Oncologic Emergencies Flashcards
define ocologic emergency:
any clinical oncologic situation that requires rapid diagnostic attention and therapeutic intervention
Hyponatremia in a smoker- think what disease?
SIADH from lung cancer
Silhouette sigh on x-ray is when?
aortic knob disappears
Large mediastinal mass in a smoker w/ facial swelling and periorbital edema?
Lung cancer! & SVC smashed due to the mass = superior venacava syndrome = cant drain from head and neck
Superior vena cava syndrome:
-what is it?
-any condition that is (benign or malignant) caused by obstruction of blood flow through the SVC = emergency!
What fraction of body blood does the SVC return to the heart?
What happens when obstructed?
1/3 of venous return to heart
Venous collaterals return blood to the heart via the inferior vena cava or azygous venous systems
SVC syndrome -
Signs and symptoms:
1) presence of venous collaterals/venous dilation
2) edema of head, neck, arms, upper chest, LARYNX, and BRAIN
3) shortness of breath
4) Head fullness
5) cyanosis
6) cough
7) chest pain
8) headaches
9) CONFUSION
10) COMA
*** = emergency!!!!
Etiology of SVC syndrome:
1) malignancy in 70% of cases - usually lung and NHL
2) benign:
a) SVC stenosis or thrombosis due to intravascular devices (central venous catheters, pacemaker wires)
b) fibrosing mediastinitis - ex) hitoplasma capsulatum
SVC syndrome diagnostic studies:
- Chest X-ray
- -CT scan - contast** BEST CHOICE IF MALIGNANT OBSTRUCTION
- -venography* - BEST CHOICE IF THROMBOSIS FROM IV CATHETER OR PACEMAKER
- MR
- histologic diagnosis for malignancy (Biopsy)
SVC treatment:
- *1) alleviate symptoms - SVC endovascular stents** BEST** - BETTER WITHIN HOURS!
2) treat underlying disease - Malignancy: RT (depends on tumor type), Chemo, steroids, diuretics
neutropenic fever:
definition of:
- single temp >38.3C/101F - oral
- sustained temp for >1hr >38C/100.4F
- some may not have fever especally those on glucocorticoids - these patients have hypotension, tachycardia, tachypnea, changes in metal status and or hypothermia
- abs neutrophil count (ANC-bands +PMNs) less than 500cells/microliter. Total WBC count X%of PMN+BANDS
- neutropenia >7 days is greater risk for infection
Types of neutropenic fever syndromes
1) microbiolocially documented infection - neutropenic fever with a clinical focus of infection and an associated pathogen
2) Clinically documented infection- neutropenic fever with a clinical focus (pneumonia, mucositis) but without isolation of an associated pathogen
3) unexplained fever - neutropenic fever without a clinical focus or an isolated pathogen
Neutropenic fever is usually induced by?
chemo therapy! - this Tx suppresses myelopoiesis and affects the integrity of the GI mucosa = bacteria and fungi can cross intestinal mucosa
What is promptly used in all neutropenic fever patients?
*Empiric antibiotics - DO NOT WAIT FOR CULTURES
Neutropenic fever - patient evaluation procedure:
1) meticulous history and PE DAILY (HE SAYS TO DRAW BLOOD FIRST AND IMMEDIATELY GIVE ANTIBIOTICS while slide written opposite)
2) Lab: CDC with differential, LFTs, CMP, cultures of blood, urine, sputa, anything suspicious
- -> IMMEDIATELY GIVE ANTIBIOTICS –> THEN PE and Hx (inspect all IV sites, catheters, skin surfaces - NO RECTAL EXAM)
3) Radiology: CXR, CT chest, anything suspicious
Pathogenesis of Neutropenic fever:
- direct effect of chemo on mucosal barriers and immune system - from mouth to anus = mucous = its affected - chemo induces mucositis occurs (everywhere) = seeding of the bloodstream from endogenous flora = major cause of episodes
- obstruction of lymphatics, bilary tract, GI, or GU w/ or w/o indwelling catheters
- breeches in host defenses due to the underlying malignancy itself
How often is infectious source found in neutropenic fever?
What is only evidence of infection in most patients?
WHere do we hink 80% of documented infections are from?
- only 20-30% of time
- bacteremia in 10-25% of patients
- infections arise from the patient’s endogenous gut flora
Most often give what to Tx neutropenic fever?
- 3rd generation cephalosporin (broad spectrum)-
- DO NOT give vancomycin which is only good against G+
What are the pathogens in neutropenic fevers?
More often is which class of pathogens??
1) gram + (staph, strep, Staph epidermidis is most common) — USUALLY GRAM +
2) gram - (E Coli, Pseudomonas)
3) fungal (candida, aspergillus)
4) viral (HSV, Herpes zoster, CMV, EBV)
which organism class most often causes Neutropenic fevers?
GRAM + organism _ staph epidermidis
When do we begin to think fungal for neutropenic fever?
risk inc with duration and severity of neutropenia, prolonged antibiotic use and number of chemo cycles
Rarely is the INTIAL cause of neutropenic fever…
fungal