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
What pathogen is most common in central venous catheter associated neutropenic fever?
Candida - fungal
Neutropenic fever treatment:
- broad spectrum antibiotics immediately after blood draw/cultures - WITHIN 1 hr!
- antifungals as needed
- remove infected devices
- G-CSF not usually needed
narrow pulse pressure?
lack of perfusion in general
pulsus paradoxus definition:
variable pulse with respiration: - disappears with inspiration and reappears with expiration
electrical alternans is what?
seen in pericardial effusiion and tamponade - have alternating large and small QRS
the heart moves in the pericardial sac (due to above two conditions) and so on certain beats it is further or closer to the chest leads
Signs/Symptoms of pericadial tamponade:
-JVD
-narrow Pulse pressure
-pulsus paradoxis
-electrical alternans (on EKG)
-cough
chest pain
-shortness of breath
weakness
-tachycardia
-diminished heart sounds
-friction rub
Pericadial tamponade effects on body?
hypotension
Dec CO
bc heart cant open and close properly
Diagnosis of pericardial tamponade?
EKG is test of choice for suspected pericardial effusion and tamponade
NOT CT!!!
Appearance of heart on Xray with pericardial tamponade or effusion?
“old waterbottle” look
Tx of pericardial tamponade:
drain fluid:
- pericardiocentesis - BEST CHOICE
- pericardial window surgery for recurrent effusions
Test of choice for Malignant spinal cord compression (MSCC)?
MRI
Definition of malignant spinal cord compression?
- compression of the spinal cord or cauda equina by an extra dural tumor = spinal cord injury/compromsed blood flow-ischemia = spinal cord infarct
Cancers that could metastasize and cause MSCC?
lung
breast
prostate
multiple myeloma
Most frequent site of MSCC?
Second? Third most?
thoracic spine
lumbosacral
cervical
signs and symptoms of MSCC?
- localized back pain: worse with movement, coughing, supine position
- radicular component: pain down limb
- Lhermitte sign - feeling of electric shock down the spine with neck flexion
- Motor - weakness, spasticity, reflexes, typically symmetric and greates with thoracic lesions
- sensory findings - numbness, paresthesias
- bladder and dowel dysfunction (late)
First symptom in most MSCC patients?
localized back pain - worse with movement coughing, supine position
Lhermitte sign - is…
feeling of electric shock down the spine with neck flexion
MSCC - cauda equina syndrome - signs and symptoms:
- low back pain
- decreased sensation over butt, posterior thigh and perineum (saddle distribution)
- bladder and bowel dysfunction
- decreased patella and achilles reflex
- lower extremity weakness
MSCC diagnostic test? Why would you maybe have to pick a different test?
- MRI - is test of choice - see difference bw bone and soft tissue
- if patient has pacemaker use CT myelogram
intramedullary tumor vs leptomeningeal tumor?
differentiate how diagnostically? And Tx for each?
- use MRI
- intra=tumor part of the spinal cord itself - SURGERY OR CHEMO DEPENDING ON WHERE AND SHAPE
- lepto=tumor spread to megninges - CHEMO
goal for MSCC treatment:
relieve pain and maintenance and or recovery of neurologic function
TUmor lysis syndrome:
-how happens?
syndrome caused by rapid death (following chemo) or cell turnover of a large volume of rapidly proliferating cells
- *Tumor lysis syndrome (TLS)
- characteristics?
- hyperkalemia
- hyperuricemia
- hyperphosphatemia
- hypocalcemia
- metabolic acidosis
- acute kidney injury - 1-5 day onset - (AKI - from uric acid crystal deposition in the renal tubule)
TLS is most common with which diseases?
lymphomas and leukemia (hematologic malignancies)
General Pathophysiology of TLS?
-cancer cells die –> releaee of potassium, phosphorus and nucleic acids –> metabolized to hypoxanthine –> metabolized to xanthine–> to uric acid
—> PPT of uric acid = PPT of calcium phos and Vice versa ==========vicious cycle!
-release of cytokines from tumor cells = systemic inflammation = multisystem organ failure
Issues with hyperphosphatemia in TLS?
- causes secondary HYPOcalcemia = neuromuscular instability, seizures, and dysrhythmia
- can PPT calcium phosphate crystals in organs - especially bad if in cardiac tissues = more dysrhythmias
Issue with hyperkalemia in TLS?
fatal dysrhythmias!
Issue with hyperuricemia in TLS?
= acute kidney injury
1) precipitates in tubules
2) induces renal vasoconstriction
3) impaired autoreg
4) dec RBF
5) oxidation
6) infammation
Main thing to look at with tumor lysis syndrome???
Risk of acute kidney injury! want to prevent it from happening!
High risk group for TLS?
- pre-existing chronic renal insufficiency
- oliguria
- volume depletion
- hypotension
- acidic urine
Prevent TLS by?
1) HYDRATION!!!!! - KEEP THEM PEEING!!
2) allopurinol (xanthine oxidase inh) - block conversion of xanthine and hypoxanthine to uric acid
3) rasburicase (urate oxidase)- oxydizes urin acid to more water soluble allantoin —– EXPENSIVE!!!
4) DIALYSIS
Signs and symptoms of pulmonary emboli:
- non-specific but most commoN:
- -dyspnea with exertion or at rest
- -pleuritic chest pain
- -cough
- -calf or thigh pain or swelling
- -tachypnea
- -tachycardia
- -rales
- -JVD
—-Frequently asymptomatic!
Diagnosis - pulmonary embolus:
- chest xray but really poor sensitivity and specificity– will see pleural effusion and atelectasis
- V/Q scan - only when there is contraindication to IV contrast ex) kidney issues
***-CT pulmonary angiogram - CTPA- BEST TEST! - really good for excluding Pulmonary Emboli
Tx for PE?
1) resuscitation - respiratory and hemodynamic
2) diagnostic studies when the patients are stable
3) initiation of anti-coagulation with low molecular wieght heparin (LMWH) if there is no contraindciation to anticoagulation
