KC Onc and Special Pop Flashcards
*What are 2 Definitions of fever in febrile neutropenia
A single temperature at or above 38.3° C
A sustained temperature of at least 38.0° C for at least 1 hour
*What are 2 Definitions of neutropenia
ANC less than 500 cells/mm 3
An ANC expected to drop below this threshold within 48 hours
*4 biochemical changes in tumour lysis syndrome
- HYPERuricemia (i.e. high uric acid, source is DNA, which is metabolized to uric acid)
- HYPERphosphatemia (phosphate primarily intracellular electrolyte)
- HYPOcalcemia (due to binding of phosphate)
- HYPERkalemia
*2 reasons to treat hypocalcemia in TLS
Hypocalcemia with 1) cardiac (e.g. dysrhythmia, heart block) 2) neurologic (e.g. seizure, coma) instability
- Can also give calcium if hyperkalemia with ECG changes
Otherwise should avoid giving calcium just for hypocalcemia; supplemental calcium will only increase calcium-phosphate deposition in the viscera
*What are 5 non-infectious causes of fever in an oncology patient
VTE, drug side effect (ex. chemo), tumor burden, transfusion reaction, inflammation
*what is the classic triad of hyperviscosity?
Classically presents with the triad of neurological deficits, visual changes, and mucosal bleeding.
*Treatment of hyperviscosity
Plasmapheresis (temporizing measures: hydration, phlebotomy, hydroxyurea)
*What are high risk criteria in patients with febrile neutropenia?
Opposite of MASCC score:
Severe symptoms
Hypotension
COPD
Heme cancer with prev. fungal infection
Dehydration
Inpatient
Over 60yo
*What are the indications for IV vancomycin in a patient with febrile neutropenia?
Hypotension or CVS unstable
Clinically suspected catheter infection
Positive culture for gram+ organisms
Known colonization MRSA (or ceph resistant pneumococcus)
?other: skin/soft tissue infection, pneumonia (page 1498)
*What is the appropriate PO antibiotic regimen for a patient with febrile neutropenia being discharged home?
Amox/Clav + cipro
“moxifloxacin monotherapy has shown similar outcomes”
*Lymphoma patient on chemo presents with increasing SOB and pleuritic CP, afebrile. 5 Differential Diagnoses
- Pulmonary embolism
- Pericardial effusion/tamponade
- Pericarditis/myocarditis
- Pneumonia
- Pneumothorax
- Mass/airway obstruction
- Acute heart failure
*3 treatments of tumour lysis syndrome
- Intravenous fluids, as high as 5-6 L daily
- Prevent/treat hyperuricemia (allopurinol and rasburicase)
- Correct other electrolytes
consider dialysis)
Caveats: - Calcium: To minimize risk of calcium phosphate nephropathy, calcium should only be given in setting of cardiac (e.g. dysrhythmia, heart block) or neurologic (e.g. seizure, coma) instability
- Potassium: Management of hyperkalemia same as any other etiology, including use of calcium
- Uric acid: Allopurinol to decrease production, rasburicase to increase elimination
List 5 features associated with low risk febrile neutropenia
[Box 115.1] - MASCC criteria
Hx: age <60, fever while outpatient, no hx of prior fungal infection, no hx of COPD
O/E: asymptomatic or mild symptom burden, no dehydration, no hypotension
Which with febrile neutropenia can be treated as an outpatient
1) meet low risk criteria (MASCC score => 21)
2) no evidence of PNA, line infection, cellulitis, or organ failure
3) have reliable follow up with their oncologist
4) have demonstrated clinical stability during an observation in the emergency department that lasts at least 4 hours
Which cancers are most likely to cause spinal cord compression
Prostate, breast, lung
List 4 ultrasound findings of cardiac tamponade
pericardial fluid, RV diastolic collapse, RA systolic collapse, plethoric IVC
What is pulsus paradoxus
> 10 mmHg change in systolic blood pressure between the inspiratory and expiratory phases of the cardiac cycle
What is Kussmaul’s sign
paradoxically increased JVP with inspiration
List 3 cancers associated with hypercalcemia
Lung, lymphomas, esophagus, head and neck, cervical, endometrial
What diuretic should be avoided in hypercalcemia
Thiazides (increase calcium reabsorption)
List 5 risk factors for tumor lysis syndrome
Tumor related: high proliferation rate, large tumor burden, increased WBC, bone marrow involvement, kidney involvement, high sensitivity to chemo agents
Host related: low urine output, CKD
List 2 cancers at a particular risk for tumor lysis syndrome
lymphoma, leukemia
List 2 reasons why high WBCs counts in cancer are particularly prone to causing leukostasis
Blast cells are larger and less deformable than WBCs leading to increased viscosity
Leukemic cells may trigger additional endothelial adhesion mechanisms
List 3 cancers and 3 non cancerous causes of SVC syndrome
Cancers: lung, thyroid, breast, lymphoma
Non cancers: thyroid goiter, tuberculosis, pacemaker wires, indwelling central line, thoracic aortic aneurysms, pericardial effusion, post radiation
List 2 medications that can be used in invasive fungal infections
Amphotericin B, caspofungin
Which medications can be used to treat listeria infections
Ampicillin, gentamicin, Septra
Vanco, cephalosporins are not effective
Which medications can be used to treat legionella infections
Azithromycin or levofloxacin (respiratory fluoroquinolone)
List 5 causes of bilateral infiltrates in the immunocompromised patient
Viruses: CMV, RSV, influenza
Bacteria: PCP
CHF, TRALI, radiation injury, chemo induced toxicity, ARDS, pulmonary hemorrhage, cancer
List 5 causes of focal infiltrate in the immunocompromised patient
Bacterial: Legionella, MRSA, TB
Fungi: aspergillosis, mucormycosis,
PE, cancer
List 5 side effects of corticosteroid use
adrenal insufficiency, peptic ulcer disease, pancreatitis, psychosis, glaucoma, poor wound healing, hyperglycemia, avascular necrosis of the bone, spontaneous fractures
List 6 causes of functional asplenia
sickle cell disease, ulcerative colitis, celiac disease, sarcoidosis, amyloidosis, RA, SLE
*Define and give two examples for different types of restraints (chemical, physical, environmental)
a. Chemical
1. versed
2. ketamine
b. Physical
1. 4 point restraints
2. Mittens
c. Environmental
1. Placing the stretcher in slight Trendelenburg with the guardrails up
2. A locked room with CCTV and security monitoring
*5 considerations for safety when using waist restraints?
- Make sure the patient doesn’t have the restraints on too tight
- Make sure they don’t have open wounds, abdo surgical sites
- Make sure there’s nothing compromising their ability to breath freely
- Make sure they have normal peripheral pulses
- Make sure they can urinate
*5 things to consider for your own safety when seeing a violent patient?
- Do not see patient if they’re actively violent
- Let security know that you’re seeing a potentially violent patient, ask them to stand nearby
- Leave the door slightly open, stand near the door to allow quick escape
- Make sure the patient has been searched for weapons, devices, needles
- Do not bring anything with you that could be potentially used as a weapon
*List 3 classes of antipsychotic medications and give one example of each (to restrain a patient)
- Benzos (Midaz)
- Typical Antipsychotics (Haldol)
- Atypical antipsychotics (Risperdal)
*When using waist restraints, what are 3 considerations to decrease the risk of asphyxiation?
- Avoid prone position
- Use of chemical sedation if patient continues to struggle against physical restraint
- Frequent re-assessments/Monitoring
- Position changes
- Remove restraints as soon as possible
Describe 10 elements of verbal de-escalation
[Box 189.4] see photo
*Name 5 causes of pneumonia in immunocompromised patients?
CMV
Aspergillus
Candida
Pseudomonas
Staph aureus
*Recognize PCP, what is the prophylaxis for this condition?
Septra
*When is the infectious risk highest for a transplant patient and over what period does the risk decline?
1-6 months, declines after?
*What are 5 complications of lung transplant?
Anatomic
- Anastomosis
- Pneumothorax
- Hemothorax
- Pleural effusion
- Empyema
- Persistent air leaks
Rejection (25% in first year)
Infection
- CMV most common opportunistic infection post lung transplant
Drug toxicity
List 3 bacterial, viral, and fungal opportunistic infections
Bacterial: pseudomonas, mycobacterium, listeria, nocardia, clostridium
Viral: HIB, HBV, EBV, HCV, HSV, VZV, CMV
Fungal: candida, cryptococcus, aspergillus, histoplasma, strongyloides
List 5 medications that can interact with anti-rejection medications
Antibiotics: rifampin, fluoroquinolones, macrolides, aminoglycosides, fluconazole, amphotericin
Anti convulsants: carbamazepine, phenobarbital, phenytoin
Cardiac meds: colchicine, diltiazem, verapamil
What are the SPICE organisms and what is their clinical relevance
SPICE: Serratia, providencia, indole-positive proteus, citrobacter, enterobacter
Also pseudomonas and acinetobacter
These bacteria have inducible AmpC Beta lactam genes that can create B lactam resistance despite apparent sensitivity
Avoid third generation cephalosporins
Needs 4th generation cephalosporins ex. cefepime, carbapenems, aminoglycosides, or fluoroquinolones
List 4 categories of complications post organ transplant
Anatomic/surgical, rejection, infection, drug toxicity
RAID
List 3 vascular and 3 non vascular complications of solid organ transplant
Vascular: thrombosis, stenosis, AV fistula, pseudoaneurysm, bleeding
Non vascular: complications to bile ducts, bronchi, ureters - leaks, obstructions from scarring or migration
What are the three phases to transplant rejection
Hyperacute: days in the peri-operative periods, occurs d/t preformed antibodies or ABO incompatibility
Acute: days to week with constitutional sx
Chronic: months to years with chronic rejection, fibrosis, inflammation
List 4 categories of transplant medications, side effects, and examples of each
Induction agents/mono clonal antibodies ex. Alemtuzumab - risk of immunosuppression
Calcineurin inhibitors ex. Tacrolimus, cyclosporin - risk of nephrotoxicity, neurotoxicity
Rapanycin inhibitors ex. Sirolimus - risk of nephrotoxicity, impaired wound healing, pneumonitis
Antimetabolites ex. azathioprine, mycophenolate - risk of hepatotoxicity and bine marrow depression
Corticosteroids
List 4 physiologic changes in the transplanted heart
Increases resting heart rate to 95-110 due to lack of parasympathetic tone
Medications affecting autonomic nervous system ex. Atropine will have no use
Increased risk of silent or asymptomatic MI
Donor and recipient SA nodes may show two different P waves
What is the most common vascular complication post hepatic transplant
Hepatic artery thrombosis
*5 medical interventions you would do
HIV PEP
Hep B PEP
Gono/chlam treatment
Trich treatment
Tetanus
Levonorgestrel + antiemetic
*4 populations at risk
Homeless,
Those with severe disabilities (eg, serious injury, chronic disease, chronic mental health problems),
Incarcerated men and women,
Children.
College-aged women (especially freshman),
Nonheterosexuals,
Those who use drugs and alcohol,
Sex workers.
*3 signs in a male
The anal and rectal examination should include visualization to look for potential foreign bodies and gross injury, such as tears, abrasions, bleeding, erythema, hematoma, fissures, engorgement, and friability.
*2 reasons for urine tox screen in the sexual assault patient
• Period of unconsciousness
• Period of loss of motor control
• Amnesia or confused state with suspicion of sexual assault
• Patient suspicion or belief that she or he was drugged prior to or during sexual assault
And
• Less than 72–96 hours since assault (depending on jurisdictional protocol)
What is the ideal imaging in the non fatal strangulation patient
CTA neck +/- CT head if concerns for hypoxic brain injury
List 5 signs on history that may suggest human trafficking
[Box 59.1]
see photo
