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FRCEM Final SAQ > Haematology & oncological emergencies > Flashcards

Haematology & oncological emergencies Flashcards

1
Q

2 life threateining complications of SVC obstruction?

A

cerebral oedeam AND oedema of the upper airways

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2
Q

classify the causes of SVCO

A
  1. extrinsic =
    * thoracic malignancy
    * thyroid adenoma
    * goitre
    * mediastinal lymphadenopathy
    * mediastinal fibrosis
  2. intrinsic =
    indwelling catheter/pacemaker lines and associated thrombus
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3
Q

ED management of SVCO

A
  1. sit the patient up
  2. start oxygen to maintain sp02 >94%
  3. arrange CT neck and chest to determine the cause
  4. referal to oncology to consider radiotherpay in cases of tumour to shrink the size
  5. also consider dexamethason 16mg iv stat
  6. adrenaline nebuliser ( 5ml 1 in 1000 ) to reduced laryngeal oedema
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4
Q

What are the complications of svco

A
  1. cerebral oedema
  2. laryngeal oedema with stridor and airway obstruction
  3. cardiac failure +/- tamponade
  4. VTE of axillary/scv ( PE )
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5
Q

what is pembertons signs

A

facial plethora , cyanosis and distension of neck veins with raising both arms simultaneously

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6
Q
  1. what are the clinical features of methaemaglobinaemia?
  2. explain the pathophysiology of MetHB?
  3. what is the normal MetHB level and what is abnormal ?
  4. What is the ED management of Met HB?
  5. indications for exchange transfusion and hperbaric oxygen?
A
  1. ABG will show a saturation Gap with A normal or raised PaO2 in the presence of clinical cyanosis and low oxygen saturation level that does not improve with oxygen
  2. Pathophysiology of MetHB = a functional anaemia in which the o2 carrying capacity of HB is reduced
  3. normal = 1%, abnormal ( i.e. clinical cyanosis is present ) when levels are > 10%
  4. ED Mangement=

if significant symptoms or levels are >30% -
then give 1 mg/kg IV of 1% methylene blue as 1st line

  1. G6PD deficiency or severe poisoning
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7
Q
  1. What is your differential diagnosis of a child presenting to the ED with epistaxis and FBC reveals: wcc 17, HB 3, Platelets 10 ?
  2. what is your immediate priorities in the ED management of this child?
A
    • acute leukaemia/lymphoma
    • ITP
    • sepsis
    • local trauma
    • Viral illness from URTI
    • Sepsis screen ( blood cultures, urine cultures, cxr )
      • start antibiotics to cover for sepsis
      • liason with a paediatric oncologist/haematoligist
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8
Q

What is essential thrombocytopaenia?

A

an uncommon, chronic, meyloprolipherative disorder characterized by platelet count > 450. it is caused by a mutation of the JAK2 gene.

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9
Q

Name the common manifestations of essential thrombocytopaenia.

A
  1. burning pain of extremities ( fingers and toes ) worse on exposure to heat . ( due to microvascular occlusions)
  2. thrombosis of large veins and arteries
  3. headaches /paraesthesia/TIA’s
  4. other less common -GIB, pulmonary HTN, priapism
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10
Q

A patient receiving a blood transfusion has a reaction. What 7 types of blood transfusion reactions can you list?

A

List:

  1. Transfusion related acute lung injury ( TRALI )
  2. graft-vs-host disease
  3. TACO ( transfusion associated circulatory overload )
  4. acute haemolytic reaction
  5. delayed haemolytic reaction ( due to antibody reaction )
  6. febrile transfusion reaction ( due to cytokines stored in the blood products )
  7. allergic reaction
  8. TTBI ( transfusion transmitted bacterial infection )

Memory aid:
TRALI & GVHD ate TACO’s. 1 had an acute haemolytic reaction, the other had a delayed reaction. Both developed febrile & allergic reactions.

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11
Q

What is the most common blood transfusion reaction?

Frcemexamprep.com ( FEP.com )

A

Febrile transfusion reaction.

which presents with 1 degree rise in temperature from baseline. caused by the cytokines in leukocytes in transfused red cells.

treatment is supportive - anti-pyretics.

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12
Q

Which blood transfusion reaction is the most serious to occur that has a mortality rate of 10%?

WHat are the common symptoms of this reaction and how would you manage?

A

Acute haemolytic reaction.
often due to ABO incompatibility due to administration error.

symptoms include - fever, chills, nausea, vomiting, dark urine, feeling of impending doom.

Management: STOP the transfusion. administer IV fluids, diuretics may be required.

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13
Q

A 73 year old with atrial fibrillation on warfarin ( INR was 2.3 a few days ago ) presents to ED following a head injury. ct scan confirms the presence of a subdural haematoma.

Outline how you will manage her warfarin reversal?

A
  1. In the presence of major active bleeding, regardless of INR -
  • stop the warfarin
  • 5-10mg IV vit K
  • & PCC or FFP’s 15ml/kg
  1. If INR > 8 with no/minor bleeding
  • stop warfarin
  • give 1mg slow IV Vit K or 5mg oral Vit K
  • restart warfarin when INR is < 5.0
  1. if the INR 6-8 with no/minor bleeding:
  • reduce dose warfarin
  • restart warfarin when INR <5
  1. if INR is high but <5:
  • reduce the dose of warfarin and
  • measure INR 2-3 days later to ensure it is falling

( NICE CKS )

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14
Q

Name 5 antibiotics that interact with warfarin and prolong the INR?

A
  • Metronidazole
  • Doxycycline
  • ofloxacin
  • ciprofloxacin
  • co-trimoxazole
  • chloramphenicol
  • Sulphonamide

Memory aid:
Me DOCCCS prescribed me antibiotics that made my warfarin go wonky high!

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15
Q

a 45 year old receives a transfusion of blood products. shortly after the transfusion is commenced she develops chills &Rigors. she has a temperature of 44 degrees celcius, bp 80/40 and HR 115. sp02 is 97% on air.

what is the cause of her symptoms? and what is the most likely causativ organism?

Which type of blood product is this woman most likely to have received?

A

TTBI.

Transfusion transmitted bacterial infection.
A rare complication of blood transfusion.
organism is Yersinia enterocolitica.

usually transmitted during platelet transfusion as platelets are stored at room temperature.

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16
Q

How do you manage a transfusion transmitted bacterial infection?

A
  1. stop the transfusion
  2. blood cultures & gram stain requested
  3. broad spectrum antibiotics commenced
  4. blood pack should be sent back to blood bank
17
Q

A 55 year old presents with tiredness, night sweats and easy bruising. she has splenomegaly on examination and her blood results came back positive for philadelphia chromosome.

  1. what is the diagnosis?
  2. name one complication that presents with severe left upper quadrant pain?
  3. What type of drug is the mainstay of treatment of this condition?
A
  1. Chronic myeloid leukaemia
  2. complications include splenic infarction
  3. tyrosine kinase inhibitors are the calss of drugs used to treat CML.
18
Q

Which investigations would you request to confirm a diagnosis of multiple myeloma?

what 3 key findings would be diagnostic?

A
  • urinary protein electrophoresis
  • serum electrophoresis
  • quantitative immunoglobulin levels
  • skeletal survey
  • bone marrow aspirate/biopsy

3 key diagnostic features:

  • in serum or urine: presence of monoclonal protein
  • xray: lytic lesions
  • bone marrow aspirate: increased number of plasma
    cells
19
Q

What are the most common presenting features of multiple myeloma?

A
  1. anaemia ( due to bone marrow infiltration )
  2. bone pain ( commonest symptom, and usually affects spine and ribs )
  3. renal failure (due to tubulopathic effects of light chains )
  4. neurological features
    * hypercalcaemia causes lethargy, confusion
    * hyperviscosity can cause headach & retinopathy
    * commonest peripheral neuropathy is carpal tunnel syndrome
  5. infections - commonly pyelonephritis and pneumonia
20
Q

List 4 factors that would qualify a patient with atrial fibrillation to take dabigatran etexilate for prevention of stroke & systemic embolisation in patients with non-valvular AF?

A

CHADVASC score criteria

C - ccf
H - htn
A2 - age > 75
D - dm
S2 - previous stroke/tia
Va - vascualr disease
S -sex 
C
21
Q

What are the contra-indications to prescribing dabigatran etexilate?

A
  • active bleeding
  • significant risk of major bleeding ( recent G-U ulcer, oesophageal varices, recent intracranial haemorage )
  • prosthetic heart valves
22
Q

What is the reversal agent for DAbigatran etexilate?

A

IDArucizumab

23
Q

What is the mechanism of action of warfarin?

A

It inhibits vitamin K dependant synthesis of clotting factors 2,7,9,10.

Memory aid:
war on clotting factors that are dependent on Vit K i.e. 2,7,9,10

24
Q

a 35 year old with epistaxis presents has a history of menorhagia. she is prescribed a medication to help with this. she states that her father and brother suffer with the same disorder. her blood results show a normal HB and platelets but her bleeing time & APTT are both prolonged.

  1. what is the most likely diagnosis?
  2. what is the most common mode of inheritance of this disorder?
  3. what is the medication she has previously been prescribed?
A
  1. von willebrands disease
    is the most common hereditary coagulation disorder ( 1 in 100 ). arises from a deficiency of von wilebrand factor. vWF has 2 roles:
    *normally binds to factor 8 to prevent it from rapid break down within the blood. a deficiency of vWF leads to a reduction in factor VIII
    * and is also required for platelet adhesion, and a deficiency will result in abnormal platelet function ( although platelet count remains normal )

hence why the bleeding time AND APTT is both prolonged.

  1. autosomal dominant
  2. desmopressin can be used in mild cases
    mechanism of action is to raise the patients own levels of vWF
25
Q

In a patient with von Wilebrand disease- what treatment would you give in mild vs severe cases?

A

Mild cases: * desmopressin
Severe cases: * cryoprecipitate infusions
* Factor VIII concentrate

26
Q

What is the mechanism of action of Dabigatran etexilate?

A

Direct thrombin inhibitor

FRCEM Final SAQ (16 decks)

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