Oncologic emergencies Flashcards
Types of body systems effected by oncologic emergencies
– Metabolic, neurologic, cardiovascular, respiratory, genitourinary,
gastrointestinal, hematological
Causes of oncologic emergencies
– Increased tumor size
– Tumors may secrete substances that mimic substances in the body
How do oncologic emergencies usually present
May be first s/s of cancer
May be sign cancer has advanced
What are the treatment goals in an oncologic emergency
• Immediate intervention to prevent loss of life or quality of life
• STAT aggressive supportive measures followed by definitive treatment
of the underlying malignancy
3 types of metabolic emergencies
Tumor lysis syndrome
SIADH
Hypercalcemia
Risk factors of tumor lysis syndrome
acute leukemias most common Testicle cancer Small cell lung CA Breast CA aggressive lymphoma
What happens in tumor lysis syndrome
Either as a result or treatment or as a result of worsening tumor, cells lyse and release contents which exceeds capacity for kidneys elimination
How does tumor lysis syndrome present
labs and manifestations
Increased K, cramps, N/D paralysis, paresthesias, ECG changes
Hyperphosphatemia: Oliguria/anuria/azotemia
Hypocalcemia: Tinnitus, twitching, seizures, parathesias and hypotension
Hyperuremia: N/V, AMS, edmea
Interventions for tumor lysis syndrome
Aggressive IV hydration, to regulate electrolyte levels and perfuse kidney
Allapurinol 300 mg PO: prevent uric acid synthesis
Rasburicase: 30 min infusion for TLS
Hemodialysis for acute episodes
SIADH
Too much antidieuretic hormone the prevalence of 1-2% of persons with cancer
Risk factors of SIADH and medications that can cause this
Small-cell lung cancer (60%), pancreatic, prostate, brain cancers
• Is adverse effect of cyclophosphamide (Cytoxan), vincristine, cisplatin
What happens in the body during SIADH
Water intoxication
ADH is secreted without response to usual feedback mechanism
Kidneys continue to retrun water to the body which dilutes the Na levels
SIADH symptoms when it is slow onset
• Subtle mental and cognitive changes, i.e. memory loss, apathy, impaired abstract thinking • Fatigue, myalgia • Headache • Thirst
SIADH symptoms when it is rapid/severe onset
Asterixis (flap/tremor of hand when wrist extended)
Confusion
Seizures, coma
Diagnostic findings of SIADH
Serum Na <130 mmoL/L
Urine Na >20 mmoL/L
Urine osmolality exceeds that of plasma
SIADH Interventions
Treat the tumor—combination chemotherapy; RT
Fluid Restriction (<1000mL or <500 mL if there is a poor response
Declomycin in divided doses is given for refractory low Na
3%hypertonic Na by slow infusion to treat Neurosymptoms (seizure/coma)
Furosemide (Lasix) w/ normal saline infusion
how common is Hypercalcemia and what is the survival rate
• Is most common metabolic emergency; experienced by 25% of persons
with cancer
• 50% of patients diagnosed will die within one month of onset
• Mean survival 1-6 months
What is the cause of hypercalcemia
& special consideration
Altered calcium metabolism in bones kindeys, intestines esp in the presence of metastatic disease
Parathyroid hromone like substance screted by cancer cells (paraneoplastic syndrome)
Renal func/dehydration/physical activity
What are the diagnostic criteria fo hypercalcemia
Calcium levels of >11
K, Na, PO4 decreased
BUN/Creatinine Increased
What are the clinical manifestations of hypercalcemia
Loss of appetite Nausea and vomiting Constipation and abdominal pain Increased thirst and frequent urination Fatigue, weakness, and muscle pain Confusion, disorientation, and difficulty thinking Headaches Depression
Systems issues with hypercalcemia
Kidney stones Irregular heartbeat Myocardial Infarction Loss of consciousness Coma
What do you assess in hypercalcemia
Assess levels of dehydration, renal function and CV status
What medications do you give for hypercalcemia
IV rehydration: IV hydration with NS 3L/24 hrs
Loop diuretics to enhance secretion of Ca
Bisphosphonates: decrease Ca levels (safest)
-IV aredia/zometa
Gallium nitrate: to prevent bone breakdown
calcitonin: band-aid response, shouldn’t be given as the primary treatment, usually given with biphosphates
Hemodialysis: if ca cannot be corrected with meds
Name the neurologic emergencies
Spinal cord compression Related to brain tumors • Increased intracranial pressure (ICP) • Seizures • Altered mental status Paraneoplastic syndromes
Spinal cord compression risk factors
• “Liquid” tumors, i.e. lymphomas or multiple myeloma
• Solid tumors with bony metastases, such as prostate, lung, breast, renal
cell
What causes a spinal cord compression in an oncologic emergency
From rapidly growing mass pressing against spinal cord
Results in collapse of vertebrae
Most commonly caused by bone metastasis in the spine
30% of patients will have metastases in >1 area of the spine
How will a patient with spinal cord compression present
95% of patients present with back pain
• Intense, localized and persistent
• May radiate to lower back, buttocks, legs or arms
• Sensory or motor: Numbness/difficulty walking
if Lumbosacral – incontinence of bowel or bladder, urinary retention, leg pain or numbness
(can become permanent w/o immediate tx)
How is spinal cord compression diagnostics
Radiological Spinal films CT with myelography **MRI is gold standard **** Biopsy of the lesion Surgical
Types Cardiovascular emergencies
Cardiac tamponade
SVC syndrome
Cardiac tamponade risk factors
Lung ca
Breast ca
Hematologic ca
What can cause cardiac tamponade
Can result from pressure of metastases outside of heart;
pericarditis secondary to radiation therapy
How much fluid causes cardiac tamponade
Normally 50 ml of fluid between visceral (serous) and fibrous
parietal layers; tamponade can result from as little as 200 ml
“Stress relaxation” over weeks to months with parietal stretch;
sac can hold 2 L or more before tamponade occurs
what happens in Cardiac tamponade
Fluid collection → Compression → Decreased CO
cardiac tamponade most common clinical manifestation
Exertional dyspnea most common symptom; occurs in 80% of
patients
Beck’s triad cardiac tamponade
Beck’s triad of hypotension, increased jugular venous
pressure, decreased heart sounds in acute tamponade
Beck’s triad cardiac tamponade
Beck’s triad of hypotension, increased jugular venous
pressure, decreased heart sounds in acute tamponade
Clinical manifestations of cardiac tamponade
Exertional dyspnea Chest heaviness, distant heart sounds, tachycardia, pericardial friction rub Narrow pulse pressure Shortness of breath, anxiety Tachycardia Beck’s triad
Cardiac Tamponade
Diagnostics tests & what they show
Chest- X Ray: Enlarged cardiac silhouette with increased transverse diameter (water bottle heart) ECG: • Nonspecific ST and T wave changes • Tachycardia • Low QRS voltage • Atrial dysrhythmias Echocardiogram: dec filling/dec CO Pericardiocentesis: Tx & dx drain fluid and test is confirmation
Cardiac tamponade ecg shows
ECG • Nonspecific ST and T wave changes • Tachycardia • Low QRS voltage • Atrial dysrhythmias
How to treat cardiac tamponade
Pericardiocentesis with placement of indwelling drainage
catheter
Sclerosing therapy, balloon pericardotomy, or surgical window (stop the buildup of blood)
Prognosis poor with paradoxical hemodynamic instability in
postoperative period
Nursing interventions for after pericardiocentisis
Oxygen therapy
IV hydration
Vasopressor therapy
Causes of SVC syndrome
thrombosis caused by implantable IV
devices, i.e. tunneled CV catheters, port catheters,
pacemaker leads
Mediastinal mass obstructing blood flow; most common
causes are lung cancer, non-Hodgkin’s lymphoma, metastatic
breast cancer
Previous radiation therapy to the mediastinum
What happens in they body to lead to SVC syndrome
Presence of mediastinal mass or thrombosis results in high
venous pressures and upstream vessel engorgement
Collateral vein dilation results in an effort to reduce this
pressure
SVC Syndrome clinical manifestations common symptoms
Common Symptoms Facial edema Facial redness Periorbital edema Distention of veins in head, neck and chest Dyspnea at rest, cough
SVC Syndrome clinical manifestations rare symptoms
Rare symptoms Difficulty Swallowing Chest pain Hoarseness Cyanosis Hemoptysis
Superior Vena Cava Syndrome
Diagnostics
Chest x-ray Computed tomography (CT) scan Magnetic resonance imaging (MRI) Venography Ultrasound
Superior Vena Cava Syndrome
Interventions
► Elevation of head: to dec pressure above SVC ► Corticosteroids: dec swelling ► Diuretics: dec fluid vol Thrombosis req intervention ► Thrombolysis ► Stents ► Bypass surgery tx based on symptoms
Type of respiratory emergencies
Airway obstruction
Massive hemoptysis
Toxic lung injury
Airway Obstruction clinical manifestations
Dyspnea Cough Wheezing Hemoptysis Stridor
Airway Obstruction diagnostics
Bronchoscopy
Biopsy
Airway Obstruction Intervention
Airway Securement Surgery if indicated (rare) Radiation Obstruction reduction techniques Stent Laser vaporization Photodynamic therapy Cryotherapy Endobronchial brachytherapy
Massive hemoptysis risk factors
Bronchogenic carcinoma
Metastatic cancer to bronchus or trachea
Platelet dysfunction
Massive hemoptysis definition
≥ 500mL of blood over a 24hour period or
A bleeding at a rate of ≥ 100mL/hour
Massive Hemoptysis
Intervention
Maintain airway patency Localize the source of bleeding Control the bleeding Pulmonary angiography and embolization Surgery
Toxic lung injury risk factors
Radiation Therapy • Cobalt Chemotherapy drugs • Arsenic trioxide • Bleomycin – 20% of patients receiving this therapy • Idarubicin Pre-existing lung disease (i.e. COPD)
