Emergency- Cord Compression Flashcards
You have a 78M with known prostate cancer on watchful waiting. He has come into A&E with AUR and back pain.
How would assess the patient?
I would assess the patient immediately as this is not only a urinary retention but it could also be a cauda equina syndrome.
I would review the patient in a ABCDE approach according to the ATLS approach. Provide oxygen if required, obtain IV access and take bloods- FBC, U&Es, PSA, CRP, Coag, then start a bag of fluids.
Then examine the patient’s abdomen for palpable bladder and scars, if possible would do a bladder scan. I would catheterise using a 16ch catheter 2 way, test the urine and if positive for C&S.
when the patient is more comfortable I would take a focussed urol hx on diagnosis of prostate Ca and current treatment. I would clarify on any new neurology, bony pain, weight loss or VH. Also would ask for associated LUTS, faecal incontinence and saddle paraesthesia, then PMhx for performance status, DHx to check for anticoag and allergies
Then I would perform a neuro exam, checking for power tone reflexes in both lower limbs and sensation especially perianal and anal tone. I would also palpate for spinal tenderness.
If I am concerned for cauda equina I would keep the patient on bed rest, prescribe 8mg dexamethasone BD with PPI cover, DVT prophylaxis and order an urgent MR whole spine.
The MRI spine confirmed CES. How would you proceed
In patients with no history of prostate cancer and new CES that I would consider contacting the neurosurgeons for possible decompression
In prostate cancer and CES then I would start this patient on immediate ADT. In our hospital we would prescribe an LHRH antagonist such as degaralex to ensure rapid hormone manipulation. Another method is subcapsular orchidectomy.
I would then contact oncall oncology for an urgent palliative radiotherapy.
Castrate level= <50ng/dl
Degaralex= takes approx 72hrs
Orchidectomy= take approx 10hrs
LHRH analogues and antiandrogen= several weeks
