Haematologic Emergencies - University of Doha PDF

The Institution of Excellence in Technical and Vocational Education and Training www.udst.edu.qa HAEMATOLOGIC EMERGENCIES HSPA 2303 Emergency Medical Care III Fall 2024 Sarah Higgins Master of Philosophy in Emergency Medici...

The Institution of Excellence in Technical and Vocational Education and Training www.udst.edu.qa HAEMATOLOGIC EMERGENCIES HSPA 2303 Emergency Medical Care III Fall 2024 Sarah Higgins Master of Philosophy in Emergency Medicine Bachelor of Emergency Medical Care Scenario (1 of 4) You are dispatched for a 30-year-old man reporting shortness of breath and severe abdominal pain. When you arrive, you are greeted at the front door by a concerned family member. The woman points to the bedroom and says, “He’s in there! He’s having another attack!” When you enter the bedroom, you find an African man sitting on the edge of the bed holding his stomach. What, if anything, about his appearance gives you cause for concern? What information do you already have at your disposal? Introduction Hematologic disorders can be complex, difficult to assess, and challenging to treat in the prehospital setting. Although you may only provide limited interventions, the ones you provide can be lifesaving. Anatomy and Physiology (1 of 2) Blood and plasma: “the fluid of life” Respiratory: carries oxygen to tissues and carbon dioxide away Nutritional: carries nutrients Excretory: ferries waste products from metabolism Regulatory: transports hormones to target organs Defensive: carries defensive cells and antibodies to protect the body Anatomy and Physiology (2 of 2) Blood makeup: plasma and formed elements Plasma: 55% of total blood volume 92% water Remaining 8% of being made up of various solutes, including proteins, electrolytes, clotting factors, and glucose Formed elements: 45% of total blood volume Red blood cells: 99% of total elements Leukocytes, platelets (thrombocytes) Production Hematopoietic System Organs and tissues involved in the production of blood cells Bone marrow, spleen, liver and lymph nodes Produces circulating blood cells, including leukocytes, erythrocytes, and thrombocytes All cells found in the blood are derived from hematopoietic stem cells. Blood-Forming Organs © Jones and Bartlett Learning. Inflammatory Response 1. Antibodies counteract foreign or unidentified antigens 2. Patients with an autoimmune disorder may produce antibodies to their own proteins. The Immune System White blood cells: leukocytes Produced in the bone marrow Small number always circulating in the blood Larger reserve ready to act against infectious-type material Several subcomponents: Neutrop Basophil Eosinoph Lymphoc hils s ils ytes Blood Classifications Based on the “ABO” system Primary antigen in plasma membrane Secondary antigen: Rh antigen General Assessment Perform the same examination on everyone. Focus on signs and symptoms that are immediately life threatening. Fully understand the chief complaint. Be inquisitive about patient’s history and SAMPLE history. Offer support and understanding to both patient and family. Look for changes in level of consciousness. Ascertain whether pain is localized or felt throughout. General Management (1 of 2) All patients should receive: Oxygen: amount depends on patient condition IV fluids ECG: treat symptomatic rhythms Transport: to the nearest facility that can manage these patients Comfort: place the patient in a position of comfort. Pharmacology: pain management is often necessary. Psychological support: be supportive of and communicate therapeutically with the patient. General Management (2 of 2) Scenario (2 of 4) When you introduce yourself, the patient tells you his name and that he has sickle cell anemia. He reports that he has had similar episodes in the past and is afraid he is having another “flare-up.” The patient looks frightened and tells you his grandfather died of sickle cell anemia at a relatively young age. You apply supplemental oxygen at 15 L/min via nonrebreathing mask. What complications are common with sickle cell anemia? What are your treatment priorities given your understanding of patients with sickle cell anemia? Specific Conditions: Anemia Lower than normal hemoglobin or RBC level Usually, an underlying disease is present. Hematologic disorders Iron deficiency is most common. Mentrua Frequen Frequen GI Blood l t Blood t Loss Bleedin Donatio Diagnos g ns tic Tests Assessment and Management of Anemia Common complaints Feeling worn down/no energy/overexertion Cannot catch breath Angina-type pain General management Check and monitor airway (high-flow oxygen when necessary). Check vital signs frequently. Cardiac monitor for chest pain. Manage blood pressure. Use IV fluids cautiously. Transport. Specific Conditions: Neutropenia An abnormally low number of neutrophils Neutrophils: Make up most of the circulating WBCs A primary defense against infections Eliminate bacteria, bacterial fragments, and certain viruses from the blood Patients are more susceptible to infection Lead to sepsis and can be life threatening Cancer patients with neutropenia develop a fever after receiving chemotherapy (febrile neutropenia). Specific Conditions: Leukemia (1 of 2) Develops in the Lymphoid System May be acute or chronic WBCs develop abnormally and/or excessively May cause anemia, thrombocytopenia, and leukocytosis Chemotherapy typically leads to leukopenia ( WBC) WBC count often elevated. Early treatment is key. Usually chemotherapy and radiation Courtesy of Bill Branson/National Cancer Institute. Specific Conditions: Leukemia (2 of 2) Chron Acute ic Children or young Older patients (>65) adults Abnormal mature lymphoid cells Bone marrow is accumulate in: replaced with Bone marrow abnormal Lymph nodes lymphoblasts Spleen Peripheral Blood Found by chance during routine blood tests High lymphoid count Assessment and Management of Leukemia (1 of 2) Complaints relate to severity of the disease and current treatment Headache Fatigue Dyspnoea s Neurologi Fever Bone Pain cal Deficit Diaphores Hypotensi Tachycardi is on a Vital Signs - Shock Assessment and Management of Leukemia (2 of 2) General management Provide airway support and oxygen therapy. IV fluid therapy Analgesics for pain management Constant positive support Be ready: patient condition may deteriorate quickly. Scenario (3 of 4) When you ask the patient to point to the area of pain, he puts his hand over his left upper quadrant and says that he has vomited a few times this evening. He also mentions that he has had chills and feels like he cannot catch his breath. There is dullness when percussing the lowest intercostal space in the anterior axillary line on the left side. He has some tenderness in his left upper quadrant, and you can feel a portion of the spleen. What, if anything, is abnormal about your physical assessment findings? Given your assessment, what do you think are potential sources of the patient’s chief complaints? Specific Conditions: Lymphomas Malignant disease Non- Night Persistent Hodgkin Chills Hodgkin Sweats Cough 2 Peaks 15-35yrs Swelling of Any age Loss of Weight 55-60yrs lymph Appetite Loss nodes May be Painless hereditary Generalize Fatigue Bone Pain d Itching Indolent, Progressive aggressive or enlargement highly of lymphoid aggressive glands Disease Spleen & response Lymph Nodes depends Assessment and Management of Lymphomas Ask specific questions. What type do you have? What kind of treatment are you receiving? General management to include: Chemotherapy or radiation therapy Aggressive pain management Fluid therapy Supplemental oxygen © Jones and Bartlett Learning. Courtesy of MIEMSS. Treat abnormal heart rhythms. Transport to appropriate facility if possible. Specific Conditions: Polycythemia (1 of 2) Overabundance or production of RBCs Caused by single stem cell or existing diseases Can arise in people who live in high-altitude areas May cause: Stroke TIA Deep vein thrombosis Pulmonary embolism Myocardial infarction Headaches Abdominal pain (due to enlarged spleen) Specific Conditions: Polycythemia (2 of 2) Treatment: phlebotomy and cancer-type therapy Desire to reduce hematocrit below 45% in men and 42% in women Initially focus on chief complaint Underlying pathology may be polycythemia, now could be a stroke or cardiac event Assessment and Management of Polycythemia Assessment findings vary widely. Altered LOC due to stroke or TIA Hypoxia due to poor circulation Respiratory distress, changes in peripheral pulse rate/skin colour Tachycardia Purplish skin with red hands and feet General management to include: Administer oxygen as needed. Establish IV access for pain control. Be supportive. Specific Conditions: DIC (1 of 2) Disseminated intravascular coagulopathy May result from any number of life-threatening conditions Massive injury Hypotension Sepsis Obstetric complications Specific Conditions: DIC (2 of 2) First stage: increase of thrombin and fibrin Causes aggregation of platelets Defibrination, or a breakdown of the fibrin clots Second stage: uncontrolled hemorrhage Results from severe reduction in clotting factors Assessment of DIC Identify signs and symptoms commonly associated with DIC or progression toward this coagulopathy With severe trauma: Respiratory difficulty Signs of shock Skin changes Cold and clammy Pallor Black and blue marks (purpura) on chest and abdomen Management of DIC Prehospital treatment must be started early. Maintain the airway and give high levels of O2. Treat early shock aggressively, keep warm. Pain management and treatment for abnormal heart rhythms Patients who have DIC due to severe trauma have a poor survival rate and will need strong support. Specific Conditions: Hemophilia (1 of 2) Bleeding disorder Clotting does not occur or is insufficient (von Willebrand disease) Two types: Type A: low levels of factor VIII Type B: deficiency of factor IX (Christmas factor) Primarily affects males Levels determine severity of disease Specific Conditions: Hemophilia (2 of 2) Type A and type B have the same signs and symptoms. Acute and chronic bleeding May or may not be life threatening Spontaneous intracranial bleeding is a common major cause of death. Treatment primarily for acute bleeding May require transfusion or infusion of factors Assessment of Hemophilia Common complaints Pallor, weak pulse, and hypotension Frequent bleeding of unknown origin Nosebleeds, bloody sputum, or blood in urine or stool Hypoxia Management of Hemophilia General management to include: ABCs High-flow oxygen Treatment of heart dysrhythmias IV therapy is temporary measure; patient will need transfusion of blood or plasma. Analgesics for pain Maintain body temperatures. Immediate follow-up Specific Conditions: Sickle Cell (1 of 2) Common inherited disorder Primarily affects those of African Canadian, Puerto Rican, and European populations Can occur in anyone Specific Conditions: Sickle Cell (2 of 2) Gene defect of HbA hemoglobin Mutation inheritance from one or both parents Abnormal hemoglobin sticks together, causes RBCs to be misshapen Abnormal RBCs are destroyed or broken down faster than normal; patients have anemia. Altered shape causes blockage of small blood vessels, also: Decreased oxygen delivery to tissues Painful crises: thrombosis or strokes Sequestration crises: acute enlargement of the spleen Chest crises: lung injury with severe hypoxia Aplastic crises: RBC production temporarily stopped Normal RBCs and Sickle Cells © Jones and Bartlett Learning. Assessment of Sickle Cell Disease Life-threatening conditions are common. Shortness of breath/signs of pneumonia Hypotension Jaundice or yellowing of the eyes (icteric sclera) Multiple system involvement with high levels of pain Some report only fatigue or achiness along with fever. Management of Sickle Cell Disease General management to include: High levels of oxygen Rapid transport IV fluid therapy for dehydration Higher level of analgesia for pain control Specific Conditions: Thalassemias Hereditary conditions due to mutations Decreased or absent production of the alpha-globin or beta-globin chains of hemoglobin Beta-thalassemia major occurs in offspring of parents who are both carriers for thalassemia. Alpha-thalassemia results from deletions in one or more of the four genes responsible for alpha-globin synthesis. Scenario (4 of 4) You gently transport the patient to the nearest appropriate facility and continue to monitor his condition en route. Although he reports that his feeling of shortness of breath has decreased, he continues to have abnormal skin signs. The emergency department nurse indicates that she is familiar with this patient because he has had periodic exacerbations of sickle cell anemia. One such incident required multiple blood transfusions secondary to a severe sickling crisis. Should this patient receive analgesics? Why or why not? Would this call change if the patient had the same or similar signs and symptoms in the presence of trauma? Transfusion of Blood and Blood Products (1 of 4) Blood transfusions Red cells Plasma Platelets Transfusion of Blood and Blood Products (2 of 4) Risks Transfusion-related reaction Transmission of bloodborne disease Transfusion of Blood and Blood Products (3 of 4) Prehospital blood products Orders for administration of blood and blood products from direct medical control Air medical carries blood products. Part of care for the patient experiencing an acute, massive hemorrhage Transfusion of Blood and Blood Products (4 of 4) Massive hemorrhage protocol Allow activation of an interdisciplinary team Provide: expert patient care, immediate access to blood, prioritize rapid laboratory testing Use strategies to prevent hypothermia and further blood loss Every paramedic should: Be able to recognize a patient experiencing a massive hemorrhage Take basic measures to prevent further blood loss Also consult local or regional guidelines References 1. Caroline, N. L., & American Academy of Orthopaedic Surgeons. (2017). Paramedic: Nancy Caroline’s Emergency Care in the Streets. Jones & Bartlett Learning. Thank you +974 4495 2222 [email protected] Location University of Doha for Science & Technology 68 Al Tarfa, Duhail North P.O. Box 24449 Doha, Qatar