Onco emergencies Flashcards
1
Q
Neuro onc. emergencies?
A
- cord compression
- CNS mets w/ sxs
- Vascular events: hyperviscosity, leukostasis
2
Q
Cardiopulm onc. emergencies?
A
- cardiac tamponade
- SVC syndrome
3
Q
Metabolic onc. emergencies?
A
- tumor lysis, hypercalcemia, SIADH
4
Q
Hematological onc. emergeniecs?
A
- neutropenic fever, thrombocytopenia, overanticoagulation
5
Q
Right now this minute emergencies?
A
- neutropenic fever, tamponade, cord compression, CNS mets with sxs
6
Q
Emergencies that need to be taken care of today but not ASAP?
A
- coagulopathies, tumor lysis, leukostasis, hyperviscosity, severe thrombocytopenia, INR over 9 (worried about spontaneous brain bleed)
7
Q
If not today, but tomorrow emergencies?
A
- SVC syndrome
- most hypercalcemia
- most CNS mets w/o edema
- INR 5-9
8
Q
How does spinal cord compression present in most pts? When does this usually occur?
A
- as back pain
- inflammation and paresthesias
- autonomic dysfxn follows motor/sensory dysfxn
- usually occurs in diseases with vertebral body mets (prostate, breast, lung, MM) - most common thoracic, not hematogenous dural mets
- rapid deterioration (days) predicts worse outcome than longer (weeks)
- back pain is usually first presenting sx ( precedes other sxs by 7 weeks)
9
Q
Dx and Tx of cord compression secondary to tumor?
A
- Need: MRI/CT (+/- myelogram) of the whole spine
- decadron: 4-6 mg q 4-6 hrs, PO or IV - but some studies suggest 24 mg q 6 hrs after 100 mg bolus
- neurosurgery in most circumstances: esp no dx or very rapid onset
- XRT: radiation therapy if multiple levels
10
Q
Brain mets presentation, MC primary cancer? What else should you consider if no dx of cancer? Tx?
A
- presentation: HA, seizures, alt. mental status, or focal deficits
- MC from lung or breast if no prior known primary (GI, sarcomas, prostate CA are unusual)
- if no dx: and is isolated to brain, consider lymphoma or HIV
- tx: surgery + radiation therapy for isolated mets improves survival vs either alone
- decadron into pt if there is edema, focal sxs
- dilantin into pt only if seizure witnessed/suspected
- good imaging of whole brain: MRI if poss.
- neurosurgery if no dx, or clearly an isolated met
11
Q
Presentation of hyper viscosity? Most commonly assoc with? Less commonly?
A
- relatively nonspecific sxs: somnolence, HA, blurry vision, dizziness
- hyperviscosity mostly with Waldenstrom’s
- less commonly with MM or polycythemia Vera, rarely essential thrombocytosis
- serum viscosity is usually over 5 cp, in PV Hgb usually above 19 or 20, and in ET platelets are well over 10^6
12
Q
Tx of hyperviscosity?
A
- HYDRATE the pt
- apheresis for IgM + chemo (need Hem/Onc for chemo)
- phlebotomy for PV: replace units with NS, want Hgb around 15
- hydroxyurea and aspirin for ET
13
Q
Leukostasis MC assoc with? Presenting sxs?
A
- MC in AML with WBC greater than 100,000 (CLL, CML uncommon even with WBC of over 300,000)
- alt mental status, coma common, but other organs also involved
- hypoxia, renal insufficiency,
- may worsen during induction chemo fo AML
- 1 wk mortality if untx 20-40% of time
- this may be first presenting sx of AML
14
Q
Tx of leukostasis?
A
- HYDRATE pt
- quinton access (renal) and chemo (onc) - chemo have to tx prophylactically for tumor lysis
- an LP for cytology to rule in/out CNS leukemia
- steroids may help too
15
Q
What is cause of cardiac tamponade? Most common primaries? Triad? What will EKG show? CXR?
A
- malignant effusions - these are common but not commonly sx
- pressure on heart muscle b/c pericardial sac fills up with fluid - ventricles can’t fill - leads to becks triad:
hypotension, JVDm muffled heart sounds - EKG: electrical alternans, low voltage, ST elevation throughout
- lung, breast cancer MC primaries
- presents with left or right sided failure, pulsus paradoxus and big heart on CXR (globular shaped)
16
Q
Dx and tx of cardiac tamponade?
A
- echo and cytology from pericardiocentesis
- catheter drainage of pericardial space
- medical management
- oncology input re: chemo
- CT surgery re: subxiphoid pericardial window or balloon pericardiotomy, esp for recurrent effusions in pts with good performance status
- Tx: tx underlying malignancy!
17
Q
MC cause of SVC syndrome? Presentation? Emergency?
A
- usually from lung cancer, also from lymphoma, breast cancer, mediastinal tumors
- present: facial edema (esp in morning) , symmetric or asymmetric upper extremity edema common, SOB but not hypoxia, progressively enlarged veins over anterior chest wall.
- only relative emergency even with CNS sxs
- 90% of time it is a tumor compressing SVC
- infra-aygous SVC obstruction will present with more severe sxs
18
Q
Dx and tx SVC snydrome?
A
- pulse ox/CXR
- chest CT to outline mass that will need therapy
- oncology will be involved: chemo for small cell, lymphoma, germ cell
- radiation for almost all else
- heparin or coriticosteroids
- IR: stenting for sxs (new tx)
19
Q
When does tumor lysis syndrome occur? Usually due to? Sxs?
A
- occurs in tumors with high body burden and high chemosensitivity: usually high grade lymphomas or leukemias, small cellm germ cell is less common
- usually due to therapy, already know dx, may occur at onset of therapy, or after a day or 2, up to 5 days
- few clinical sxs other than being ill with obvious lab abnormalities due to renal failure:
hyperuricemia
hyperkalemia
hyperphosphatemia
hypocalcemia
(due to rapid cell turnover of tumor cells (w/ or w/o anti-tumor therapy)
20
Q
Pre-tx fix for tumor lysis syndrome?
A
- fix conditions that will make effects worse: dehydration, renal obstruction, IV contrast
- get baseline labs: K, Ca, Phos, uric acid, LDH, Cr
- alkaline diuresis: D5 - 1/2 NS with 2 or 3 NaHCO3 at 200 cc/hr, keep urine pH over 7, keep urine output high (use lasix and mannitol)
- allopurinol 600 mg load, then 300/day to keep uric acid production down
- rasburicase (super expensive)
21
Q
What do you have to do during tx for tumor lysis sydrome?
A
- keep in mind that high K+ and low Ca2+ kills people
- keep alkaline urine output high
- check BID lytes, phos, UA, Ca, LDH, Cr
- try to keep phosphate less than 7, Ca greater than 6, and K less than 6
- if Ca low, give Mg too!
- if phos above 7 switch NaHCo3 to NS to prevent CaPO4 deposits in kidneys (oral phosphate binders (amphogel) helps)
- acute K rx is good, but insulin D-50 preferred over IV Ca if Ca-P product high. Use Kayexalate
- May need dialysis
22
Q
MC causes of hypercalcemia? Presentation?
A
- breast, lung, MM MC
- squamous cancers from mult sites often make PTH-rP, even w/o bony mets (prostate very rare despite bony disease)
- usually is gradual in onset: fatigue, N/V, constipation, anorexia, apathy, decreased consciousness MC
- pts always volume depleted due to calcium induced renal tubular defects
23
Q
Tx of hypercalcemia? Hypecalcemia predicts what kind of survival?
A
- volume replete pt
- furosemide
- IV pamidronate (aredia) 90 mg over 3-4 hrs or if renal fxn is ok - IV zoledronic acid 4 mg over 15 min
- dialysis, calcitonin, and steroids not as effective but can be used as adjunctive tx
- predicts a short survival (better now though, greater than 5 months compared to 2 mos in past)
24
Q
MC cause of SIADH?
A
SCLC
25
Presenting sxs if serum sodium is under 120 meq/L ni SIADH?
- anorexia
- irritability
- N/V
- constipation
- muscle weakness
- myalgia
- decreased BUN and serum osmolarity
- increased urine osmolarity and sodium levels
26
Presenting sxs if serum sodium is less than 110 meq/L in SIADH?
- seizure
- coma/death
- abnormal reflexes
- papilledema
- decreased BUN and serum osmolarity
- increased urine osmolarity and sodium levels
27
Tx and monitoring of pt with SIADH?
- tx underlying tumor
- limit fluid intake to 500-1000 ml/day
- furosemide
- parenteral Na+ replacement w/ severe neuro sxs
- monitor lytes: Mag, K+, Ca2+
28
Neutropenic fever - sxs? long term vs short term neutropenia and causative organisms?
Why is this so dangerous? When does neutropenia occur?
- may initially be very subtle, then rapid development of hypotension, dyspnea, sepsis
- duration of neutropenia predicts organisms:
short term - more likely to be gram negative than gram positive, long term neutropenia (weeks): could be fungal, viral, opportunistic
- most pts are neutropenic due to chemo not malignancy in marrow
- most neutropenia occurs 10-15 days after chemo is given
- this is an EMERGENCY!!!!
29
Dx and tx plan for neutropenic fever?
- fully eval pt for a source: blood, CXR, sputum, UA, skin, LP?
- if there is a suspected source tx it
- if there isn't a suspected source, tx empirically for gut flora:
cefipime, moxifloxacin, pip/gent, aztreonam
- add coverage for lack of response
30
Most cases of isolated profound thrombocytopenia are do to what? Sxs?
- idiopathic, immune
- sxs vary:
asx, mucosal bleeding MC - epistaxis, gingival bleeding, bullous hemorrhages
cutaneous bleeding: petechiae, ecchymoses, menorrhagia, CNS bleeding least common
31
How do you tell the diff b/t platelet and clotting factor bleeding?
- platelet defect: bleed from skin, mucous membranes, will have bleeding after minor cuts, petechiae will be present, small, superficial ecchymoses, immediate and mild bleeding after surgeries
- clotting factor deficiency: site of bleeding - deep in soft tissue, won't have bleeding after minor cuts, no petechiae, ecchymoses are large and palpable, common to hae hemarthrosis, and muscle hematoma, bleeding after surgery is delayed and severe
32
What do you have to rule out when pt comes in with thrombocytopenia? What should you assess the pt for? Tx?
- Rule out: TTP, DIC, HIT, HELLP, do this by checking smear, LDH, PT/PTT, fibrinogen, any heparin in last 4-10 days, pregnant?
- assess pt for active bleeding
- transfuse pt if actively bleeding (or if you know problem is platelet production)
- prednisone 1 mg/kg/d if pt is well (plt will rise in days)
- IV-IG x 2 days if pt is ill (plt will rise in hrs)
- know that in kids, most will remit, and in adults most will relapse and reqr a splenectomy
33
Cause of overanticoagulation?
- warfarin and other anticoags being used more and more (esp in cancer pts- b/c have increased change of clotting)
- have to be careful b/f newer agents (LMWH and direct thrombin inhibitors) don't have antidotes
34
For pts on warfarin that you are worried about being overanticoagulated what should your approach be?
- assess whether there is sig bleeding
- assess for head trauma
- assess whether pt should be anticoag. again in the future
- give FFP (2 units) and 5 mg IV vit K for sig bleeding
- give PO (2-5 mg) vit K for INR greater than 9 w/o bleeding
- avoid SQ vit K if pt is to be anticoag in the future
35
For pts on non-warfarin agents - what should your approach be?
- assess for bleeding and head trauma
- ID the specifc agent and call pharm/heme
- for sig bleeding, consider protamine sulfate for heparin or LMWH (slow admin). Dose reqrs pharm help
- for sig bleeding, esp with fondaparinux (arixtra) consider recombinant activated Factor VII
36
When do heme and onc emergencies usually occur: b/f or after cancer dx?
- after
