Hematology

Lynn K. Wittwer, MD, MPD

 Hematology
 Cellular Components
 Components of Blood
 Red Blood Cells
 White Blood Cells
 Inflammatory process
 Coagulation
 Hemorrhage
 Blood Typing
 Clotting disorders
 Aticoagulant/antiplatelet therapy
 Hematology
Spleen
Spleen

Blood
Blood Kidneys
Kidneys
Hematopoietic
Hematopoietic
System
System

Bone
Bone Liver
Liver
Marrow
Marrow
 Cellular Components
Pluripotent Stem Cell

Myeloid Multipotent Common Lymphoid

Stem Cells Stem Cells

Unipotent Lymphocytes
Progenitors

WBC’s
Basophils RBC’s
Eosinophils
Thrombocytes Erythrocytes
Neutrophils
Monocytes
Platelet Erythropoietin
s
 Components of Blood
Plasma Components
 Plasma
 Transport mechanism
Water
 90-92% water. 90%
 6-7% proteins
 2-3%
 Fats
 Carbohydrates (glucose)
 Electrolytes
 Gases (O2, CO2)
 Chemical messengers

Other Protein
3% 7%
 Components of Blood
 Red Blood Cells
 Erythrocyte
 Hemoglobin – O2 bearing
molecule
 Comprised of 4
subunits:
 Globin (binds to 1
O2 molecule)
 Heme (iron)
 100% saturation = 4
globin subunits carrying
O2
 Each gram of Cellsalive.com
hemoglobin = 1.34
ml O2
 Components of Blood

 Red Blood Cells (cont.)

 Oxygen Transport
 Oxy-hemoglobin
dissociation curve
 2,3-DPG
 Components of Blood
 Red blood cell
production
 Erythropoiesis
 Erythropoietin
 Hemolysis
 Sequestration
 Laboratory analysis of
red blood cells
 Red blood cell count
 Hematocrit
 Hemoglobin
 Components of Blood
 White Blood Cells (Leukocytes)
 Margination
 Phagocytosis

The macrophage is using its internal

cytoskeleton to envelop cells of the fungus
Candida albicans.
 Components of Blood
 Leukocytes (cont.)
 White Blood Cell Count
 Normal 5-9 k WBC’s
 Leukopoiesis
 Granulocytes Human Neutrophil:
Phagocytosis of Strep pyogenes
 Neutrophil
 Basophil
 Eosinophil
 Monocytes
 Lymphocytes
 Components of Blood
 Leukocytes (cont.)
 Immunity
 Subpopulation of lymphocytes known as T cells and B cells
 T cells develop cellular immunity.
 B cells produce humoral immunity
 Components of Blood
 Leukocytes (cont.)
 Autoimmune disease
 May be specific or general
 Alterations in the immune process
 Immunosuppression
 HIV
 Anti-rejection medication
 Chemotherapy/Cancer
 Components of Blood
 Inflammatory Process
 MAST CELLS.
 Immunoglobulin E antibody IgE,
 
 Antigens
 Antigens stick to the mast cell IgE
antibodies, causing granules in the
mast cell to fire their contents into
the surrounding tissue.
 This releases a host of inflammatory
materials - leukotrienes, tumor
necrosis factor, interleukin-4 and
other cytokines that turn on other
inflammatory cells.
 These materials cause fluid to leak
from the capillaries and white cells
including neutrophils, T cells and
eosinophils to leave the circulation.
The end result is a "local
inflammatory response", a red, itchy
welt.
Cellsalive.com
 Components of Blood
 Platelets (Thrombocytes)
 Megakaryocytes
 Thrombopoietin
 Thrombocytopenia
 Thrombocytosis
 Components of Blood
 Hemostasis- 3
mechanisms
 Vascular spasm
 Contraction of tunica
media
 Platelet plug
 Platelet aggregation
 Coagulation
 Formation of fibrin
clot
This scanning electron micrograph shows the fine structure of
a blood clot. Platelets released from the circulation and
exposed to the air use fibrinogen from the blood plasma to
spin a mesh of fibrin.
 Components of Blood
 Hemostasis (cont.)
 Fibrinolysis
 Lysis of clot (plasmin)
 Thrombosis
 Thrombolytics
 Medications affecting clot formation
 Alter the enzyme
on the platelet.
 Affect the coagulation cascade.
 Enhance clotting.
Coagulation Cascade - Synopsis
 Hemorrhage
Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood Loss (% Up to 15% 15%-30% 30%-40% >40%
volume)
Pulse <100 >100 >120 >140
BP Normal Normal Decreased Decreased
Pulse Pressure Normal or Decreased Decreased Decreased
increased
Resp. Rate 14-20 20-30 30-40 >35
Urine Output (ml/hr) >30 20-30 5-15 Negligible
Mental Status Slightly Mildly Anxious, Confused,
anxious anxious confused lethargic
Fluid Replacement Crystalloid Crystalloid Crystalloid and Crystalloid and
(3:1) rule blood blood
 Blood Products and Blood Typing
 Blood Types
 Antigens
 A, B, AB, O
 Rh factor
 Rh+ = ~85%
 Rh- = ~15%

Blood transfusion
Blood Products and Blood Typing

Blood Typing - ABO

Blood type Antigen present Antibody
on erythrocyte present in
serum
O None Anti-A, Anti-B
AB A and B None
B B Anti-A
A A Anti-B
 Blood Products and Blood Typing
Compatibility Among ABO Blood Groups
Reaction with serum of Recipient
Donor Cells AB B A O
AB - + + +
B - - + +
A - + - +
O - - - -
-= no reaction
+ = reaction
Blood Products and Blood Typing

Brady; Paramedic Care Principles and Practice

 Transfusion Reactions
 Hemolytic Reaction
 Signs & Symptoms
 Facial flushing, hyperventilation, tachycardia, hives,
chest pain, wheezing, fever, chills, and cyanosis
 Treatment
 Stop transfusion, change all IV tubing, and initiate IV
therapy with normal saline or lactated Ringer’s.
 Consider furosemide, dopamine, and diphenhydramine.
 Transfusion Reactions
 Febrile Non-hemolytic Reactions
 Signs & Symptoms
 Headache, fever, and chills
 Treatment
 Stop transfusion, change all IV tubing, and initiate IV
therapy with normal saline or lactated Ringer’s.
 Consider Diphenhydramine and an antipyretic.

 Observe closely to ensure reaction is non-hemolytic.

 General Assessment - Management
 Focused History and
Physical Exam
 SAMPLE history
 Hematological disorders
are rarely the chief
complaint.
 Physical exam
 Evaluate nervous system
function.
 Skin signs
 General Assessment - Management
 Physical Exam (cont.)
 Lymphatic signs
 Gastrointestinal signs
 Epistaxis
 Atraumatic bleeding gums
 Thrush
 Atraumatic splenic/hepatic pain
 Musculoskeletal signs
 Arthralgia (rheumatoid arthritis)
 Hemarthrosis
 Cardiorespiratory signs
 Tachycardia, cx pn, dyspnea - CHF
 Genitourinary signs
 Hematuria
 Menorrhagia
 infection
 Diseases of Erythrocytes
 Anemias
 Anemia is a sign, not a separate disease process.
 Signs and symptoms may not be present until the body
is stressed.
 Differentiate chronic anemia from acute episode.

 Treat signs and symptoms.

 Maximize oxygenation and limit blood loss.
 Establish IV therapy if indicated.
Diseases of Erythrocytes

Brady; Paramedic Care Principles and Practice

 Diseases of Erythrocytes
 Sickle Cell Disease
 Normal red cells maintain
their shape as they pass
through the capillaries and
release oxygen to the
peripheral tissues (upper
panel). Hemoglobin polymers
form in the sickle rell cells
with oxygen release, causing
them to deform. The
deformed cells block the flow
of cells and interrupt the
delivery of oxygen to the
tissues (lower panel).
 Diseases of Erythrocytes
 Sickle Cell Disease (cont.)
 Sickle cell crises
 Vaso-occlusive
 Musculoskeletal/abdominal pain
 Priapism
 Renal/cerebral infarctions
 Hematological
 Lowered hemoglobin
 Splenic sequestration
 Infectious
 Management
 Follow general treatment guidelines prn.
 Consider analgesics.
 Diseases of Erythrocytes
 Polycythemia
 Overproduction of erythrocytes.
 Occurs in patients > 50 years old or with secondary
dehydration.
 Most deaths due to thrombosis

 Results in bleeding abnormalities:

 Epistaxis, spontaneous bruising, GI bleeding.
 Management:
 Follow general treatment guidelines.
 Diseases of Leukocytes
 Leukopenia/Neutropenia
 Too few white blood cells or neutrophils.
 Follow general treatment guidelines and provide
supportive care.
 Leukocytosis
 An increase in the number of circulating white
blood cells, often due to infection.
 Leukemoid reaction
 Diseases of Leukocytes
 Leukemia
 Cancer of hematopoietic cells
 Initial presentation
 Acutely ill, fatigued, febrile and weak, anemic.
 Thrombocytopenia

 Often have a secondary infection.

 Management
 Follow general treatment guidelines.
 Utilize isolation techniques to limit risk of infection.
 Diseases of Leukocytes
 Lymphomas
 Cancers of the lymphatic system
 Hodgkin's
 Non-Hodgkins
 Presentation
 Swelling of the lymph nodes
 Fever, night sweats, anorexia, weight loss, fatigue, and pruritis
 Management
 Follow general treatment guidelines.
 Utilize isolation techniques to limit risk of infection.
 Clotting Disorders
 Thrombocytosis and Thrombocytopenia
 Thrombocytosis
 An abnormal increase in the number of platelets
 Thrombocytopenia
 An abnormal decrease in the number of platelets
 Sequestration
 Destruction (ITP)
 Decreased production
 Management
 Provide supportive care and follow general treatment
guidelines.
 Clotting Disorders
 Hemophilia
 Deficiency or absence of a blood clotting factor
 Deficiency of factor VIII causes hemophilia A.
 Deficiency of factor IX causes hemophilia B.

 Deficiency is a sex-linked, inherited disorder.

 Defective gene is carried on the X chromosome.
 Signs & Symptoms
 Numerous bruises, deep muscle bleeding, and joint
bleeding.
 Clotting Disorders
 Hemophilia (cont.)
 Management
 Treat the patient similarly to others.
 Administer supplemental oxygen.
 Establish IV access.
 Be alert for recurrent or prolonged bleeding, and prevent additional
trauma.
 Von Willebrand’s Disease
 Deficient component of factor VIII
 Generally results in excessive bleeding.
 Generally is not serious; provide supportive care.
 Clotting Disorders
 Disseminated Intravascular Coagulation
 System activation of coagulation cascade.
 Results from sepsis, hypotension, OB
complications, severe tissue or brain injury,
cancer, and major hemolytic reactions.
 Multiple Myeloma
 Cancerous disorder of plasma cells.
 Pathologic fractures are common.
 Anticoagulants/Antiplatelets
 Classifying agents
 Anticoagulants
 Block synthesis and activation of clotting factors
 Antiplatelets
 Interfere with platelet aggregation or activation
 Fibrinolytics
 Dissolve fibrin component of thrombi
 Anticoagulants/Antiplatelets
 Anticoagulants
 Warfarin
 Blocks activation of Vit K
 Interferes w/ coagulation factors II, VII, IX, and X

 Unfractionated Heparin
 Binds antithrombin III (AT-III)
 Inhibits coagulation factors IX and X and thrombin

 Hirudin (medicinal leech)

 Prevents thrombin binding
 Anticoagulants/Antiplatelets
 Antiplatelets
 Aspirin
 Prevents platelet activation through cyclooxygenase
blockade.
 Prevents production of thromboxane A2
 Allows prostacyclin synthesis
 Ticlodipine
 Deforms platelet membrane fibrinogen receptor
 Anticoagulants/Antiplatelets
 Antiplatelets (cont.)
 Glycoprotein IIb-IIIa Receptor Inhibitors
 G IIb-IIIa = platelet membrane receptor of fibrinogen
 Abciximab
 Eptifibatide
 Tirofiban
 Fibrinolytics
 Activate plasminogen to plasmin = fibrinolysis
 Streptokinase
 Anistreplase
 Tissue Plasminogen Activator
 Reteplase
 Urokinase