and Blood Function

• The human body needs multiple organ systems working seamlessly for good health
• Acute emergencies that EMTs encounter often involve the cardiovascular and respiratory systems
• This learning material addresses diseases related to the hematologic (blood) and renal (kidney) systems.
• Hematology is the medical specialty focused on blood disorders
• Nephrology is the medical specialty focused on kidney diseases
• Many medical conditions can arise from diseases of the hematologic and renal systems
• Certain patients with specific diseases in these systems are more likely to require EMS services

Anatomy and Physiology of Blood

• Blood works as an organ with key functions related to transportation, regulation, and protection
• Normal blood clotting requires platelets, clotting factors, and a functioning vascular system

Disorders of the Blood

• Blood disorders include a range of coagulopathies, which affect blood clotting
• Causes of coagulopathies can be genetic, acquired, or due to medications

EMT Care for Coagulopathies

• EMTs are to identify patients with coagulopathies, and provide appropriate care to stabilize them
• Decision-making should focus on optimizing patient outcomes

Anemia and Sickle Cell Anemia

• Different types of anemia have distinct characteristics
• Sickle cell anemia's pathophysiology leads to specific disease presentations, requiring targeted EMT care

EMT Care for Sickle Cell Anemia

• EMTs are to distinguish between sickle cell anemia and sickle cell trait
• Key signs and symptoms of sickle cell emergencies include pain and hypoxia, with oxygen therapy being crucial
• EMTs must consider ALS support based on the patient's condition

Anatomy and Physiology of the Kidneys

• The kidneys maintain blood balance by filtering waste and regulating hydration
• Each renal structure has a specific function in this process

Diseases of the Renal System

• Renal diseases include urinary tract infections, kidney stones, and renal failure
• Acute renal failure has sudden causes, while chronic renal failure develops over time
• Treatments for renal failure: Hemodialysis and peritoneal dialysis

EMT Care for End-Stage Renal Disease

• End-stage renal disease and dialysis complications require careful EMT management
• Missing dialysis can have severe consequences
• EMTs must be prepared to handle various dialysis-related complications
• Special considerations are needed for kidney transplant patients

The Hematologic System

• Blood serves as organ system with critical functions including clotting, oxygen delivery, and waste removal
• Blood consists of solid components - red blood cells, white blood cells, and platelets - and plasma.
• Red Blood Cells (RBCs) make up most of the blood cells and give blood its red color
  • RBCs contain hemoglobin, which binds to oxygen for delivery to cells
  • RBC count is measured by a hemoglobin count
• White Blood Cells (WBCs) are crucial for immune response and infection control
  • Different types include neutrophils, which which fight bacterial infections, and eosinophils, which are associated with allergies
• Platelets: Fragments of larger cells, essential for clot formation
  • These aggregate rapidly to stop bleeding but can cause harmful clots such as coronary artery plaque rupture
  • Aspirin is used to prevent platelet aggregation during heart attacks
• Plasma: Liquid component of blood, suspending cells and platelets
  • Contains dissolved nutrients and crucial proteins like clotting factors

Blood Clotting

• When bleeding occurs, the body activates its clotting system to prevent excessive blood loss
• Platelets and clotting factors are the two major components responsible for clotting
• Platelets provide the body's most rapid and initial response by clumping together to stop bleeding
• Clotting factors are proteins produced in the liver and released into the bloodstream in inactive forms
• When blood vessel damage occurs, clotting factors are activated to initiate clotting
• Activated clotting factors form clots through a series of steps, also known as clotting cascades
• Clotting cascades result in the formation of stable clots, which replace the initial platelet clumps to effectively control bleeding

Coagulopathies

• Coagulopathy: Abnormal blood clotting, resulting in either excessive clotting or, more commonly, slow clotting leading to uncontrolled bleeding
• Slow clotting can be due to issues with the clotting cascade, insufficient or dysfunctional platelets, or a combination of these factors
• Medications are the most common cause of coagulopathy encountered by EMTs
  • Medications are often prescribed to slow clotting in patients with certain medical conditions
• Liver disease can lead to coagulopathy because the liver produces clotting factors
  • Advanced liver disease such as cirrhosis can result in inadequate clotting factor production

Inherited Genetic Disorders

• Such disorders can cause coagulopathies
  • Hemophilia: Prevents production of certain clotting factors
  • Von Willebrand's disease: The most common inherited blood disorder, where platelets are functionally defective, though present in normal numbers
• Medical conditions that benefit from reduced clotting include those at risk for heart attacks, strokes, or abnormal cardiac rhythms like atrial fibrillation

Common Blood-Thinning Medications

• Coumadin® (warfarin)
• Pradaxa® (dabigatran)
• Eliquis® (apixaban)
• Xarelto® (rivaroxaban)
• Lovenox® (enoxaparin)
• Aspirin and Plavix® (clopidogrel), which inhibit platelet aggregation
• Patients on these medications have a higher risk for life-threatening bleeding
• Injury can lead to potential upgrades to trauma center transport even for minor cases, following local protocols

Identifying Patients with Coagulopathies

• A thorough patient history is crucial for assessing a patient with suspected clotting disorders
• Identifying patients at risk for abnormal bleeding involves reviewing a patient's past medical history and current medications
• EMTs should prioritize obtaining a SAMPLE history, especially for trauma patients
• It is essential to ask trauma patients if they are on any blood thinners during assessment

Anemia

• Anemia: Deficiency in the normal number of red blood cells (low hemoglobin count)
• Acute anemia comes from trauma or sudden massive bleeding from the gastrointestinal tract
  • Symptoms include rapid pulse rate, cool and clammy skin, and eventual hypotension
• Chronic anemia develops over time due to recurrent heavy menstrual periods, slow gastrointestinal blood loss, or disease affecting bone marrow or hemoglobin structure
  • Symptoms include pallor, fatigue, and shortness of breath with exertion
  • Signs of shock appear only after a prolonged period
• Assessment for chronic anemia can be done by examining the color of the patient's conjunctiva on the lower eyelid
  • Anemic patients have very pale conjunctiva

Sickle Cell Disease

• Sickle cell disease (SCD) is an inherited genetic defect affecting hemoglobin, leading to abnormal red blood cell (RBC) structure
• SCD predominantly affects individuals of African descent, with an incidence of about 1 in 365 African American births
• The abnormal hemoglobin in SCD causes RBCs to lose their normal doughnut shape and compressibility, resulting in sickle-shaped cells
• These sickle-shaped RBCs have a shorter lifespan, leading to chronic anemia known as sickle cell anemia (SCA)
• Normal RBCs are flexible and can pass through small capillaries to deliver oxygen, whereas sickle-shaped RBCs cannot

Complications with Sickle Cell Disease

• Destruction of Spleen: Blockages by abnormal RBCs lead to spleen damage, increasing the risk of severe infections
• Sickle cell pain crisis: Severe pain in arms, legs, chest, and abdomen due to sludging of sickled RBCs in capillaries
• Acute chest syndrome: Characterized by shortness of breath and chest pain because of blocked blood vessels in the lungs, leading to hypoxia
• Priapism: Painful, prolonged erections in males due to blocked blood drainage from the penis
• Stroke: Occurs when sludging RBCs block blood vessels supplying the brain
• Jaundice: Yellowish pigmentation of body tissues due to the liver being overwhelmed by the breakdown of RBCs
• Life span: Patients with SCA have a shorter life span and may become dependent on narcotic pain medications due to persistent painful crises
• Sickle cell trait: Individuals with the trait carry the gene but do not suffer from the disease or its complications and normal life spans
• The spleen may become non-functional because of damage from sickled red blood cells, which can increase susceptibility to infections
• Vaso-occlusive crisis occurs when sickled red blood cells block microcirculation, causing hypoxia and severe pain, often in bones, joints, abdomen, and soft tissues
• Acute chest syndrome results from vaso-occlusive crisis in the lungs, leading to difficulty breathing, chest pain, cough, and fever
• Priapism, a prolonged and painful erection, occurs when sickled red blood cells block blood flow out of the corpus spongiosum
• Sickle cell patients are at higher risk for ischemic stroke because of possible sickled cells affecting brain microcirculation or larger arterial vessels
• Jaundice, characterized by yellowed skin and eye whites, occurs when the liver is overwhelmed by the breakdown of red blood cells, impairing its function

The Renal System

• Consists of two kidneys, two ureters, a bladder, and a single urethra:
  • Kidneys filter blood to produce urine
  • Ureters transport urine from the kidneys to the bladder
  • The bladder stores urine until it is excreted
  • The urethra carries urine from the bladder to the outside of the body
• The kidneys filter blood to remove waste products, excessive salts, and fluids
• During dehydration, the kidneys retain help necessary fluids
• These functions make the kidneys essential for life

Urinary Tract Infections (UTIs)

• Common in the renal and urinary system
• UTIs are caused by bacteria and affect the bladder, leading to painful and frequent urination
• If untreated, a bladder infection can spread to the kidney, resulting in pyelonephritis
  • Pyelonephritis symptoms include unilateral flank pain and more severe illness
• UTIs can become serious or life-threatening if bacteria enter the bloodstream, particularly in elderly patients

Kidney Stones

• Kidney stones are a common and painful condition related to the renal system
• Stones are usually composed of calcium and form within the kidney
• They cause no symptoms if they remain in the kidney
• A severe unilateral flank pain that radiates to the groin occurs when a stone descends from the kidney and becomes lodged in the ureter
• Associated symptoms of kidney stone pain include nausea and vomiting
• Patients may lose ability to urinate normally due to obstructions (tumors, enlarged prostate) or neurologic disorders
  • Urinary catheters drain urine in the cases
  • Common insertion point for a urinary catheter is the urethra
  • Some patients use long-term catheters, while others self-catheterize
  • Catheters may be placed into the kidneys by an urologist or surgeon
  • Complications of urinary catheters include acute and chronic urinary tract infections and local trauma at the insertion site
  • Renal failure is the serious kidney disease, where the kidneys cannot filter blood and remove toxins and excess fluid

Renal Failure Types

• Acute renal failure can result from shock, toxic ingestions, and other causes
  • It may be reversible if the underlying cause is identified quickly and treated, such as severe dehydration treated with intravenous fluids
• Chronic renal failure develops gradually due to long-term conditions, such as diabetes, uncontrolled high blood pressure, or polycystic kidney disease
• End-stage renal disease (ESRD: occurs when kidneys can no longer sustain life as a result of irreversible renal failur
  • Patients with ESRD typically require dialysis to survive
  • Dialysis is a medical that removes toxins and excess fluid using an external system
    • The main types of dialysis are hemodialysis and peritoneal dialysis

Hemodialysis

• Most common form, and given to over 90% of ESRD patients for 3-4 hours each in specialized outpatient centers, three times a week
• A patient is connected to a dialysis machine to filter blood and remove all those toxins
  • There are two catheters to connect patient to the dialysis machine
  • One catheter allows blood to flow out of the body into the dialysis machine
  • The other catheter returns filtered blood to the body
• Patients who have End-Stage Renal Disease (ESRD) on HD need specialized access to their blood circulation
  • Two-port Catheter: Placed into one of the major veins of the torso
  • Arteriovenous (A-V) fistula: Connects an artery and a vein, which is surgically-created in an extremity
• Arteriovenous (A-V) fistula characteristics
  • Turbulent Flow: The connection between the artery and vein causes turbulent blood flow
  • Thrill: A properly functioning A-V fistula creates a characteristic vibration, known as a thrill, detected through palpation
• ESRD patients are protective of their fistulas and prefer blood pressure measurements to done on another extremity

Peritoneal Dialysis

• ESRD patients often manage their condition using peritoneal dialysis (PD) at home
• PD is slower than hemodialysis (HD) and typically requires multiple daily treatments
• Many patients prefer over HD because it allows for home treatment
• PD is the most common form of dialysis outside of the United States and Canada
• This method utilizes the fluid to remove toxins and excess fluid from the body with large surface area
• ESRD patients on PD have a permanent catheter through the abdominal wall to inject fluid
• Doctors inject Several liters of a formulated dialysis solution into the abdominal cavity for for several hours to absorb and discard
• This creates cycles of fluid is filling and draining

Peritoneal Dialysis - The Methods

• There are two types of peritoneal dialysis:
  • Continuous ambulatory peritoneal dialysis (CAPD)
  • Continuous cycler-assisted peritoneal dialysis (CCPD)
• Using CAPD involves fluid injection and removal from the peritoneal catheter in around 4-6 hours
  • Patients use gravity to perform these cycles several times a day
• While the patient sleeps, CCPD uses use the same type of catheter to empty the peritoneal cavity
• In the morning, the last injection and removal lasts all day

Medical Emergencies with End-Stage Renal Disease

• Can be categorized due to a loss of kidney function, and emergencies that result from the actual dialysis
• These patients often suffer diabetes and high blood pressure, which can cause medical emergencies outside of renal failure

ESRD Complications

• Missed dialysis are the most serious complications
  • Reasons: bad weather, poor compliance, and illness
• The symptoms: shortness of breath, fluid build-up, electrolyte imbalance, the danger of elevated potassium levels, and electrical distrubances

Dialysis Major Complications

• Hemodialysis complications
  • Frequent access to large blood vessels can lead to several issues
  • Bleeding from the A-V fistula site when needles are removed
  • Clotting and function with the palpation
  • Contamination with the IV
• Peritoneal Dialysis Complications
  • Acute peritonitis happens in bacterial infection
  • Symptoms are cloudy fluid, abdominal pain, and fever

Major Risks

• Underlying conditions with diabetes and high hypertension are also dangerous
• Kidneys are the most transplanted organs, with 21,000 transplants performed annually in the US
• A transplant involves connecting a single healthy kidney to the blood supply and ureter
• The patient must receive immunesuppresive drugs in order to avoid organ rejection

Explore hematologic complications linked to liver disease, platelet function in hemostasis, and clotting factor roles. Understand red blood cell function, aspirin risks, plasma's clotting role, and coagulopathy signs. Investigate white blood cells, sickle cell crisis, jaundice, and stroke risk.