Exam 1: Malignant emergencies Flashcards
SVC Syndrome can be caused by what type of catheter?
Thrombosis from indwelling catheter (IV cath)
Most common sx of SVC Syndrome?
Dyspnea
Followed by cough and orthopnea
What are the two most frequent signs of SVC syndrome?
Neck vein distension (JVD) AND facial swelling/fullness
What do the arm veins, neck veins, and face look like in SVC Syndrome?
Distended arm and neck veins. Facial swelling/fullness.
What is an ominous sign of SVC syndrome that represents a true emergency?
Papilledema
What is compressed or occluded in SVC Syndrome?
Superior Vena Cava
Dx to confirm SVC Syndrome?
CXR first, confirm with Chest CT with contrast
Tx of SVC Syndrome? (Hint: position? meds? remove?)
- keep in head-up position (to make fluid go down)
- IV steroids (shrinks tumor swelling)
- IV diuretics (Torsemide)
- Anticoagulants or thrombolytics (if clot in SVC)
- Emergent mediastinal radiation
- remove central IV catheter if present
Acute Spinal Cord Compression usually results from extension of what?
Extension of spinal bony metastases
Where do mets most commonly occur in Acute Spinal Cord Compression?
Thoracic spine
What are the 4 most common tumors causing spinal cord compression
Breast Lung Prostate Renal cell All 4 hide in bone
Other tumors include lymphomas, MM and sarcomas which destroy bone
Sx in Acute Spinal Cord Compression?
Localized back pain (most common) +/- tenderness (may be absent with lymphomas)
- paraparesis/paraplegia
- distal sensory deficits
- gait disturbance
- urinary incontinence
Dx of choice for Acute Spinal Cord Compression? What other studies can you do ?
MRI STUDY OF CHOICE
cervical, thoracic, or lumbar spine films (but neg films don’t rule out SCC)
radionuclide bone scan (>90% sensitivity, except for multiple myeloma)
Tx for Acute Spinal Cord Compression? What is key tx?
Spine immobilization. Emergent decompressive Laminectomy.
Key tx=radiation!
+/- IV steroids / diuretic / mannitol for swelling
Foley cath for incontinence
What are the most common tumors causing hypercalcemia
Metastatic breast, lung or prostate ca
Multiple myeloma
NHL
Head+neck scc
2 most common types of Hypercalcemia of Malignancy?
- Humoral hypercalcemi of malignancy via PTHrP
- Local bone destruction
Less commonly Tumor production of Vit D analogues
Sx of Hypercalcemia of Malignancy?
Moans, bones, stones, groans, psych undertones.
Vague malaise/weakness, polydipsia, anoexia, nausea, confusion
Can lead to seizures
Lower the albumin what happens to calcium levels?
Lower albumin, higher calcium
Formula for Corrected Calcium? What is dangerous?
Corrected Ca2+ = Total Ca + {0.8 X (4.0-albumin)}
>12 is dangerous
Low Serum ___ can indicate Hypercalcemia of Malignancy?
Low Serum Cl-
QT in Hypercalcemia of Malignancy?
Short QT
PR in Hypercalcemia of Malignancy??
Long PR
Voltage in Hypercalcemia of Malignancy?
Low voltage
IV hydration until when in Hypercalcemia of Malignancy?
Voiding 150-200 mL/hr
Once euvolemic what to give in Hypercalcemia of Malignancy?
Loop diuretics
Which diuretic to avoid in Hypercalcemia of Malignancy?
Thiazide!
What to avoid in Hypercalcemia of Malignancy?
PO Phosphate
What to discontinue in Hypercalcemia of Malignancy? (hint: 4)
- Calcium
- VitD
- Thiazides
- NSAIDs
Meds to control high Ca2+ in Hypercalcemia of Malignancy?
SC/IM Calcitonin, Bisphosphonates, corticosteroids, dialysis, AVOID ORAL PHOSPHATE
Calcitonin quickly lowers serum calc levels
Bisphosphonattes block osteoclasts bone resorption
Corticosteroids most effective (elevated Vit D)
HD for renal/heart failure
Which bisphosphonates to avoid in renal failure?
Zoledronic acid
Which two bisphosphonates are IV. Which one is SQ
Pamindronate 60-90mg IV over 60 minutes
Zolendronic Acid 4mg IV over 15 minutes
- don’t use in renal failure
Denosumab 120 mg sc
Normal ANC?
> 1000
Neutropenic ANC?
500-1000
Severe neutropenia?
<500
How to calculate ANC?
ANC=(WBC)(% neutrophils + % bands)
What is ANC if WBC=6000; Seg=30%; Band=3%
ANC=(6000)(0.30+0.03)
ANC=2000
When does Febrile Neuropenia most commonly occur?
During nadir after chemo
When is nadir in Febrile Neuropenia?
5-10 days after chemo. Lasts 5 days.
Which gram bacteria from central lines in Febrile Neuropenia?
Gram positive
Which gram are enteric bacteria in Febrile Neuropenia?
Gram negative
Sx of Febrile Neuropenia?
ASx to severe sepsis
UTI without pyuria (no WBCs in urine)
What exam should you try to avoid in febrile neutropenia
Internal rectal exam
Don’t want to compromise mucosa
Single PO temp above what in Febrile Neuropenia?
> 101.3F
Sustained temp above ___ for how long in Febrile Neuropenia?
> 100.4 for 1 hour
How many blood cultures in Febrile Neuropenia? Where?
2x peripheral
1x from catheter
What is involved in febrile neutropenia work up
Blood Cx (2 sets one from Peripheral vein and one from catheter)
Urine Cx
Sputum Cx and gram stain
Stool, CSF Cx if inficated
CXR –may be nl, consider a CT if respiratory complaints
Which 2 abx for Febrile Neuropenia?
Vanco=staph and strep
Cefepime=gram + and pseudomonas
What time frame to give abx in Febrile Neuropenia?
Within 1 hour of presentation
Tx if afebrile Neuropenia? (Hint: based on ANC)
IV Abx for 5-7 days then PO Abx when ANC >1000
- continue initial abx until blood cx available, then adjust abx based on culture/sensitivities
- treat for 5-7 days of IV and consider PO if ANC >1000
Tx for febrile Febrile Neuropenia?
IV Abx for 5-7 days.
When to add antifungal in Febrile Neuropenia?
After 4 days (>72h)
Fluconazole and ketoconazole
What medication makes neutrophils? What dose?
G-CSF.
5mcg/kg/day SC . (300-480mcg/day)
When to D/C (discharge) tx in Febrile Neuropenia? (3 criteria)
- ANC normal >1000
- Afebrile for 24h
- Cx negative
Most common tumors causes of tumor lysis syndrome
Leukemia’s with high WBCs
Lymphomas
Small cell ca
Metastatic adenoca
What is tumor lysis syndrome? What happens to cancer cells in Tumor Lysis Syndrome?
Rapid destruction of CA cells after chemo or radiation
metabolic complications which occur after tx of bulky chemo-responsive malignancies
When does Tumor Lysis Syndrome happen?
6-72 hours after chemo or radiation
What sort of complications occur with Tumor Lysis Syndrome?
Metabolic complications from release of cell contents into serum
metabolic complications that occur in tumor lysis syndrome?
What 3 things are elevated? what is low?
HyperK,
Hyperuricemia,
Hyperphophatemia
Hypocalcemia. (D/t precip of calc phosphate)
Can lead to Acute renal failure and arrhythmias
Etiologic factors of TLS. What two elevated labs are attributed with acute tumor lysis
High preRx serum LDH or uric acid
large tumor burden, high growth fraction, high preRx serum LDH or uric acid, pre-existing renal insufficiency
What to do with chemo and radiation in Tumor Lysis Syndrome?
STOP THEM!
How hydrate in Tumor Lysis Syndrome?
Aggressively with diuresis
How to treat elevated uric acid in Tumor Lysis Syndrome?
Alkalize urine to pH 7 with NaHCO3 (bicarb)
How to treat HyperK in Tumor Lysis Syndrome?
CaCl2, NaHCO3, Glucose/Insulin, Kayexalate
When to do emergent hemodialysis in Tumor Lysis Syndrome? (hint: K, uric acid, Cr, peeing)
- K>6
- Uric Acid >10
- Cr >10
- or can’t tolerate diuretics
Which med to prevent uric acid build up in Tumor Lysis Syndrome?
Allopurinol
Which med to rapidly decrease uric acid in Tumor Lysis Syndrome?
Rasburicase
Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin so it can be secreted.
All treatments for tumor lysis
Stop the chemoRx, hold any further lysis
Aggressive IV hydration NS/ diuresis
+/- alkalinize urine to pH 7 (NaHco3)
–Decreases uric acid but may worsen hypocalcemic tetany
CaCl2, NaHCO3, glucose / insulin, kayexalate for hyperkalemia
Emergency hemodialysis
–If K > 6, uric acid > 10, creat. > 10, or unable to tolerate diuresis
Can use allopurinol for prevention pre & Post Chemo
Rasburicase – rapid degredation of uric Acid
What happens to the kidneys with tumor lysis
Proteins and nuclei acids broken down by xanthine oxidase to uric acid
Excess uric acid accumulated in kidney and results in uric acid Nephropathy and AKI
elevates phosphate causes dec urine output. Binds to serum calc which also precip in kidney
How often is Malignant Pericardial Temponade an early sign of malignancy?
Rarely!
Heart tones in Malignant Pericardial Temponade?
Muffled/decreased
JVD in Malignant Pericardial Temponade?
Yes they will have JVD
Pulsus paradoxis in Malignant Pericardial Temponade?
> 10mmHg
QRS complex in Malignant Pericardial Temponade?
Low voltage
Most common causative tumors in pericardial tamponade
Melanoma HL acute leukemia Lung ca Breast ca Ovarian ca
Radiation pericarditis
Friction rub in Malignant Pericardial Temponade?
Rarely
what is the EKG like for malignant pericardial tamponade?
low QRS voltage +/- pulses alternans
Dx of choice for Malignant Pericardial Temponade? What will it show?
Echo! Will show equalization of heart chamber pressures.
Tx for Malignant Pericardial Temponade?
MC Needle catheter pericardiocentesis.
Others=pericardial window, pericardiectomy, radiation, intrapericardial chemoRx or sclerosis
Si/sx of malignant pericardial tamponade
–Dyspnea / weakness +/- chest pain
-Hypotension / narrow pulse pressure
-Friction rub rare –Jugular venous distention
-Muffled (decreased) heart tones
-Pulsus paradoxicus > 10 mm Hg
-Low EKG QRS voltage +/- pulsus alternans
+/- cardiomegaly on CXR
causative tumors of SVC syndrome
- small cell (oat cell) lung cancer
- squamous cell lung cancer
- lymphoma
- anaplastic mediastinal cancer
what can form in spinal column and cause acute spinal cord compression?
epidural abscess/hematoma
what IV steroid is given for tx of acute spinal cord compression?
Decadron aka dexamethasone
-decreases swelling of tumor
what is key in tx of acute spinal cord compression? what does it do?
radiation - shrinks the tumor pressing on the cord
When and why do you do a corrected calcium
Done in setting of hypO albuminemia. Low albumin = less ionized Ca bound to albumin = pseudohypOcalcemia.
The labs for calcium drawn measure the ionized calcium, and thus will report a false low. Your patient may have hypercalcemia but without a corrected value may appear normocalcemic.
What IV fluid is tx of choice for hypercalcemia?
Normal saline
what needs to be given immediately to pts with hypercalcemia?
HYDRATION - IV FLUIDS -> TO PEE OUT THE CA
-Normal Saline is of choice
How do bisphosphonates work?
block osteoclastic bone resorption
when would hypercalcemic pt go on dialysis?
pt with renal or heart failure
not life-long, just for acute episode
used b/c fluid will start to back up -> CHF
what is febrile neutropenia defined as?
single oral temp >101.3 F
sustained temp >100.4 for 1 hr
ANC <1000
risk of infection if neutropenic increases with what?
- duration of neutropenia
- severity of ANC <100
- comorbidities
- central lines
- hepatic or renal insufficiency
when to use G-CSF for febrile neutropenia?
- profound neutropenia, shock, co-morbidities
- worsening clinical course and expected prolonged neutropenia
- pt not responding to abx
what is G-CSF? what does it do?
Granulocyte Colony Stimulating Factor
speeds up resolution of neutropenia (stimulates production or neutrophils)
how long does it take G-CSF to work? how long do you have to wait to give it again?
- profound neutropenia, shock, co-morbidities
- worsening clinical course and expected prolonged neutropenia
- pt not responding to abx
