Hematology+Round+2

=Hematology Pediatric Round 2 = Thalassemias: Autosomal recessive disorders Impaired rate of hemoglobin chain synthesis Alpha or beta, major or minor Major inherited genes from both parents, Minor inherited from one parent - only mild anemia Beta thalassemias most common and most difficult

Incidence/etiology: Betas - Mediterranean decent - Italians, Greeks, Arabs, Jews Alphas - Chinese, Vietnamese, Cambodian, Laotian Present some in the AA community

Beta Thalassemia - Cooley's anemia Normal hgb A has four globin components Combine with four heme complexes to form one hgb molecule In beta thalassemia beta globin synthesis impaired so carry less hgb. <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Also free alpha chains are in these RBCs so they are destroyed in the marrow or spleen <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Anemia + RBC destruction <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Kidneys release erythropoietin which stimulates the marrow to produce more RBCs <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Bone marrow becomes hyperplastic so bones enlarge



<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Noted in the second six months of life as hgb F replaced by hgb A <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Signs and symptoms of severe anemia <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Facies - protruding forehead, maxillary prominence, wide set eyes, flattened nose <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Pathologic fractures - expansion of bones to accommodate hyperplastic marrow <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Decreased bone mineralization - expansion of bones to accommodate hyperplastic marrow <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Malocclusion - maxillary overgrowth <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Splenic enlargement - Increased RBC destruction <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Jaundice - RBC hemolysis <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Bronzing of skin - iron accumulation in skin

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Family history <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Clinical presentation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Labs - extremely low hct.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Treatment : <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Goal - no cure will die by 5 or 6 if not treated <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Try and normalize hct and hgb relieve anemia <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Can add 2 decades to life <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Blood transfusions every 2-3 weeks *(can lead to iron overload)* <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">*Splenectomy eliminates the site of hemolysis so decreases need for transfusions* <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">*Iron from repeated transfusions builds up in organs and tissues = hemosiderosis* <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">*Chelating agents used to reverse or reduce effects of iron overload* <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Desferal, SQ over 8-12 hours, 5-7 days a week or Exjade, new tablet can be dissolved in water or juice and drunk once/day <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Stem cell transplant or cord blood transplant



<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Nursing Interventions: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Blood transfusions <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Observe for reactions, follow protocol <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Support services, emotional support <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Refer to appropriate agencies

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Case Study: Beta Thalassemia =

media type="youtube" key="LuJuJC3ZHwA?version=3" height="447" width="546"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Explain the cause and mechanism of Beta Thalassemia and the classifications.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What is Cooley’s disease? <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What population is most affected? <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What is the treatment? <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What happens if there is not treatment? <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Is there a cure?

media type="youtube" key="82313FtBDNc?version=3" height="379" width="602"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Aplastic Anemia:

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Primary (congenital)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Fanconi syndrome, autosomal recessive trait <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Pancytopenia, hypoplasia of the bone marrow <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Patchy brown skin discoloration <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Multiple congenital anomalies associated with the musculoskeletal system and the GU

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Secondary (acquired)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Idiopathic –drugs, infection, human parvovirus, hepatitis, irradiation, immune response <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Can be moderate or severe <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Treatments immune suppression or transplantation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Nursing care is similar to the child with leukemia

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 27.299999237060547px;">Hematology <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 23.65999984741211px;">Coagulation disorders =

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Coagulation maintains hemostasis

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Maintains blood volume, blood pressure, and flow

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Three parts - platelets, clotting factors, vasculature

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The inflammatory response

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">media type="youtube" key="_bNN95sA6-8" width="462" height="346"


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Normal coagulation reaction - **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Injured vessel - endothelial sloughing exposes subendothelial - platelets attracted to this tissue and adhere to vessel wall - platelets release biochemical mediators serotonin and histamine direct platelet activity and vasoconstriction to minimize blood loss - WBCs sent to site - Platelets aggregate into plugs - blood clot formation.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Fibrin protein formed through a series of reactions called the coagulation cascade which involves numerous clotting factors. Fibrin created only when injury occurs but fibrinogen and prothrombin circulate all the time.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">media type="youtube" key="cy3a__OOa2M" width="560" height="315"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">**Clotting Disorders include:**

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Hemophilia

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Von Willebrand's Disease

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Idiopathic thrombocytopenic purpura

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Disseminated Intravascular Coagulation

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Epistaxis

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">**Hemophilia:**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Group of disorders one factor in the first phase of coagulation deficient

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Incidence/etiology:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemophilia A - most common, 1/5,000 males, 80-85% cases

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Deficiency factor VIII

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemophilia B, Christmas Disease, deficiency factor IX (Christmas factor) 10-15%

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemophilia C, deficiency of factor XI, = in males and females, less severe, mild bleeding disorders

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">All result in improper clotting can be fatal.

media type="youtube" key="4eK2AgP2-sE" width="560" height="315"


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Pathology: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Missing or decreased levels of factor VIII, IX or XI impairs or prevents clotting


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Clinical Manifestations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Depend on the amounts of clotting factors in the blood

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Mild has 5-35% of normal factor levels - excessive bleeding only occurs after severe trauma

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Moderate - 1-5% of normal - excessive bleeding after trauma

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Severe - less than 1% - spontaneously

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">First year of life bleeding occurences rare

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hematomas - pockets of blood

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemarthrosis - bleeding into joints

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hematuria - blood in urine

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Epistaxis - nose bleed


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Diagnosis: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Thromboplastin generation test


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Treatment Hemophilia A: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Recombinant Factor now instead of plasma

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Amount depends on degree

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">May give prophylactically 3-4 xs a week

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Caregivers taught to give immediately after injury

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Desmopressin acetate (Stimate) effective prior to dental or surgical procedures

<span style="color: #666666; font-family: Roboto,Arial,Helvetica,sans-serif; font-size: 15px; vertical-align: baseline;">Desmopressin (DDAVP), synthetic vasopressin, used to treat mild hemophilia A. Available I.V., SQ or nasal spray (Stimate), however, lower-dosage nasal sprays aren’t effective in treating bleeding. Desmopressin triggers release of clotting factors from blood-vessel walls into the bloodstream. It’s not effective in every patient (must undergo a test to determine if their body responds to the medication). Desmopressin causes fluid retention. Monitor patient fluid intake after administration to prevent hyponatremia, especially in children.


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Treatment Hemophilia B **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Plasma instead of recombinant factor

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Desmopressin acetate doesn't work

<span style="color: #c0211e; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Nursing Care:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Prevent bleeding safety in the environment

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Education of care givers…

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">School, noncontact sports

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Soft toothbrush

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Medical ID bracelet

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Pain tx acetaminophen

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Venipuncture versus finger or heel stick

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">RICE for injuries with factor replacement therapy

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Passive ROM for joints and hemarthrosis, rarely splint or aspiration

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Healthy body weight

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Team: pediatrician, hematologist, physical therapist, orthopedist, social worker, nurse

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">***If signs of neurological impairment are noted in a child with hemophilia such as irritability, altered level of consciousness, vomiting may = intracranial bleed > take to hospital. If head trauma occurs even without symptoms take to the hospital and treat as if intracranial bleed.** *

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 27.299999237060547px;">Case Study: Hemophilia =

media type="youtube" key="FS64UXi74lY" width="504" height="377"

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//<span style="font-family: 'Times New Roman',Times,serif; font-size: 21.486398696899414px;">Issac is 4 years old. His parents are divorced and are on good terms. Issac is supposed to spend the summer with his dad. Prior to this he has lived several states away so his involvement with Issac has been limited. The father has called the office to discuss Issac's needs to prepare for caring for him this summer. He is extremely motivated and excited to be able to spend more time with his son but he is also nervous. //=====

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.800600051879883px;">What is the treatment?
<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">**Von Willebrand's Disease**

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">media type="youtube" key="CNS6vXRusKI" width="504" height="377"


 * <span style="color: #c82226; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Von Willebrand's Disease **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Hereditary bleeding disorder deficiency

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Absence of Von Willebrand factor and factor VIII.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">This anomaly affects males and females.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Nursing care is the same as for hemophilia


 * <span style="color: #c82226; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Idiopathic Thrombocytopenia Purpura (ITP) **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Acquired, cause unknown

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Thrombocytopenia, destruction of platelets

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Most frequent thrombocytopenia of childhood

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Purpura (petechiae beneath the skin)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Normal bone marrow

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Normally seen between 2 and 10

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Acute (self limiting) or chronic

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Acute often follows URI, measles, rubella, chicken pox or parvovirus

<span style="color: #c0211e; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Nursing Care:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Supportive

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Course is self limited most often

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Activity restricted

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Prednisone

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">IV immune globulin

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Anti-D antibody in lieu of above options

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Splenectomy if persists over a year…risks

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">*Teaching, only acetaminophen for pain, no contact sports…


 * <span style="color: #c0211e; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Disseminated Intravascular Coagulation (DIC) **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Consumption coagulopathy…

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Occurs as a complication of a number of pathogenic processes such as shock, hypoxia, acidosis, systemic disease, sepsis, rickettsial and some viral infections

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">When the first phase of the clotting process is abnormally stimulated

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">1st too much thrombin is generated > fibrinogen > fibrin

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">2nd fibrinolytic > destruction of clotting factors > uncontrollable bleeding/organs

<span style="color: #bb3535; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Nursing Care:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Treat the underlying cause

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Platelets and fresh frozen plasma

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Exchange transfusion with fresh blood

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">IV administration of heparin to inhibit thrombin, limited to those unresponsive to other measures


 * <span style="color: #bb3535; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Epistaxis: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Nose bleeding

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Common in childhood

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Nose especially septum, highly vascular

<span style="color: #bb3535; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Causes:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Trauma, injury, nose picking

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">URI, allergic rhinitis

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Persistent nose bleeds require evaluation

<span style="color: #bb3535; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Nursing Care:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Stay clam

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Educate

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Bleeding usually stops in 10-15 minutes

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Sit up, lean forward, do not lay down (aspiration)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Apply pressure for 10 minutes

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Insert cotton or wadded tissue into nostril

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Ice

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">May pack with epinephrine soaked gauze

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Petroleum or water soluble jelly to prevent crusting

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Environmentally add humidifier

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Evaluate if prolonged > 30 minutes

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The inflammatory response located at

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/_bNN95sA6-8

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Coagulation Cascade video located at

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/co6ar6vVp70

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemophilia video located at

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/FS64UXi74lY

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemophilia and Kids video located at

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/4eK2AgP2-sE

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">UnderstandingVon Willebrands Disease located at

http://youtu.be/CNS6vXRusKI