Emergencies Flashcards
Neurological Emergencies
Cord Compression
CNS metastases
Vascular events: Hyperviscosity/ leukostasis
Cardiopulmonary Emergencies
Cardiac tamponade
SVC syndrome
Metabolic Emergencies
Tumor lysis
Hypercalcemia
SIADH
Hematological Emergencies
Neutropenic fever
Severe thrombocytopenia
Overanticoagulation
Emergencies That Need to be Approached Immediately
Neutropenic fever
Tamponade
Cord compression
CNS metastases with symptoms
Emergencies That Need to be Approached Today
Coagulopathies Tumor lysis Leukostasis Hyperviscosity Severe thrombocytopenia (
Emergencies That Need to be Approached Today or Tomorrow
SVC Syndrome
Most hypercalcemia
Most CNS mets without edema
INR 5-9
Neurological: Cord Compression
Inflammation Paresthesia Autonomic dysfunction Usually with vertebral mets Rapid deterioration = worse outcome
How does cord compression occur?
Thecal sac becomes compressed
Spread through venous plexus & blood stream
Examination of Cord Compression
MRI/CT of whole spine
Decadron
Neurosurgery
XRT: radiation if multiple levels
How do steroids help with cord compression?
Decreased risk of paralysis due to reduction in inflammation
What is the most common brain tumor?
Brain mets
CNS Metastases with Symptoms
Headaches Altered mental status Vision changes Ataxia CN problems Seizures Personality changes Confusion Sensory changes
Which cancers like to go to the brain?
Lung Breast Colorectal Melanoma Kidney Germ cell Neuroblastoma Sarcoma Prostate
Presentation of Brain Metastases
Headache
Seizures
Altered mental status
Focal deficits
What improves survival of isolated brain mets?
Surgery + radiation
Necessary Steps to Treat Brain Metastases with Symptoms
Decadron: edema, focal symptoms
Dilantin: seizures
MRI imaging
Neurosurgery
Symptoms of Leukostasis
Altered mental status Coma Other organs involved: brain, respiratory Hypoxia Renal insufficiency
Leukostasis Mostly In
AML: WBC > 100,00
Relatively Nonspecific Symptoms Hyperviscosity
Somnolence
Headache
Blurry vision
Dizziness
What condition is hyperviscosity most common with?
Waldenstrom’s
Less Common Conditions with Hyperviscosity
Multiple myeloma
Polycythemia vera
Essential thrombocytosis
Polycythemia Vera Hemoglobin Levels
> 19 or 20
Essential Thrombocytosis Platelet Level
> 10^6
Necessary Steps to Treat Hyperviscosity
Hydrated
Apheresis for IgM + chemotherapy
Phlebotomy for polycythemia vera
Hydroxyurea & aspirin for essential thrombocytosis
Necessary Steps to Treat Leukostasis
Hydrated Quentin access (renal) Chemotherapy LP for cytology rule in/out CNS leukemia Steroids
Most Common Primaries with Cardiac Tamponade
Lung
Breast
What does an EKG show with cardiac tamponade
Electrical alternans
Low voltage
ST elevation in all leads
Presentation of Cardiac Tamponade
Left or right sided failure
Pulsus paradoxus
Big heart on CXR
3 Main Reasons for Tamponade
Malignancy
Idiopathic
Autoimmune
Beck’s Triad
Low arterial blood pressure
Distended neck veins
Distant, muffled heart sound
Necessary Steps to Treat Cardiac Tamponade
Echo & cytology from pericardiocentesis
Catheter drainage of pericardial space
Medical management
Chemotherapy
Subxiphoid pericardial window or balloon percardiotomy
Define Pulsus Paradoxis
Drop of 10 mmHg in arterial blood pressure on inspiration
Cancers with SVC Syndrome
Lung cancer Bronchogenic carcinomas Lymphoma Breast cancer Mediastinal tumors
Presentation of SVC Syndrome
Facial edema
Symmetric or asymmetric upper extremity edema common
SOB but not hypoxic
Necessary Steps to Treat SVC Syndrome
Pulse Ox/CSR Chest CT to outline mass Chemo for small cell, lymphoma, germ cell Radiation for almost all else Heparin or corticosteroids IR: stenting
Tumor Lysis Syndrome
Occurs in tumors with high body burden & high chemrsensitivity
Usually due to therapy
Few clinical symptoms other than being ill with obvious lab abnormalities due to renal failure
Cancers Associated with Tumor Lysis Syndrome
High-grade lymphomas
High-grade leukemias
Small cell
Germ cell
Tumor Lysis Syndrome Lab Abnormalities
Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Necessary Steps for Pre-Treatment of Tumor Lysis Syndrome
Fix conditions that will make effects worse: dehydration, renal obstruction, IV contrast
Baseline labs: K, Ca, Phos, Uric acid, LDH, Cr
Alkaline diuresis: D5 1/2 with 2-3 amps NaHCO3/1 at 200+ cc/hr
Allopurinol 600 mg, then 300/day to keep uric acid production down
Rasburicase
Necessary Steps During Treatment for Tumor Lysis Syndrome
High K+, low Ca++
Keep alkaline urine output high
Check BID electrolytes, phos, UA, Ca, LDH, Cr
Keep phosphate 6, K
Cancers Associated with Hypercalcemia
Breast
Lung
Multiple myeloma
SCC make PTH-rP
Presentation of Hypercalcemia
Gradual in onset Fatigue N/V Constipation Anorexia Apathy Decreased consciousness
Pathologic Role of PTH-rP
Does everything PTH does but without negative feedback system
Necessary Steps to Treat to Hypercalcemia
Volume replete patient
Furosemide
IV Pamidronate (Aredia) or IV Zoledronic (Zometa)
Adjunct: dialysis, calcitonin (Miacalcin), steroids
Symptoms of SIADH with Serum Sodium
Anorexia Irritability N/V Constipation Muscle weakness Myalgia
Symptoms of SIADH with Serum Sodium
Seizure
Coma/Death
Abnormal reflexes
Papilledema
SIADH Most Common in What Cancer
Small cell lung cancer
Lab Results of SIADH
Decreased BUN & serum osmolarity
Increased urine osmolarity & sodium levels
Necessary Steps to Treat SIADH
Treat tumor
Limit fluid intake to 500-1000 mL/day
Furosemide
Parenteral sodium replacement with severe neurological symptoms
Monitor electrolytes: Magnesium, K+, Ca++
Presentation of Neutropenic Fever
Initially subtle
Rapid development of hypotension, dyspnea, sepsis
Short-term Neutropenia Predicts What Type of Organisms
Gram-negative»_space; gram-positive
Long-term Neutropenia Predicts What Type of Organisms
Fungal
Viral
Opportunistic
Necessary Steps to Treat Neutropenic Fever
Evaluate patient for a source: blood, CXR, sputum, urine, skin, LP
Suspected source: treat it
Not a suspected source: treat empirically
Empiric Antibiotics to Treat Gut Flora
Cefipime Moxifloxacin Pip/Gent Aztreonam Add coverage for lack of response
Symptoms of Severe Thrombocytopenia
Asymptomatic Epistaxis Gingival bleeding Bullous hemorrhages Petechiae Eccymosis Menorrhagia CNS bleeding least common
Platelet Defect Bleeding
Site: skin, mucous membranes Minor cut bleeding: yes Petechiae: present Ecchymoses: small, superficial Hemarthrosis: rare Bleeding after surgery: immediate, mild
Clotting Factor Defect Bleeding
Site: deep in soft tissue Minor cut bleeding: not usually Petechiae: absent Ecchymoses: large, palpable Hemarthrosis: common Bleeding with surgery: delayed, severe
Necessary Steps to Treat Thrombocytopenia
Be sure it’s not TTP, DIC, HIT, HELLP
Assess for active bleeding
Transfuse if patient is actively bleeding
Prednisone 1mg/kg/day if patient well
IVIG x 2 days if patient ill
Kids: remit
Adults: relapse & require splenectomy
What does HELLP stand for?
Hemolysis
Elevated Liver enzymes
Low Platelet count
Overanticoagulation
Agents being used more & more
INR’s up to 5
INR’s >9
Necessary Steps to Treat Overanticoagulation for Patients on Warfarin
Assess whether there is significant bleeding
Assess for head trauma
Assess whether the patient should be anti coagulated again in the future
Give FFP & Vitamin K for significant bleeding
Give PO Vitamin K for INR >9 without bleeding
Avoid SQ Vitamin K
Necessary Steps to Treat Overanticoagulation for Patients on Non-Warfarin Agents
Assess for bleeding & head trauma
Identify the specific agent & call pharmacy/hematology
For significant bleeding, consider protamine sulfate for heparin or LMWF
Significant bleeding, consider recombinant activate Factor VII
