Haematology & Oncology Flashcards
Oncological Emergency
2021.1 Case based discussion
discuss with an examiner the assessment and management of an adult male patient with a history of metastatic melanoma who has presented unwell with SOB?
Patient requires respiratory support
SHORTNESS OF BREATH IN ONCOLOGY:
DIFFERENTIAL DIAGNOSIS:
- PE
- Pneumoniae (immune compromised, neutropenic)
- Malignant pleural effusion
- Malignant pericardial effusion with tamponade
- Superior vena cava syndrome
Haematological - anaemia
Pneumothorax
Lung tumour burden
ASSESSMENT:
chemotherapy - when last dose
metastatic disease to where ? lungs
prognosis, palliative
goals of care
co-morbidities
POCUS:
PE
Pleural effusion
Cardiac tamponade
Sickle Cell Disease
Sickling is exacerbated by:
- hypoxia
- acidosis
- dehydration / hyperviscosity
- fever
- inflammation
Tips:
- When ordering blood transfusion, tell the blood bank that the patient has sickle cell disease. They will provide blood that has minimal risk of causing allo-immunization.
Pain crisis (diagnosis of exclusion)
- pain is legitimate (don’t assume patient is malingering)
- are taught how to cope with pain with distraction methods
- ask them is this their typical sickle cell pain
- what pain meds have they taken prior to presenting
- what works for you in terms of your analgesia requirements
- treat pain adequately with opiates
Hydroxyurea - reduce pain episodes, reduce admissions, reduce transfusions
Refer to haematologist and sickle cell clinic for education
HISTORY:
- does this feel like usual pain crisis?
- analgesia regimen at home
- multiple transfusions?
- baseline Hb?
- what sickle cell complications in the past?
INVESTIGATIONS:
- Hb, reticulocyte count
COMPLICATIONS:
Pain crisis - erythrocyte sickling causes micovascular occlusion (usually in bone) –> pain
Acute chest syndrome:
- high mortality
- vicious cycle with microvascular occlusion of lungs, hypoxia worsens sickling
- present with fever, hypoxia, pulmonary infiltrates on CXR
- need urgent blood transfusion or exchange transfusion
Aplastic crisis
- severe drop in Hb
- present with syncope and in shock
- reticulocyte is dramatically low or zero
- need immediate blood transfusion
Splenic sequestration
- tender hepatosplenomegaly
- high bilirubin, ALT, LDH
- high reticulocyte
Sepsis (functionally asplenic)
Priapism
Stroke
- common in children
- urgent CT and blood transfusion or exchange transfusion
Avascular necrosis
Renal failure
- usually have low Cr
Blunt eye trauma –> hyphaema and traumatic glaucoma
MANAGEMENT:
Analgesia:
- paracetamol
- NSAIDs - regular ibuprofen
- morphine 5-10mg IV
- ketamine PCA
Oxygen - only if hypoxic
Can suppress bone marrow, increasing need for transfusions
IV fluids - hyperchloraemic metabolic acidosis can increase sickling
- need to give 5% dextrose with 0.45% NS
- large volumes can cause pulmonary oedema
BLOOD TRANSFUSIONS:
- need to discuss with haematologist first
- accept low Hb of 70
- want to prevent alloimmunisation. alloimmunization will make future transfusions very difficult when they really need it.
no steroids for acute pain crisis. causes rebound pain when the steroids are stopped.
Hypercalcemia
Causes:
**Primary hyperparathyroidism (parathyroid adenoma)
**Malignancy (PTH related protein)
non-small cell lung cancer
multiple myeloma
breast cancer
Secondary hyperparathyroidism - chronic renal failure (chronic hypocalcemia –> increased PTH)
- sarcoidosis (increased GI absorption)
- Vitamin D toxicity (increased GI absorption)
- thiazides (reduce renal excretion)
Clinical Features:
- polydipsia, polyurina, dehydration
Stones:
- renal stones
Psychiatric moans:
- confusion
- hallucinations
Bones:
- bone pain/fractures
Abdominal groans:
- abdominal pain, nausea/vomiting
- pancreatitis
- peptic ulcer disease
ECG:
- short QT
MANAGEMENT:
Dilute serum calcium and promote diuresis and renal excretion
- Rehydration with IV fluids (0.9% NS, not hartmann’s) 4-6L over 24hr
Decrease calcium resorption from bone - inhibits osteoclast activity
- Bisphosphonates
Pamidronate 60-90mg over 4hrs - Calcitonin
Salcalcitonin 100IU SC/IM/IV TDS
Decrease calcium absorption from the gut
- Corticosteroids – prednisone 30mg daily (in malignancy and sarcoidosis)
Forcibly remove excess calcium from the circulation
- Haemodialysis
Tumour Lysis Syndrome
Renal failure in oncology
Pre-renal:
- hypovolemia (vomiting)
Renal:
RTA (nephrotoxic medications - chemotherapy, tumour lysis syndrome)
- infiltrating tumours
Post renal:
pelvic masses compressing ureters
Electrolyte and metabolic derangements secondary to rapid cell destruction, usually following chemotherapy for lymphoma or leukemia. These patients present with hyperkalemia, hyperphosphatemia, hypocalcemia, and severe renal failure.
Risk factors:
More common in haematological malignancies
- Burkitt’s lymphoma
- Acute lymphoblastic leukemia
Large tumour burden
Just commenced chemotherapy
Dehydration
Pre-existing renal failure
Pre-existing hyperuricemia
Lab findings:
*hyperuricaemia
- hyperkalaemia
- hyperphosphataemia
- lactic acidosis
- hypocalcaemia
Treatment for tumor lysis syndrome: The first treatment priority is to lower the potassium. Be cautious about giving calcium, as these patients have high phosphate! in case dialysis is needed.
Rasburicase (an enzyme that transforms uric acid into soluble allantoin) is used to manage tumor lysis syndrome
IV Fluids
Allopurinol
Dialysis
