Medicine Specialties C - ONCOLOGICAL EMERGENCIES - Cord compression, S.V.C.O, Hypercalcaemia, Pericardial tamponade, Neutropenic sepsis, P.E

Question 1

Oncological emergencies * Spinal cord compression * Superior vena cava obstruction * Hypercalcaemia * Pericardial tamponade * PE What are the presenting symptoms of spinal cord compression?

Answer 1

Signs and ysmptoms * BACK PAIN * Nocturnal pain usually worse and pain with straining * Limb weakness and difficulty walking * Sensory loss or bladder / bowel dysfunction

Question 2

What is the classical type of back pain associated with SCC? * Radiating down the back of both legs * Intermittent * Radiating around the rib cage * Boring through the chest wall, from the back to the front

Answer 2

Back pain that radiates around the rib cage

Question 3

What are the sensory changes that can occur due to cord compression? (touched more in neuro notes) What is the change in bladder and bowel symptoms?

Answer 3

Sensory changes can affect DCML tract and/or spinothalamic tract Resulting in loss of one or all of: * Proprioception * Light touch * Vibration /deep touch * Pain and temperature perception affected also

Question 4

What is the cause of malignant cord compression?

Answer 4

The majority of malignant cord compression is due to vertebral body collapse/compression iminging the spinal cord Rarely however it can occur due to direct extension of a tumour into the vertebral column

Question 5

What is the urgent management of spinal cord compression?

Answer 5

Urgent managemnt of cord compression is STEROIDS and SCAN Dexamethasone and MRI

Question 6

What is the usual treatment options carried out after steroids have been administered?

Answer 6

Radiotherapy is the commonest and the mainstay of treatment Decompression surgery is considered but has some restrictions

Question 7

When may surgery be tried in malignant cord compression?

Answer 7

Surgery should be considered in any patient with * Single vertebral involvemnt * No evidence of widespread mets * Radio resistant primary * Previous RT to sit * Unkown primary to get tissue

Question 8

SUPEIOR VENA CAVA OBSTRUCTION What are the causes of SVCO as an oncological emergency?

Answer 8

Due to extrinsic compression from a tumour - most common or due to venous thrombosis in the SVC obstructing the vein - consider if current or past central venous access

Question 9

What are the symptoms/signs of suprerior vena cava obstruction?

Answer 9

Reduced venous return from the head neck and upper limbs causes swelling of face neck, one or both arms (one arm suggest more distal) Headache Lethargy Shortness of breath Distended neck, chest wall and abdominal veins

Question 10

What are the initial investigations carried out to diagnosis SVCO?

Answer 10

CXR - is there mass Venogram - is there a mass CT Chest

Question 11

What are the treatment options if it is a clot causing the SVCO?

Answer 11

If there is a clot causing the SVCO Can thrombolyse eg alteplase or Anti-coagulate - LMWH

Question 12

If the treatment of the SVCO is due to extrinsic compression due to a tumour, what is the treatment option?

Answer 12

Give O2 if needed Give dexamethasone to reduce inflammation Stenting provides the most rapid relief of symptoms but the underlying tumour must be treated Radiotherapy or chemotherapy (specific cancers are sensitive eg SCLC) depending on the sensitivy of the underlying cancer

Question 13

MALIGNANCY ASSOCIATED HYPERCALCAEMIA What causes the malignancy assoicated hypercalcaemia in cancer patients? - affects up to a quarter of all cancer patients (what tumours are most common with local bone destruction)

Answer 13

Causes * PTHrP (parathyroid hormone related protein) - produced by the tumour - increases osteoclast activity causing increased calcium * Local bone destruction due to an invading tumour - especially lung, breast and myeloma * Tumour production of vit D analogues eg producing calcitriol

Question 14

What are the symptoms of hypercalacemia?

Answer 14

* Stones - renal/biliary calculi * Bones - bone pain due to bone resorption * Groans - abdo pain, contipation, nausea * Thrones - polydipsia / polyuria * Psychiatric overtones - confusion, depression, anxiety, reduced GCS * Also cardiac arrhythmia

Question 15

Which investigations should be carried out in a patient with suspected malignant hypercalcaemia?

Answer 15

Measure calcium levels Measure urea & electrolytes - looking for dehydration Measure phosphate - low in hyperparathyroidism

Question 16

What is the treatment of malignant hypercalcaemia?

Answer 16

Initial treatment is rehydration (aggressive rehydration) IV biphosphonates (prevent bone resoprtion) Calcitonin can be given - more rapid but short term effect

Scottish palliative care guidelines image below - initially trial 1-3litres IV saline. If remains high, trial bisphosphonate. Re-measure in 5 days (dont repeat Tx until 7 days passed to prevent hypocalcaemia occurring)

Question 17

How does calcitonin work? Where is it produced?

Answer 17

Calcitonin is a hormone that is produced in humans by the parafollicular cells (aka C-cells) of the thyroid gland. Calcitonin is involved in helping to regulate levels of calcium and phosphate in the blood, opposing PTH’s action. Reduces calcium reabsorption in kidney and absorption from gut. Decreases bone resorption.

Question 18

If levels of caclitonin are raised in the blood, what cancer might this make you think of?

Answer 18

Medullary thyroid cancer is a form of thyroid carcinoma which originates from the parafollicular cells (C cells), which produce the hormone calcitonin.

Question 19

CARDIAC TAMPONADE aka PERICARDIAL TAMPONADE How does a pericardial tamponade develop?

Answer 19

Pericardial effusion develops increasing intrapericardial pressure - this compresses the ventricle reducing cardiac output and collapsing the right atrium increasing venous back pressure Eventually the heart pumping stops

Question 20

What are the causes of cardiac tamponade?

Answer 20

Malignancy Trauma Infection eg TB Post-MI Coonnective tissue disease Increased urea (Uraemia)

Question 21

What are thee symptoms of pericardial tamponade?

Answer 21

Primarily shortness of breath Fatigue Palpitations Stmptoms of pericarditis (chest pain improved by sitting forward)

Question 22

What are the signs of pericardial tamponade? (eg. Beck’s triad and signs on inspiration eg Kaussmaul sign, pulsus paradoxus)

Answer 22

* Beck’s triad * Increased JVP * Decreased blood pressure * Muffled heart sounds Kaussmaul sign - Increased JVP on inspiration Pulsus paradoxus - pulse fades on inspiration (venous return drops when intra-thoracic pressure raised)

Question 23

What investigations are carried out to diagnose pericardial tamponade? What is seen?

Answer 23

CXR - enlargement of cardiac silhouette - globular heart ECG - reduced complex size, also electrical alternans Echocardiogram - may be diagnostic - rim of pericardial fluid

Question 24

Image shows the globular heart as seen on CXR Describe the ECG changes seen in pericardial tamponade?

Answer 24

Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats and a possible wandering base-line. It is seen in cardiac tamponade and severe pericardial effusion.

Question 25

What is the management of a cardiac tamponade?

Answer 25

PERICARDIOCENTESIS - needle inserted to drain the fluid in the pericardial space

Question 26

NEUTROPENIC SEPSIS What is a neutropenic sepsis defined as?

Answer 26

Neutropenic sepsis = * Sepsis plus neutrophil count

Question 27

How would you clinically assess the patient for sepsis?

Answer 27

NEWS >/= 5 and infection = think sepsis or If 2 or more of the following and clincial supicion of sepsis then think sepsis (SIRS) * Temperature 38 * Pulse rate >90 beats per minute * Altered mental state * WCC 12 * Respiratory rate >20 breaths per minute * Known or suspected neutropenia (eg chemo)

Question 28

How is the sepsis 6 bundle carried out? Carry out within one hour

Answer 28

Blood cultures Urine output Fluids IV Antibiotics Lactate and FBC Oxygen

Question 29

If suspecting patient of neutropenic sepsis, you should assess the patients within 15 minutes What would make you want to start antibiotics before completing a full septic screen or waiting for blood results to come back?

Answer 29

If patient has had chemotherapy within the past 3 weeks(assume neutropenia) AND has temperature ≥38⁰C or <36⁰C OR clinical evidence of significant sepsis (SIRS≥2) Then initiate antibiotic therapy within 1 hour – do not wait for the blood results to come back. Always take blood cultures before giving antibiotics but do not wait for full infection screen to be performed

Question 30

If a patient does meet the criteria for treating a neutropenic sepsis * Chemotherapy within the past 3 weeks and has temperature ≥38⁰C or /=2) What antibitoics are given?

Answer 30

Piperacillin + Tazobactam Add gentamicin if septic shock

Question 31

If the patient doesnt meet the criteria for neutropenic sepsis (shown above), then carry out the sepsis 6 bundle in full and wait for bloods results What are the antibiotics of choice in this case and when do you have to administer them in a septic patient? (if pen allergic?)

Answer 31

If patient doesnt meet the criteria for neutropenic sepsis complete sepsis 6 bunde within 1 hr If the source of the sepsis is known or suspected, refer to Hospital antibiotic man for advice * If unkown then prescribe IV amoxicillin, gentamicin and metronidazole * If pen allergic - IV Vancomycin, gentamicin and metronidazole * Review antibiotics when blood results return

Question 32

PULMONARY EMBOLISM What are the signs and symptoms of a pulmonary embolism?

Answer 32

Acute deterioration in SOB Tachypnoea Tachycardia Low pa CO2 - blowing it off Pleuritic chest pain Unilateral leg swelling Haemoptysis

Question 33

What investigations are carried out in a patient with a suspected PE?

Answer 33

FBC ABG - may show decreased PaO2 and decreased PaCO2 ECG - S1, QIII, TIII (deep S waves, pathological Qwaves, inverted Twaves) Depending on Well’s score - either immediate CTPA or D-dimer

Question 34

How is PE treated? Normally and if cancer (long term)

Answer 34

PE - Give LMWH for 5 days or until INR reaches 2-3, then give warfarin - for 3 to 6 months Only consider Thrombolysis if the person is haemodynamically unstable with a massive PE Give LMWH alone for 6 months in cancer patients

Question 35

What can be given as an alternative therapy to heparin/warfarin uness in cancer patients?

Answer 35

Alternatively give a DOACs after 5days heparin - * direct oral thrombin inhibitors (factor IIa inhibitor eg dabigatran * or factor Xa inhibitors eg RivaroXaban /ApiXaban) Usually given for 3 months

Question 36

QUESTION TIME If you suspect a patient may have impending spinal cord compression, what should you do as a Junior Dr? * Refer to Physio and arrange an urgent bone scan * Refer to Neurology and start dexamethasone 8mg bd * Arrange an urgent MRI spine and start dexamethasone 8mg bd * Refer to Neurosurgery and start dexamethasone 8mg bd

Answer 36

Arrange an urgent MRI spine and start dexamethasone 8mg bd

Question 37

True or false * SVCO leads to swollen chest wall veins on a patient’s back * SVCO may be caused by left sided lung tumours * SVCO may be treated with anticoagulation * SVCO may be partially treated by interventional radiologists * SVCO is best diagnosed by MRI thorax

Answer 37

SVCO may be treated with anticoagulation TRUE SVCO may be partially treated by interventional radiologists TRUE * SVCO leads to swollen chest wall veins on a patient’s back FALSE * SVCO may be caused by left sided lung tumours FALSE * SVCO is best diagnosed by MRI thorax FALSE -

Question 38

In a patient with malignant hypercalcaemia the single most useful blood test to perform ( after the corrected calcium level!) is * FBC * U&Es * LFTs * PTH * Myeloma screen

Answer 38

U&Es

Question 39

In a patient with malignant hypercalcaemia, which is the first treatment a Jr Dr should initiate? Pamidronate Zolendronate iv fluids Oxygen Paracetamol

Answer 39

IV fluids

Question 40

True or False Pericardial tamponade causes: * Diastolic heart failure * Systolic heart failure * Large QRS complexes on the ECG * Muffled heart sounds on auscultation * Bradycardia * Hypertension

Answer 40

* Diastolic heart failure - True - heart cannot fill * Muffled heart sounds on auscultation - True (Beck’s triad, also raised JVP and low BP) * Systolic heart failure - False * Large QRS complexes on the ECG - small complexes and electrical alternans * Bradycardia - False * Hypertension - False

Question 41

Neutropenic sepsis: TRUE OR FALSE Is defined as sepsis in a patient with cancer and with a neutrophil count If suspected, the patient must receive antibiotics within 2h of admission to hospital Antibiotics should only be given once the neutrophil count is confirmed A full septic screen should be completed before antibiotics are given

Answer 41

Neutropenic sepsis: Is defined as sepsis in a patient with cancer and with a neutrophil count If suspected, the patient must receive antibiotics within 2h of admission to hospital - FALSE (within 1 hour) Antibiotics should only be given once the neutrophil count is confirmed - FALSE immediately A full septic screen should be completed before antibiotics are given - FALSE, give Abx immediately)

Question 42

A patient with cancer Has a very low risk of PE Has their risk of a PE heightened by recent surgery Who has a PE should not be thrombolysed as risks of bleeding are too great And with a PE will have raised pCO2 levels on ABGs Has no proven benefit for taking LMWH to reduce the risk of PE if they are ambulant.

Answer 42

A patient with cancer : Has their risk of a PE heightened by recent surgery - TRUE Has no proven benefit for taking LMWH to reduce the risk of PE if they are ambulant.- TRUE Has a very low risk of PE - FALSE Who has a PE should not be thrombolysed as risks of bleeding are too great - FALSE And with a PE will have raised pCO2 levels on ABGs - FALSE

Question 43

A patient with pain from metastatic malignancy affecting the thoracic spine is on MST 30mg bd How much break through Oramorph should they have? If you wish to convert them to a syringe driver over 24h, and they have used 40mg of breakthrough in the last 24h, what dose of morphine should go in the pump?

Answer 43

Breakthrough oramoprh = 1/6th of total daily dose = 1/6th of 60mg = 10mg Syringe driver over 24 hr = 50mg in pump * - total oramorph in 24hr was 60mg + 40mg = 100mg * Need 50mg in the syringe pump due to it being double the strength so half the dose

Question 44

A patient with pain from cancer: * Should be on paracetamol 1g qds, even if they are taking MST 40mg bd. * Codeine may be prescribed with paracetamol as co-co-codamol 8 / 500 or 30 / 500. * What does this dose mean? * If a patient takes co-codamol 30/500 two tablets qds, how much codeine have they taken? How much is the equivalent morphine?

Answer 44

* Should be on paracetamol 1g qds, even if they are taking MST 40mg bd. - TRUE * Codeine may be prescribed with paracetamol as co-co-codamol 8 / 500 or 30 / 500 - 8mg or 30mg of codeine with 500mg of paracetamol If a patient takes co-codamol 30/500 two tablets qds, how much codeine have they taken - 30x2x4 = 240mg of codeine The equivalent morphine (100mg morphine = 10mg codeine) so 24 mg morphne