Lecture delivered by Dr. Rajesh in Haemocon 2020 at Yenepoya Medical College Mangalore

1. Haematological emergencies
Dr Rajesh Krishna
MD ( Gen Med), MRCP(UK), FRCPath, CCT ( Haem )
Consultant Haematologist

2. Case-1
• 53 year old lady
• No significant past history
• Fatigue
• Extensive bruising
• Fever

3. • Hb 7.2 g/dL
• WBC 3.2 x 10*9/L
• Plts 12 x 10*9/L
• PT 36 sec
• APTT 52 sec
• Creatinine- 0.9 mg/dL

4. APML

5. APML
• ATRA
• Platelet transfusion
• Correct clotting
• Fluid and electrolyte management
• Management of infection
• Bone marrow biopsy
• Next day : develops Fever

6. Neutropenic sepsis
• Fever > 38 C in neutropenic patient
• Medical emergency
• Needle to patient < 30 minutes
• Hydration
• Blood cultures
• Broad spectrum antibiotics
• CXR, urine culture

7. Central line sepsis
• Check lines
• Line cultures
• Severe sepsis, hypotensive patient
• Multi drug resistant organsisms
• Line out, tip cultures

8. Treatment of APML
• t(15:17): PML-RARA
• Good risk disease
• High risk of DIC in the first 2 weeks of
treatment ( activates Tissue factor )
• All trans retinoic acid promotes maturation of
pro myelocytes
• Also given Arsenic trioxide
• High risk disease given chemotherapy

9. 6 days later

10. ATRA Differentiation syndrome

11. Case-2
• 18 year old girl
• Fainting episode
• Bruising
• Hb 7.2 g/dL
• WCC 320 x 10*9/L
• Plts 24 x 10*9/L

13. • Precursor B- Acute lymphoblastic leukaemia
• Steroid pre phase
• Next day
• K- 5.5 mmol/L
• Creatinine 1.6 mg/dL

14. Tumour lysis syndrome
• Bulky disease/ High WCC
• Raised LDH
• Hyper uricemia, hyperphosphatemia,
• Hypocalcemia
• Raised creatinine, hyperkalemia
• Aggressive hydration
• Allopurinol : inhibits xanthine oxidase
• Rasburicase : urate oxidase

15. Case-3
• 59 year old man
• Shortness of breath
• Fatigue
• Headache
• Occasional visual blurring
• Back pain

16. • Hb 9.8 g/dL
• WCC 5.6 x 10*9/L
• Plts 98 x 10*9/L
• Creatinine 2.0 mg/dL
• Electrolytes normal
• Raised globulins

17. Serum protein electrophoresis/
Urine bence jones protein

18. Serum free light chains

19. Serum protein electrophoresis and
serum free light chains
• IgG 93 g/L (6-16)
• IgA 0.1 g/L ( 0.8-4)
• IgM 0.2 g/L ( 0.5-2)
• Paraprotein 62 g/L
• SFLC kappa 12 mg/L(3-19)
• SFLC Lambda 1369 mg/L( 5-27)
• SFLC Ratio 0.01 (0.26-1.65)

20. Skeletal survey
• Lytic lesions
• Fractures

21. Bone marrow
aspirate/ Trephine
biopsy
• Plasma cells > 10 %
• They crowd out
normal bone marrow
architecture
Renal Biopsy
• Cast nephropathy

22. Diagnosis = Myeloma if following
criteria met
• Paraprotein in blood/ urine/Abnormal serum free light chain
ratio
• Bone marrow plasma cells > 10 %
• CRAB ( Hypercalcemia/ Renal impairment/ Anaemia/ Bony
lytic lesions)

23. MGUS ( Monoclonal gammapathy of
undetermined significance ) if
• Paraprotein in blood/ urine/Abnormal serum free light chain
ratio
• Bone marrow plasma cells less than 10 %
• Negative for CRAB ( Hypercalcemia/ Renal impairment/
Anaemia/ Bony lytic lesions)

24. Diagnosis = Asymptomatic Myeloma
• Paraprotein in blood/ urine/Abnormal serum free light chain
ratio
• Bone marrow plasma cells > 10 %
• Negative for CRAB ( Hypercalcemia/ Renal impairment/
Anaemia/ Bony lytic lesions)

25. Diagnosis = Myeloma if following
criteria met
• Paraprotein in blood/ urine/Abnormal serum free light chain
ratio
• Bone marrow plasma cells > 10 %
• CRAB ( Hypercalcemia/ Renal impairment/ Anaemia/ Bony
lytic lesions)

26. Hyper viscosity: Causes
• Acute leukaemia with high counts
• Waldenstrom macroglobinaemia
• Multiple myeloma
• Sickle cell anaemia
• CML with high counts

27. Hyperviscosity: Treatment
• Hydration
• Plasmapheresis ( plasma exchange)
• DVT prophylaxis
• Management of cause
• Fluid and electrolyte management

29. Cord compression
• Weakness of legs
• Bladder, bowel dysfunction
• Emergency management
• MRI spine
• Steroids : High dose dexamethasone
• Neurosurgery opinion
• Radiotherapy
• Definitive management

30. 1st line
treatment
2nd line
treatment
3rd line
treatment
MGUS: Monoclonal gammopathy of
undetermined significance
Natural history of myeloma

31. Intensive and non-intensive Options
Are you a candidate for
stem cell transplant
Symptomatic
myeloma
Clinical
trial
Yes
Induction treatment,
stem cell transplant
No
Non-intensive
drug treatment

32. Initial treatment
Thalidomide Velcade Revlimid
CTD
TD
PAD
VCD
VTD
VRD
VTD Dara
RCD
Thalidomide Velcade Doublets
MPT
CTD
VMP
VCD
MP
CD
TD
VD
Intensive
(induction prior
to transplant)
Non-intensive

33. Transfusion associated Graft versus
host disease
• Post bone marrow transplant
• Severe T cell immunosuppression
• skin rash, liver dysfunction, diarrhoea
• Invariably fatal
• Prevention: Irradiated blood products and
leukodepletion

34. Case-4
• 28 year old lady
• Bruises
• Generally unwell
• Anaemia
• Platelets 30 x 10*9/L
• Headaches

36. TTP
• Thrombocytopenia
• MAHA
• Fever
• Renal failure
• Neurology

37. • Haematological emergency
• ADAMTS13 deficiency ( VWF cleaving protein)
• Large VWF multimers cause plt aggregates in
microvasculature
• Plasma exchange 1-5 volumes x 3 days
• Steroids and iv methyl pred
• Folic acid
• Aspirin and LMWH when Plts>50

38. DD
• HUS : history of diarrhoea and oliguric/ anuric
renal failure
• DIC : Abnormal clotting

39. Thank You