emergencies Flashcards
What are the four oncological emergencies?
Hypercalcaemia
SVC obstruction
SCC
Neutropenic sepsis
Why does hypercalcaemia occur in cancer?
- Osteolytic- bones are invaded by cancer, cytokines activate osteoclast activating factor; calcium goes from bones into blood.
- Paraneoplastic- tumour secretes PTH related protein which induces bone resorption (MOST COMMON)
Is hypercalcaemia common?
Yes up to 1/3 patients
Hypercalcaemia sx may mimic?
Terminal malignancy
What might hypercalcaemia in metastatic disease indicate?
Poor prognosis
What is the thirty day mortality of patients admitted with hypercalcaemia?
about 50%
Symptoms hypercalcaemia
‘Stones, bones, groans, thrones, psychiatric overtones’
Confusion
Lethargy, weakness
depression/anxiety, cognitive dysfunction, insomnia, coma
Abdo pain, N&V
Renal/biliary stones
Constipation
Polyuria
Bone pain
Polydipsia
Anorexia
What is more significant in hypercalcaemia, the rate of calcium increase or the level?
Rate
What is normal calcium level?
2.2-2.6mmol/L
Investigations for hypercalcaemia?
Ionised calcium
Alk phosph
U&Es, eGFR
PTH
X-rays
Bone scan for mets
ECG (arrhyth)
What are you looking for in xrays in hypercalcaemia?
lytic or sclerotic bone lesions
hypercalcaemia management
- Saline 1L/4h for 24hr then every 6h for 48-72h.
- Bisphosphonates (IV pamidronate or zolandronic acid)
- If arrhyth/seizures give calcitonin and corticosteroids.
What steps can you take to reduce risk of fluid overload in hypercalcaemia?
Furosemide
Monitor output
Malignancy causes ___% SVC syndrome
90
What are three extrinsic and one intrinsic cause of SVC syndrome
Extrinsic- lung ca (65%), lymphoma (15%), other ca (10%)
Intrinsic- thrombosis due to central venous device (10%)
NSC lung cancer + SVC synd =?
poor prognosis
What happens physiologically as a result of SVC syndrome
Collateral circulation forms
Central venous pressure increased
How does SVCO present?
Headache
Oedema and redness of face and upper limbs
Cough and dyspnoea
Venous distention
Pemberton’s sign
What is pemberton’s sign
raise arms above head and see flushing, distended veins, inspiratory stridor, increased JVP
What 2 types of cancer often present with bulky lymph nodes?
Lymphoma
Germ cell tumours e.g. testicular
Investigations for SVCO
CXR- mediastinal widening and ?primary cause
CT chest/abdo/pelvis with contrast (for malig)
Tissue (characterise the malignancy for Rx)
Treatment SVCO
ABCDE, O2
16mg Dex/24hr with PPI
Elevate head
Potentially avoid IV cannula into arm veins so fluid doesn’t go to the SVC
Depends on cause… could give SVC stent (good for rapid sx relief), RT, chemo, LMWH if thrombus
Hypercalcaemia is common in which type of cancer?
Myeloma
Presentation of SCC
Back pain, worse lying down and getting worse over weeks
Radicular pain, can radiate to lower back, buttocks, legs
Saddle anaesthesia
Hyper-reflexia below lesion, maybe extensor plantars
Feel unsteady
Changes to bladder and bowel function (late finding)
Symmetrical weakness (Depends on level of lesion)
Parasthesia of toes, fingers, buttocks
SCC investigations
- MRI whole spine: within 24h if neuro signs, within 1w if suspicious back pain.
- Need to know pt cancer status, fitness, neuro function and pain
SCC management
- 16mg dex daily + PPI (make sure to check CBG regularly)
- analgesia
- Single beam RT
- Chemo
- Surgery if they are well enough in general. >1 part spine involved = less likely
- Catheterise if needed
Is SCC a good prognostic indicator
No
Diagnosis of neutropenic sepsis?
Pt having ca treatment
Neutrophil count <1x10^9/L
AND
Temp >/=38 OR other sepsis signs
When does neutropenic sepsis usually present?
7-14 days after last chemo
Mortality neutropenic sepsis?
5%
Presentation neutropenic sepsis?
Lethargy
N&V
Mottled rash
High RR (or PaO2 <4.3kPa)
High HR
WCC <4 or >12
Febrile <36C or >38C
+ infective source (ANY!)
Management/investigations of neutropenic sepsis?
Sepsis 6:
Blood cultures (peripheral), U&Es
Urine output and cultures
Fluids
Antibiotics (broad spec. e.g. piptaz. Trust guidelines)
Lactate
Oxygen 15L/min
+culture any indwelling lines
Bloods: LFT, U&E, CRP, lactate, FBC
