onc emergencies Flashcards
1
Q
superior vena cava syndrome
A
- d/t occlusion or compression of SVC
- can be thrombosis of indwelling catheter or from a tumor
2
Q
si/sx of SVC
A
- dyspnea
- cough
- orthopnea
- neck v distention
- facial swelling
- arm V distention
- papilledema- emergency
- horner’s syndrome
3
Q
dx of SVC
A
- CXR usu abnormal
- confirm with other imaging
- chest CT with contrast
- MRI
- contrast venography
- Tc99m radionuclide venography
4
Q
treatment of SVC
A
- keep head up
- IV steroids and diuretics
- emergency mediastinal radiation- call radiation oncology*
- remove central IV if in place
5
Q
acute SC compression causes
A
- tumor
- epidural abscess/ hematoma
- often from extension of spinal boney mets
6
Q
where is SC compression most common
A
- thoracic spine
7
Q
si/sx of SC compression
A
- localized back pain +/- tenderness
- paraplegia
- parasthesias
- distal sensory deficits
- gait disturbance
- urinary incontinence
8
Q
dx of SC compression
A
- spine films- often abnormal but doesnt r/o dx
- MRI*- study of choice
- bone scan
- CT with contrast
- myelography
- get imaging emergently
9
Q
tx of SC compression
A
- spine immobilization
- foley cath
- decadron
- emergent decompressive laminectomy or radiation- urgent radiation and neurosurg consult*
10
Q
hypercalcemia of malignancy etiology
A
- parathyroid hormone related protein (PTHrP)
11
Q
si/sx of hyperCa of malignancy
A
- malaise/ weakness
- polydipsia
- anorexia
- N/V
- lethargy
- confusion
- back pain
- sz
- bones, stones, moans, groans
12
Q
how do you calculate corrected Ca
A
- total Ca + [0.8 X (0.4-albumin)]
- > 12 is dangerous
13
Q
assessment of hyperCa of malignancy
A
- corrected Ca
- Cr, electrolytes, alk phos
- EKG: short QT, low voltage, long PR
- work up for skel lesions
14
Q
treatment of hyperCa
A
- IV hydration*: 150-22 cc/hr
- once euvolemic then give loop diuretics (lasix)
- bisphosphonates
- subq or IM calcitonin- quickly lowers lev
- steroids best for hematologic malignancy
- dialysis of pt cant tolerate fluids
15
Q
febrile neutropenia
A
- single oral temp > 101.3 or sustained temp > 100.4 for 1 hour
- neutropenia: ANC < 1000
- severe neutropenia: ANC < 500
- half of all cases have no identified organism
16
Q
when does febrile neutropenia usu occur
A
- during nadir after chemo
- nadir usu occurs 5-10 d after last dose
17
Q
what is the nadir
A
- when all cell counts drop after chemo
- lasts 5-7 days
18
Q
how do you calculate ANC
A
- WBC X ( % neut + % bands)
19
Q
presentation of febrile neutropenia
A
- severity ranges
- pay close attention to skin, oral cavity, perianal area, catheter, indwelling lines
20
Q
work up for febrile neutropenia
A
- blood and urine cx
- sputum cx and gram stain
- generally avoid internal rectal exam unless indication
- CXR may be normal but consider a CT if respir complaints
21
Q
tx of febrile neutropenia
A
- abx ASAP- within 1 hour
- usu give vanco + cefepime
- most admitted
- consider anaerbes, fungi, viruses, klebsiella
- can consider admin of granulocyte colony stim factor (G-CSF)
22
Q
G- CSF
A
- neupogen or neulasta
- can speed resolution of neutropenia
- no change in mortality
- reduces hospital stay by 1 day
- given SC
23
Q
indications for G-CSF
A
- profound neutropenia, shock, comorbidities
- worsening clinical course and expected prolonged neutropenia
- pt not responding to abx despite documented infx
24
Q
ongoing tx once afebrile after febrile neutropenia
A
- cont abx until blood cx
- adjust abx based on cx
- treat for 5-7 days of IV abx
- consider PO abx if ANC > 1000
- surveillance cx must be neg before d/c
25
ongoing tx for febrile neutropenia
- after 4 days add antifungal tx
- broaden coverage to include anaerobes and candidia
- ID consult
26
when can a patient be discharged for febrile neutropenia
- count recovery
- afebrile for 24 hours
- cx neg
27
bacteremia in febrile neutropenia
- infection only documented in 30-50% of cases
- 30% have bacteremia
- considered a true medical emergency
28
tumor lysis syndrome
- d/t rapid release of tumor contents -> metabolic complication
- occurs after tx of bulky chemo responsive malignancy
- may also be spont as tumor outgrows its own blood supply and dies off
- d/t rapid release of tumor contents
29
when does tumor lysis syndrome usu occur
- 6-72 hours after initiation of chemo or radiation
30
RF for tumor lysis syndrome
- large tumor burden
- high growth fraction
- high pretreatment LDH or uric acid
- preexisting renal insufficiency
31
si/sx of tumor lysis syndrome
- hyperP
- hypoCa
- hyperK
- hyperuricemia
- metabolic changes can be life threatening
- acute renal failure and cardiac arrhythmias
32
treatment of tumor lysis syndrome
- stop chemo
- aggressive IV hydration/ diuresis
- +/- alkalinizing urine pH
- Na, NaHCO3, glucose/ insulin, kayexalate for hyperK
- consider emergency hemodialysis
- allopurinol for prevention
- rasburicase
33
when is emergency hemodialysis indicated for tumor lysis syndrome
- K > 6
- uric acid > 10
- Cr > 10
- unable to tolerate diuresis
34
what does rasburicase do
- rapid deterioration of uric acid
- occurs over a matter of hours
- very expensive
- not often used for tumor lysis syndrome
35
thrombocytopenia in malignancy
- avoid all NSAIDs
- spont bleeding if plt < 10k
- plt transfusion if count < 10k or any CNS bleed
- avoid plt transfusion if consumptive state
- use HLA matched single donor plt if sensitized
36
acute malignancy related DIC
- decreased plt
- increased PT/ PTT/ FDP
- decreased fibrinogen
- treat with plt and clotting factors
- may need tumor debulking
37
chronic malignancy related DIC
- labs may be normal
| - treat intravascular thrombosis with heparin
38
cause of malignant pericardial tamponade
- tumor- would see tumor cells in aspirate
| - radiation- no tumor cells
39
si/sx of malignant pericardial tamponade
- dyspnea, weakness
- hypotension
- narrow pulse pressure
- JVD
- muffled/ decreased heart tones
- pulsus paradoxicus > 10 mmhg
- low EKG QRS voltage
- +/- pulsus alternans
40
diagnosis of pericardial tamponade
- echo
41
treatment of pericardial tamponade
- needle cath pericardiocentesis
- pericardial window
- radiation
- paricardectomy- poor prognosis
- intrapericardial chemo or sclerosis
