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Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
9
Hematology
Multimedia Directory
Slide 71
Slide 111
Blood Type Animation
Sickle Cell Anemia Animation
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Medicine (Hematology)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• 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.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Hematology: study of blood and bloodforming organs.
• Hematologic disorders:
– Red blood cell disorders
– White blood cell disorders
– Platelet disorders
– Coagulation problems
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Introduction
• Some hematologic diseases genetic in
origin
– Hemophilia A classic example.
• Some hematologic diseases more
common in certain ethnic groups.
– Sickle cell anemia among African
Americans.
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Introduction
• Hematologic disorders may predispose
patients to infection and intolerance to
exercise, hypoxia, acidosis, blood loss.
• Careful examination and history taking
necessary to clarify diagnosis.
• Often laboratory findings will be needed
to confirm diagnosis.
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Anatomy, Physiology, and
Pathophysiology
• Hematopoietic system consists of:
– Blood (both cells and plasma)
– Bone marrow
– Liver
– Spleen
– Kidneys
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Anatomy, Physiology, and
Pathophysiology
• Cellular components of blood formed by
differentiation of pluripotent stem cells
(hematopoiesis).
• Stem cells reproduce to maintain
constant population of cells.
• Mature into basophils, eosinophils,
neutrophils, monocytes, erythrocytes,
thrombocytes.
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Anatomy, Physiology, and
Pathophysiology
• Kidneys (lesser extent liver) produce
erythropoietin (hormone responsible for
red blood cell production).
• Liver removes toxins from blood and
produces many clotting factors and
proteins in plasma.
• Spleen has cells that scavenge
abnormal blood cells and bacteria.
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Anatomy, Physiology, and
Pathophysiology
• Blood volume relatively constant at
about 6% of total body weight.
• Determinants of blood volume: red cell
mass and plasma volume.
• Red blood cells remain in intravascular
compartment.
• Only changes in rate of production can
alter size of circulating red cell mass.
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Anatomy, Physiology, and
Pathophysiology
• Plasma volume can rapidly change due
to fluid shifts between intravascular
and extravascular space.
– Helps to preserve circulating blood
volume in event of acute hemorrhage.
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Anatomy, Physiology, and
Pathophysiology
• Other compensatory mechanisms:
– Vasoconstriction
– Tachycardia
– Increased cardiac contractility
• When compensatory measures fail,
patient enters decompensated shock.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Plasma: thick, pale-yellow fluid; 90–
92% water; 6–7% proteins.
– Plasma transports cellular components
of blood and dissolved nutrients
throughout body.
– It also transports waste products from
cellular metabolism to liver, kidneys,
lungs, where removed from body.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Most plasma components can move
back and forth across capillary
membranes to interstitial fluid.
– Plasma proteins have great difficulty
diffusing across membranes.
 Remain in plasma to help retain water in
capillaries (osmotic pull, or oncotic
pressure).
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Plasma proteins' other functions:
 Clotting of blood
 Dismantling of clots
 Buffering of blood's acid-base balance
 Transporting hormones and regulating
their effects
 Providing source of energy
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Electrolytes found in plasma.
 Chemical substances that dissociate into
charged particles in water.
 Essential for nerve conduction, muscle
contraction, water balance.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Carbohydrates in plasma in form of
glucose; primary energy source.
– Plasma performs role in gas transport.
 Carbon dioxide and oxygen dissolved and
transported in plasma.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Red blood cells: transport oxygen from
lungs to tissues.
– Red blood cell (RBC), or erythrocyte:
biconcave disc; does not have nucleus
when mature.
– Contains hemoglobin molecules that
transport oxygen.
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Scanning electron photomicrograph of red blood cells moving through a blood vessel. (Centers for Disease
Control/Janice Haney Carr)
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Oxygen transport
 Greater number of red blood cells,
greater potential oxygen-carrying
capacity.
 Percentage of oxygen bound to
hemoglobin increases as PO2 increases.
 Normal PO2 95–100 mmHg.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Oxygen transport
 Hemoglobin has affinity for oxygen.
 The lower the pH, the more readily
hemoglobin will release oxygen.
 Bohr effect: waste CO2 from tissues
diffuses into blood, causing hemoglobin
to give up more oxygen to tissues.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Oxygen transport
 Except for hemoglobin, most abundant
chemical in red blood cells is 2,3bisphosphoglycerate (2,3-BPG).
 During prolonged periods of hypoxia,
level of 2,3-BPG increases.
 Increased 2,3-BPG makes it difficult for
oxygen to combine with hemoglobin in
lungs.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Oxygen transport
 Rise in body temperature causes
decrease in hemoglobin's affinity for
oxygen.
 Exercise: decrease in pH and increase in
body temperature causes hemoglobin to
release oxygen.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Oxygen transport
 The greater the substance's affinity for
binding sites, the more readily substance
will bind with hemoglobin.
 Carbon monoxide has 210–250 times
oxygen's affinity for hemoglobin and
competes for same binding sites.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Erythropoiesis: red blood cell
production.
– Erythropoietin (hormone produced by
kidney): stimulates bone marrow's
production of erythrocytes.
– RBC lives approximately 120 days.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Hemorrhage, hemolysis (destruction of
the RBC), or sequestration of RBCs by
liver or spleen may significantly reduce
their life span.
– Hemorrhage may occur outside body or
be hidden within body cavity, such as in
peritoneum, retroperitoneum,
gastrointestinal (GI) tract.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Hemolysis may occur within circulatory
system in sickle cell disease and rare
autoimmune anemias.
– Spleen and liver contain scavenger cells
called macrophages; remove damaged
or abnormal RBCs from circulation.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– RBCs quantified or measured and
reported in two ways: red blood cell
count and hematocrit.
– RBC count: total number of RBCs
reported in millions per cubic millimeter
(mm3) of blood.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Hematocrit: packed cell volume of red
blood cells per unit of blood.
– Measurement obtained by placing
sample of blood in centrifuge and
spinning it at high speed so that cellular
elements separate from plasma.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Hematocrit: red blood cells heaviest
because they carry iron-containing
pigment hemoglobin; forced to
bottom of tube.
– Above red blood cells are white blood
cells; on top specimen is plasma.
– Normal values range between 40
and 52%.
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Hematocrit, including plasma.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Measure concentration of hemoglobin
present; number of grams of
hemoglobin present per deciliter of
whole blood.
– Common to measure hemoglobin in
addition to hematocrit (H&H).
– Both values indicate RBC volume and
capability.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– White blood cells (WBCs; leukocytes or
white corpuscles): circulate through
bloodstream and tissues, providing
protection from foreign invasion.
– Marginated leukocytes do not move
freely within bloodstream; attach to
blood vessels' walls.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Demargination: marginated leukocytes
return to circulation in response to
stress, corticosteroids, seizures,
epinephrine, exercise.
– Chemical signals (chemotaxis).
– WBCs engulf and destroy invader by
phagocytosis.
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White blood cells engulfing and destroying an invader in the process called phagocytosis.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Healthy people have 5,000 to 9,000
WBCs per microliter of blood.
– Infection can increase number to more
than 16,000 WBCs.
– Increase in WBC number classic sign of
bacterial infection.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– WBCs originate in bone marrow from
undifferentiated stem cells.
– Leukopoiesis: stem cells respond to
growth factors that allow them to
differentiate into three blasts:
myeloblasts, monoblasts, lymphoblasts.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– WBCs categorized as granulocytes,
monocytes, lymphocytes.
– Granulocytes: classified by type of stain
they absorb.
 Basophils: absorb basic stains; blue
granules.
 Eosinophils: absorb acidic stains; red
granules.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Granulocytes: classified by type of stain
they absorb.
 Neutrophils: absorb neither acidic nor
basic stains well; pale blue and pink
granules.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Basophils: function in allergic reactions.
 Store histamine; contain heparin, which
breaks down blood clots.
– Eosinophils: inactivate chemical
mediators of acute allergic reactions.
 Contain major basic protein (MBP), which
fights parasitic infections.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Neutrophils: function to fight infection.
 Engulf and kill microorganisms that
invade body.
 If neutrophil count low (neutropenia),
body cannot mount appropriate response
to infection.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Monocytes
 Macrophages ("garbage collectors" of
immune system) engulf both foreign
invaders and dead neutrophils.
 Monocytes and macrophages secrete
growth factors to stimulate production of
granulocytes and red blood cells.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Lymphocytes
 Primary cells involved in body's immune
response.
 Located throughout body in circulating
blood and in tissues.
 Small, round, white blood cells containing
no granules on staining.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Immunity
 Two basic subpopulations of
lymphocytes: T cells and B cells.
 T cells: responsible for developing cellmediated, or cellular, immunity.
 B cells: produce antibodies to combat
infection (humoral immunity).
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Autoimmune disease
 Body makes antibodies against its own
tissues.
 May be limited to specific organs or
involve virtually every tissue type.
 Genetic factors and viral infections.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Alterations in immune response
 Organ transplant patients must take
drugs that inhibit cellular immunity and
prevent graft rejection.
 If they do not, T cells will recognize new
organ as "not self" and begin attacking
it; called rejection.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Alterations in immune response
 Human immunodeficiency virus (HIV)
destroys cell-mediated immunity by
selectively attacking and killing T cells.
 Cancer patients often
immunocompromised by disease itself or
chemotherapy agents that attack bone
marrow.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Inflammatory process
 Nonspecific defense mechanism; wards
off damage from microorganisms or
trauma.
 Causes: infectious agent, trauma,
chemical, immunologic.
 Results in redness, warmth, swelling,
usually pain and fever.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Platelets, or thrombocytes
 Small fragments of large cells called
megakaryocytes.
 Platelets from 150,000 to 450,000 per
microliter of blood.
 Form plug at initial bleeding site; secrete
factors important in clot formation.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Platelets, or thrombocytes
 Too few platelets (thrombocytopenia) can
lead to bleeding problems and blood loss.
 Too many platelets (thrombocytosis) may
cause abnormal clotting, plugs in vessels,
and emboli that may travel to
extremities, heart, lungs, brain.
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Anatomy, Physiology, and
Pathophysiology
• Components of Blood
– Platelets, or thrombocytes
 Survive 7 to 10 days; removed from
circulation by spleen.
 Activated when they contact injured
tissue.
 As platelets aggregate, they release
chemical messengers that activate blood
clotting system.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Combined three mechanisms that work
to prevent or control blood loss:
 Vascular spasms
 Platelet plugs
 Stable fibrin blood clots (coagulation)
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– When blood vessel tears, smooth
muscle fibers in vessel walls contract.
– Causes vasoconstriction and reduces
size of tear.
– Less blood flows through constricted
area, limiting blood loss.
– Smaller tear makes it easier for platelet
plug to develop and stop blood loss.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– At any tear in blood vessel, platelets
aggregate and adhere to collagen
(connective tissue that supports blood
vessels).
– Forms platelet plug.
– Formation of stable fibrin clot (blood
coagulation) initiated by platelet plug.
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Illustration of clot formation.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Damage to cells or to vessel lining,
starts coagulation cascade.
– Sequence of events can be activated
either by damage to vessels or by
trauma to blood from turbulence.
– Either results in cascade's progression
to clot.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Most clotting proteins produced in liver;
circulate in inactive state (prothrombin
and fibrinogen).
– Damaged cells send out chemical
message; activates specific clotting
factor.
– Activates each protein in turn until
stable fibrin clot forms.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– To completely stop bleeding,
coagulation cascade relies on platelet
plug and clotting factors to interact.
– Once bleeding stops, inflammatory and
healing processes can begin.
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The coagulation cascade.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Development of clot does not end
coagulation cascade.
– Dismantling (lysing) of clot through
fibrinolysis; takes from hours to days.
– By that time, scarring has begun.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Thrombosis (clot formation), when in
coronary arteries or cerebral
vasculature, may lead to heart attack
and stroke.
– Fibrinolytics effective only against
blockages whose components include
fibrin clot.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Patients who lack clotting factors can
have bleeding disorders.
– Patients who take medications that
decrease effectiveness of platelets or
coagulation cascade may have bleeding
problems.
– Both may complicate assessment and
treatment.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Medications examples:
 Aspirin
 Dipyridamole (Persantine)
 Ticlopidine (Ticlid)
 Heparin
 Warfarin (Coumadin)
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Glycoprotein IIb/IIIa receptors on
platelet membrane; major platelet
surface receptor involved in final
pathway of platelet aggregation.
– Treat acute coronary syndrome, often in
combination with angioplasty with or
without stent placement.
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– Glycoprotein IIb/IIIa inhibitors classified
as potent platelet inhibitors.
 Abciximab (ReoPro)
 Eptifibatide (Integrilin)
 Tirofiban (Aggrastat)
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Anatomy, Physiology, and
Pathophysiology
• Hemostasis
– All below may lead to increased clotting:
 Vitamin K (AquaMEPHYTON)
 Relative or complete immobility
 Trauma
 Polycythemia
 Cancer
 By-products of tobacco use
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Anatomy, Physiology, and
Pathophysiology
• Blood Products and Blood Typing
– Blood transfusion: transplantation of
blood or component of blood from one
person to another.
– Accomplished by IV infusion.
– Various types of transfusions given for
various purposes.
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Anatomy, Physiology, and
Pathophysiology
• Blood Products and Blood Typing
– Blood type A: A antigens on RBCs; antiB antibodies.
– Blood type B: B antigens on RBCs; antiA antibodies.
– Blood type AB: RBCs have both
antigens, but neither antibody.
– Blood type O: neither antigen, but both
antibodies.
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Anatomy, Physiology, and
Pathophysiology
• Blood Products and Blood Typing
– Blood type inherited trait.
– Type AB blood: universal recipient.
– Type O blood: universal donor.
– Crossmatching blood: checking samples
from both donor and recipient to ensure
greatest compatibility.
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Blood Type Animation
Click here to view an animation on the topic of blood types.
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Anatomy, Physiology, and
Pathophysiology
• Blood Products and Blood Typing
– Rh factor: antigen with possible severe
hemolytic reaction.
 Rh positive: person has Rh factor.
 Rh negative: person does not have Rh
factor.
 Erythroblastosis fetalis (hemolytic
disease of newborn): can lead to fatal
hemolytic Rh reaction in neonates.
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Anatomy, Physiology, and
Pathophysiology
• Transfusion Reactions
– Hemolytic transfusion reaction: donor's
and recipient's blood not compatible.
– Signs and symptoms: facial flushing,
hyperventilation, tachycardia, sense of
dread, hives, chest pain, wheezing,
fever, chills, cyanosis, flank pain.
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Anatomy, Physiology, and
Pathophysiology
• Transfusion Reactions
– Stop transfusion immediately.
– Change IV tubing; IV therapy normal
saline or lactated Ringer's solution.
– Administer bolus as necessary.
– Furosemide (Lasix) administered to
promote diuresis.
– In extreme cases of anaphylactic
reaction, administer IV epinephrine.
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Anatomy, Physiology, and
Pathophysiology
• Transfusion Reactions
– Most common transfusion reaction is
febrile nonhemolytic reaction.
– Sensitization to antigens on white blood
cells, platelets, plasma proteins.
– Signs and symptoms: headache, fever,
chills.
– Always stop transfusion before
attempting to treat it.
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Anatomy, Physiology, and
Pathophysiology
• Transfusion Reactions
– Change all tubing.
– Initiate normal saline IV.
– Diphenhydramine (Benadryl) and
antipyretic (ibuprofen, acetaminophen)
for fever.
– In event of any transfusion reaction,
return all blood bags, tubing, filters to
blood bank for analysis.
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Anatomy, Physiology, and
Pathophysiology
• Transfusion Reactions
– Blood transfusion adds fluid to system.
– Patient may experience signs and
symptoms of circulatory overload.
– Same as those for left ventricular
failure; pulmonary edema, dyspnea,
chest pain.
– Hypotension not usually problem.
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General Assessment and
Management
• Patients with infection, WBC
abnormalities, or transfusion reactions
may present with febrile symptoms.
• May develop hemodynamic instability.
• Acute hemodynamic compromise found
in patients with anemia secondary to
acute blood loss, coagulation defects,
autoimmune disease.
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General Assessment and
Management
• Treatment of patients with disorders of
hematopoietic system is supportive.
• Recognize need for rapid transport in
patients with hemodynamic instability.
• May require transfusion or other
definitive care measures.
• Always contact medical direction for
questions or problems.
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General Assessment and
Management
• Perform scene size-up; take Standard
Precautions.
• Primary assessment for life threats.
• Determine responsiveness; assess
airway, breathing, circulation.
• Alterations in hematopoietic system
may present as life-threatening bleeds
or overwhelming infections with septic
shock.
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General Assessment and
Management
• Do not spend time obtaining complete
set of vital signs during primary
assessment.
• Check ABCs; quickly determine priority
for transport.
• Critical or unstable patients candidates
for expeditious transport.
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General Assessment and
Management
• Complete secondary assessment.
• Trauma patients and unresponsive
medical patients often present lifethreatening problems; noted in primary
assessment.
• For responsive medical patient, obtain
SAMPLE history; perform physical exam.
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General Assessment and
Management
• Obtain set of vital signs; place pulse
oximeter.
• Ask for chief complaint; attention to
generalized complaints.
• Note dyspnea, palpitations, dizziness
with changes in patient's position.
• Patients with hematologic problems
may suffer syncope.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Bleeding abnormalities may be
disguised as gastrointestinal upset.
• Ask about overt bleeding with vomiting
or diarrhea.
• Atraumatic bleeding of gums almost
always points to underlying
hematologic abnormality.
• Ask about changes in urination,
hematuria, menstrual pattern.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Determine any allergies.
• Make note of all of patient's
medications and compliance.
• Ask about past medical history.
• Ask about bloodborne infections.
• Family history: hemophilia, sickle cell
disease, cancer, or death at early age
not trauma related.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Inquire about social habits.
• Last oral intake and unusual events.
• If history suggests hematopoietic
problem, look for potential pathology
during physical exam.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Nervous System
– Determine level of consciousness using
AVPU system.
– Complaint of being "weak and dizzy."
– Associated with possible anemia.
– Determine whether patient had syncopal
episode.
– Always examine eyes for abnormalities.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Skin
– Jaundice (yellow skin): liver disease or
hemolysis of RBCs.
– Florid (reddish) appearance associated
with polycythemia.
– Anemia typically exhibits pallor.
– Petechiae (tiny red dots on skin).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Jaundice. (© Edward T. Dickinson, MD)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Skin
– Purpura (large purplish blotches related
to multiple hemorrhages into skin).
– Bruising.
– Inquire about pruritus (itching).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
(a) Petechiae; (b) purpura.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Lymphatic
– Affected early in hematopoietic
diseases, especially those of immune
system.
– Pay particular attention to lymph nodes;
note any enlargement; compare sides.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Gastrointestinal
– Epistaxis (nosebleed) common.
– Patients may swallow great deal of
blood; become nauseated.
– Blood acts as cathartic (laxative).
 Patients who swallow moderate amounts
of blood report loose bowel movements.
 Often dark (melena); blood bright red or
appears like coffee grounds.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Gastrointestinal
– Bleeding of gums early findings of
hematologic problems; note presence of
gingivitis.
– Liver disease can slow blood clotting.
– As liver fails, bilirubin level will increase,
resulting in jaundice.
– Problems with spleen, liver, or both can
lead to abdominal pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Gastrointestinal
– Splenomegaly common in hematologic
problems.
– Spleen can become markedly enlarged.
– Patients with sickle cell anemia will
often develop splenic infarcts.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Musculoskeletal
– Many hematopoietic problems
autoimmune in nature.
– Rheumatoid arthritis: body's immune
system attacking tissues in joints.
– Patients with blood clotting disorders
such as hemophilia will often develop
hemarthrosis (bleeding into joint).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Cardiorespiratory
– Patients with anemia often develop
dyspnea, tachycardia, chest pain.
– In severe cases, develop high-output
heart failure to compensate for
profound anemia.
– Always auscultate for breath sounds;
note crackles or rhonchi indicative of
heart problems or infection.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Genitourinary
– Due to bleeding disorders or infection.
– Bleeding disorders can cause:
 Hematuria (blood in urine)
 Blood in scrotal sac in males
 Menorrhagia (heavy menstrual bleeding)
 Frank vaginal bleeding (dysfunctional
uterine bleeding)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• Genitourinary
– Immunocompromised patients at
increased risk for developing infections.
– Sickle cell anemia can cause priapism.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• General Management of Hematopoietic
Emergencies
– Place on high-concentration
supplemental oxygen; monitor
breathing for difficulty or fatigue.
– Be ready to assist ventilations with
bag-valve mask.
– Assess circulatory system.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• General Management of Hematopoietic
Emergencies
– Consider fluid volume replacement.
– Be alert for arrhythmias; treat
accordingly.
– Create optimum environment for blood
to perform its tasks of oxygen delivery
and waste product removal.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Assessment and
Management
• General Management of Hematopoietic
Emergencies
– Transport to appropriate facility.
– Provide comfort measures: analgesia.
– Provide psychological support to both
patient and family.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– RBC diseases: too many, too few, or
improperly functioning RBCs.
– Polycythemia: excess of RBCs.
– Anemia: inadequate number of red
blood cells; inadequate hemoglobin
within RBCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Anemia
 Classified as hematocrit of less than
37% in women; less than 40% in men.
 Due to reduction in number of RBCs
cells or amount or quality of
hemoglobin in RBCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Anemia
 Sign of underlying disease process.
 Blood loss (acute or chronic) can cause
anemia.
 Can be self-limiting disease or lifelong
illness requiring periodic transfusions.
 Hemolytic anemia: destruction of RBCs;
hereditary or acquired.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Anemia
 Acquired hemolytic anemias: immune
system disorders, drug effects,
environmental effects.
 Anemias caused by inadequate RBC
production: iron deficiency anemia,
pernicious anemia, anemia of chronic
disease.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Anemia
 Sign, not disease process in itself.
 Results in hypoxia.
 Chronic anemias: pica, headache,
dizziness, ringing in ears, irritability or
difficulty concentrating, pallor,
tachycardia.
 Angina pectoris important indicator.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Anemia
 If develops rapidly, body does not have
time to compensate for change; signs
and symptoms of shock.
 If onset slower, body can adjust to
reduced availability of oxygen.
 Treat hypoxia with supplemental oxygen.
Avoid hyperoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Sickle cell disease (sickle cell anemia)
 Disorder of RBC production.
 Abnormal chemical sequence that gives
red blood cells C, or sickle, shape when
oxygen levels are low.
 Chronic anemia; results from destruction
of abnormal RBCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Scanning electron photomicrograph of sickle cells. (Centers for Disease Control/Janice Haney Carr)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Sickle Cell Anemia Animation
Click here to view an animation on the topic of sickle cell anemia.
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Sickle cell disease (sickle cell anemia)
 Average life span of sickled RBCs 10–20
days; 120 days for normal RBCs.
 Blockage of blood flow to tissues and
organs common; following period of
stress.
 This process (vasoocclusive crisis)
characteristic of sickle cell anemia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Sickle cell disease (sickle cell anemia)
 Adult sickle cell patients have multiple
organ problems.
 Disease inherited; primarily affects
African Americans.
 Vasoocclusive crises: musculoskeletal
and abdominal pain, priapism, pulmonary
problems, renal crises, central nervous
system (CNS) crises.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Sickle cell disease (sickle cell anemia)
 Hematologic crises: fall in hemoglobin
level, sequestration of RBCs in spleen,
problems with bone marrow function.
 Infectious crises: functionally
immunosuppressed; vulnerable to
encapsulated bacteria.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Red Blood Cells
– Sickle cell disease (sickle cell anemia)
 Prehospital primarily supportive.
 High-concentration oxygen to saturate as
much hemoglobin as possible.
 IV therapy with isotonic crystalloid
solution.
 May require large amounts of narcotics
for pain control.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Result from too few WBCs (leukopenia),
too many WBCs (leukocytosis), or
improper WBC function.
– Reduction in number of neutrophils
(neutropenia) predisposes patient to
bacterial and fungal infections.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukopenia/neutropenia
 Normal WBC count from 5,000 to 9,000
per cubic millimeter of blood.
 Absolute neutrophil count better indicator
of immune system's status.
 Prehospital treatment supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukocytosis
 Increase in number of circulating white
blood cells.
 Body exposed to infectious agent or
particularly stressed.
 WBC count 10,800 to 23,000 per cubic
millimeter of blood characteristic of
bacterial infection.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukocytosis
 Causes: bacterial infection, rheumatoid
arthritis, diabetic ketoacidosis (DKA),
leukemia, pain, exercise.
 Any patient with significantly elevated
WBC count should be evaluated for
possible leukemia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukemias
 Cancers of hematopoietic cells.
 Acute lymphocytic leukemia (ALL)
 Acute myelogenous leukemia (AML)
 Chronic lymphocytic leukemia (CLL)
 Chronic myelogenous leukemia (CML)
 Hairy cell leukemia
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukemias
 Chemotherapy, radiation therapy, bone
marrow transplantation have resulted in
cures of certain types.
 Deaths secondary to infection/bleeding.
 Signs and symptoms vary; moderate to
severe anemia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukemias
 Many patients present with bleeding; due
to thrombocytopenia.
 Patients will appear acutely ill.
 Prehospital treatment primarily
supportive.
 Place in position of comfort.
 Administer supplemental oxygen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Leukemias
 IV with isotonic crystalloid solution.
 Consider fluid bolus if dehydrated.
 Consider administration of analgesic.
 Increased risk of developing infection;
employ proper isolation techniques.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Lymphomas
 Cancers of lymphatic system.
 Malignant lymphoma classified:
– Hodgkin's lymphoma
– Non-Hodgkin's lymphoma
 Long-term survival rate better with
Hodgkin's lymphoma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the White Blood Cells
– Lymphomas
 Presenting sign of non-Hodgkin's
lymphoma: painless swelling of lymph
nodes.
 Fever, night sweats, anorexia, weight
loss, fatigue, pruritus.
 Treat patients with lymphomas
symptomatically.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Thrombocytosis: increase in number of
platelets; due to increased platelet
production.
 Most patients asymptomatic; prehospital
treatment supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Thrombocytopenia: abnormal decrease
in number of platelets.
– Due to decreased platelet production,
sequestration of platelets in spleen,
destruction of platelets, or any
combination of the three.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Acute idiopathic thrombocytopenia
purpura (ITP): destruction of platelets
by immune system.
 Most commonly seen in children following
viral infection.
 Prehospital treatment supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Hemophilia: blood disorder; one of the
proteins necessary for blood clotting
missing or defective.
 Deficiency of factor VIII: hemophilia A.
 Deficiency of factor IX: hemophilia B
(Christmas disease).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Hemophilia
 Hemophilia A most common inherited
disorder of hemostasis.
 Hemophilia B more rare; more severe.
 When injured, bleeding will take longer to
stop; body cannot form stable fibrin clots.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Hemophilia
 Occasionally life-threatening bleeds.
 Sex-linked, inherited bleeding disorder.
 Numerous bruises, deep muscle bleeding,
joint bleeding called hemarthrosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Hemophilia
 Most patients aware of diagnosis will tell
you; Medic-Alert bracelets or similar
devices.
 Prehospital treatment comprehensive.
 Be attentive to prolonged bleeding or
possible rebleeds.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– Hemophilia
 Administer supplemental oxygen.
 IV therapy with isotonic crystalloid.
 Be careful to prevent additional trauma.
 If joint injury with hemarthrosis, splinting
extremity will sometimes help control pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Diseases of the Platelets/Blood Clotting
Abnormalities
– von Willebrand's disease
 Component of factor VIII deficient.
 In addition to clotting problem, platelet
function abnormal.
 Disease inherited; not sex linked.
 Excessive bleeding, primarily after
surgery or injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Other Hematopoietic Disorders
– Disseminated intravascular coagulation
(DIC) (consumption coagulopathy):
disorder of coagulation caused by
systemic activation of coagulation
cascade.
 Bleeding most frequent sign; due to
reduced fibrinogen level, consumption of
coagulation factors, thrombocytopenia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Other Hematopoietic Disorders
– Disseminated intravascular coagulation
 Disease is quite grave.
 Oozing blood at venipuncture and wound
sites; purpuric rash.
 Prehospital care symptomatic.
 Administration of fresh frozen plasma
and platelets.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Other Hematopoietic Disorders
– Multiple myeloma: cancerous disorder of
plasma cells.
 Rarely found in persons under 40.
 Change or mutation in plasma cell in
bone marrow.
 Cancerous cells crowd out healthy cells;
reduction in blood cell production.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Other Hematopoietic Disorders
– Multiple myeloma
 Patient becomes anemic; prone to
infection.
 First sign is pain in back or ribs.
 Treatment: chemotherapy, radiation,
bone marrow transplants.
 Prehospital care is supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Managing Specific Patient
Problems
• Other Hematopoietic Disorders
– Multiple myeloma
 Establish IV of isotonic crystalloid
solution.
 Consider fluid bolus if symptoms of
dehydration.
 Consider analgesics if pain severe.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Hematology is study of blood and
blood-forming organs.
• Blood consists of a liquid portion, or
plasma, and formed elements—red
blood cells, white blood cells, platelets.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Each component of blood has various
functions intrinsic to sustaining
homeostasis.
• Red blood cells, composed of
hemoglobin, transport oxygen to body
tissues and remove wastes such as
carbon dioxide.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Plasma draws water into capillaries;
assists in clotting blood, dismantling
clots, buffering blood's acid-base
balance, transporting hormones and
regulating their effects, providing
source of energy.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• White blood cells protect body from
foreign invasion through processes of
chemotaxis and phagocytosis.
• Platelets travel to site of damaged
tissue and help to prevent blood loss.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Hemostasis is body's way of preventing
or controlling blood loss.
• Three phases of hemostasis:
– Vascular spasm
– Development of platelet plug
– Formation of stable fibrin clot (blood
coagulation)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Some diseases interfere with aspects of
hemostasis; people who have these
diseases may incur life-threatening
hemorrhages from minor injuries.
• As a paramedic, you must understand
hematology; breakdowns in
hematologic system can complicate
patient assessment and care.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.