112. Oncologic Emergencies Flashcards
Febrile neutropenia definition
ANC below: mild: 1000 to 1500, moderate 500 to 1000 less than 500 severe. current guidelines suggest that and see less than 500 or expected drop below the threshold within 48 hours
How to calculate the absolute neutrophil count
Percent granulocytes plus percent bands times total white blood cells divided by 100
Where are the most common sources of neutropenic fever?
Pneumonia, anorectal lesion, skin infection, pharyngitis, or urinary tract infection
Definition of fever in federal neutropenia
Single temp greater than 38.3 or a greater or sustained temperature of 38 for one hour or more
Diagnostic testing for neutropenia
Blood cultures from two sites, one can be done from the central line. Where is the other should be done properly, white blood differential, urine analysis and urine culture, chemistries and renal and hepatic function tests. VBG for lactate.
Consider CDiff, chest x-ray
When should patients were a febrile neutropenia receive antibiotics?
Prior to confirming infection given high mortality
Parental broad-spectrum, antibiotic, such as pip, Tazo or Carbapenem
Multinational Association of Supportive Care in Cancer: clinical features
age <60
onset of fever while outpatient
overall moderate sx burden
absence dehydration
no prior fungal infection or solid tumor tyoe
no copd hx
absence of hypotension
asx or overall mild symptom burden
score >/=21 suggests low risk complication; likely resolution fever <5d
Clinical features and corresponding point value of clinical index of stable febrile neutropenia:
eastern coop oncology group performance status >/=2
stress induced hyperglycemia
copd
chronic cardiovascular disease
mucositis of grade >/=2
monocyte coun <200 per microL
If pt with febrile neutropenia show signs of shock, what should they add to broad spectrum beta lactam with antipseudomonal coverage?
+ FQ or aminoglycoside
What abx for neutropenic pt with CAP?
levo 750mg IV a24h or azithro 500mg IV q24h and doxy 100mg BID
TMP for pcp if necessary
For neutropenic pt with GI sx, what abx to give?
cefepime 2g IV q8h and metronidazole 500mg PO q8h
What febrile neutropenia patients can be managed as outpt?
criteria:
- low risk criteria MASCC 21 or less
- no evidence of pneumonia, line infection, cellulitis or organ failure
- reliable daily f/u with oncology
- clinical stability in ER 4h or longer
- low suspicion of infection with drug R organism
Metastatic SC compression: where does lesion most often come from?
extradural
Metastatic SC compression: how does cord injury normally occur?
occlusion of epidural venous plexus leading to breakdown of BBB and vasgenic edema
if untx - arterial obstruction –> cord ischemia and infarct
less common direct compression
Metastatic SC compression: what cancers typically cause this?
prostate
breast
lung ca
RCC
nonHodgkin lymphoma
MM
Metastatic SC compression: where mc?
thoracic
lumobosacral
cervical
Metastatic SC compression: clinical features?
back pain (mc)
weakness (extremity often first pre. weakness)
sensory loss
autonomic function loss
Metastatic SC compression: diagnostic testing
MRI
Metastatic SC compression: tx in ED
CS: 10mg bolus IV then 16mg oral per d
if paraplegic consider first dose of 100mg IV then 96/day orally in divided doses
initiation of defin tx - surgery, rad therapy or both
Metastatic SC compression: how do steroids work?
temporize vasogenic cord edema but damage occurs without source control
Malignant pericardial disease: mc three?
pericarditis
neoplasm
effusion
Malignant pericardial disease: how can this occur as an effusion?
lymphatic flow becomes obstructed by proximal malignant LN
so mets spread to pericardial lining
mc cancers causing pericardial effusion?
lung
breast
heme
melanoma
Kussmaul sign
paradoxial incr in JVP with inspiration
Beck’s triad
hypotension
elevated JVP
muffled heart sounds
Malignant pericardial disease: ddx?
acs
hf or valve failure
pe
pleural effusion
pneumonia
ptx
Malignant pericardial disease: pericardial effusion work up?
cxr
ecg
tte
Malignant pericardial effusion findings on ecg?
nonsp st or t change
low amp qrs
electrical alternans
Malignant pericardial disease: management of pericardial effusion?
drainage by subxiphoid approach
likely will recur so needs LT f/u
fluid sampling for cytology or tumor marker analysis
Hypercalcemia: what two main hormones incr serum ca regulation?
what decr?
PTH
calcitriol - incr serum ca
decr: calcitonin
Hypercalcemia: what are two places active vitamin D works on?
bone - osteoclast activation to release
GI - to incr dietary ca uptake and dietary phosphate
Inactive vit d to active by which enzyme?
1 alpha hydroxylase
To incr ca: PTH acts on what two organs
kidneys: incr ca reuptake, decr phos reuptake
bone: osteoclast
How do cancer patients experience Hypercalcemia: 4 methods
synthesis PTHrP
overproduction calcitriol
bone osteolysis due to direct tumor spread
less common ectopic production of PTH
PTHrP producing cancers?
squamous.- head and neck, lung, esophageal, cervical, ovarian, endometrial
Cacitriol overproduction in which cancers?
hodgkin and non lymphomas
Hypercalcemia: sx
weakness
lethargy
confusion
abdo pain
n/emesis
constipation
polyruia
polydipsia
kidney injury
Hypercalcemia: ecg
qt interval shortening
to dysr and heart block
Hypercalcemia: which ca measurement needed?
free ca as lots bound to albumin
Hypercalcemia: Tx ED
- fluids ++ as helps to incr removal: 1-2L bolus, then 200-250ml/hour
–>. +/- dialysis above if needed to support u/o - bisphosphonates: inhibit bone turn over: pamidtronade 90mg over 2-4 hours or zolendronate 4mg over 15-30 mins
*expect decr 3-4mg/dl but probably not for 7-10d - calcitonin SC 4-8 units/kg q6h (faster 12-24h onset)
- Denosumab to block RANK ligand * esp if renal clearance bad
Rosen’s indications for admission for Hypercalcemia:
Ca >14
acutely incr
TLS: why does this occur?
desctruction of malignant cells so rapid that body mechanism for unwanted products are overwhelmed
TLS: 4 abnormal electrolyte/lab values
Hyperuricemia
HyperK
Hyperphos
HYPOcalcemia
AKI often as well
TLS: what other organ affected often
kidney