Oncologic Emergencies - Exam 1 Flashcards by Elisabeth Silver

what catheter can cause SVC syndrome?

indwelling catheter - I.e. PICC line that gets thromboses and then SVC get compressed

How well did you know this?

Not at all

Perfectly

what is SVC syndrome?

compression of the SVC

How well did you know this?

Not at all

Perfectly

SVC syndrome sx’s

-dyspnea, cough, orthopnea

How well did you know this?

Not at all

Perfectly

SVC syndrome signs

neck vein distention, facial swelling/fullness (b/c fluid is backing up), arm vein distention

How well did you know this?

Not at all

Perfectly

what sign of SVC syndrome represents a true emergency?

Papilledema (means more severe case of SVC syndrome)

How well did you know this?

Not at all

Perfectly

SVC syndrome dx

CXR

How well did you know this?

Not at all

Perfectly

confirm SVC syndrome with what test?

Chest CT with contrast

MRI

Contrast venography

How well did you know this?

Not at all

Perfectly

SVC syndrome treatment

keep in head-up position (to make fluid go down)
IV steroids (shrinks tumor swelling)
IV diuretics (Torsemide)
Anticoagulants or thrombolytics (if clot in SVC)
Emergent mediastinal radiation
remove central IV catheter if present

How well did you know this?

Not at all

Perfectly

if SVC has clot in it, then how do you treat pt?

anticoagulants or thrombolytics (heparin drip)

How well did you know this?

Not at all

Perfectly

what can form in spinal column and cause acute spinal cord compression?

epidural abscess/hematoma

How well did you know this?

Not at all

Perfectly

what must be evaluated urgently in acute spinal cord compression?

neuro status - as to predict the functional outcome

-a lot of neuro deficits are not reversible

How well did you know this?

Not at all

Perfectly

what does acute spinal cord compression usually result from?

extension of spinal bony metastases

How well did you know this?

Not at all

Perfectly

where is acute spinal cord compression most common in the spine?

thoracic spine

How well did you know this?

Not at all

Perfectly

sx’s of acute spinal cord compression

localized back pain +/- tenderness (may be absent with lymphomas)
paraparesis/paraplegia
distal sensory deficits
gait disturbance
urinary incontinence

How well did you know this?

Not at all

Perfectly

what is the dx study of choice for acute spinal cord compression?

MRI

How well did you know this?

Not at all

Perfectly

what other dx imaging can you get for acute spinal cord compression?

cervical, thoracic, or lumbar spine films (but neg films don’t rule out SCC)

radionuclide bone scan (>90% sensitivity, except for multiple myeloma)

How well did you know this?

Not at all

Perfectly

dx studies for acute spinal cord compression should be done how soon and with early involvement of who?

should be in emergent time frame with early involvement of consultant (ex: neuro, radiation, etc)

How well did you know this?

Not at all

Perfectly

acute spinal cord compression tx

spine immobilization
Foley catheter (for urinary incontinence)
IV steroids (Decadron)/diuretic/mannitol (decreased CSF pressure)
emergency decompressive laminectomy or radiation rx

How well did you know this?

Not at all

Perfectly

what IV steroid is given for tx of acute spinal cord compression?

Decadron aka dexamethasone

-decreases swelling of tumor

How well did you know this?

Not at all

Perfectly

what do you never want to give to someone with acute spinal cord compression? why?

bisphosphonates - b/c will bind to Ca and mess up kidney -> won’t help the spinal cord compression

How well did you know this?

Not at all

Perfectly

what is key in tx of acute spinal cord compression? what does it do?

radiation - shrinks the tumor pressing on the cord

How well did you know this?

Not at all

Perfectly

what are the 2 most common types of hypercalcemia of malignancy?

Humoral Hypercalcemia of Malignancy (via PTHrP - allows too much Ca to be in blood)

Local Bone Destruction

How well did you know this?

Not at all

Perfectly

sx’s of hypercalcemia of malignancy?

MOANS, GROANS, STONES, PSYCHIATRIC UNDERTONES

lethargy/confusion
constipation
back pain (b/c destruction of vertebrae)

How well did you know this?

Not at all

Perfectly

hypercalcemia of malignancy dx

total and ionized Ca (need albumin to calculate corrected Ca)
check Cr, electrolytes, all phos

How well did you know this?

Not at all

Perfectly

low level of what can indicate hypercalcemia of malignancy?

low serum Cl-

what does EKG in hypercalcemia show?

short QT intervals, low voltage, and long PR intervals

work-up for what in hypercalcemia?

skeletal lesions

what level of serum Ca is considered dangerous?

>12

what needs to be given immediately to pts with hypercalcemia?

HYDRATION - IV FLUIDS -> TO PEE OUT THE CA -Normal Saline is of choice

what IV fluid is of choice for hypercalcemia tx?

normal saline

once pt with hypercalcemia is euvolemic give them what for tx? avoid what?

IV loop diuretics AVOID thiazides - cause hypercalcemia

what diuretics to avoid in hypercalcemia?

thiazides b/c cause hypercalcemia

other meds for tx of hypercalcemia?

bisphosphonates | -Pamindronate, Zoledronic acid (don't use in renal failure), Denosumab

what should you D/C in hypercalcemia?

Ca, Vit D, thiazides, and NSAIDs | -Example: tums (have a lot of Ca)

how do bisphosphonates work?

block osteoclastic bone resorption

injection of what that lowers serum Ca levels for tx of hypercalcemia?

SubQ or IM Calcitonin (lower serum Ca levels)

what rate of voiding do you want to aim for when treating pt with hypercalcemia with IVF?

150-200cc/hr

when would hypercalcemic pt go on dialysis?

pt with renal or heart failure not life-long, just for acute episode used b/c fluid will start to back up -> CHF

what to AVOID in hypercalcemia?

PO Phosphate

what is febrile neutropenia defined as?

single oral temp >101.3 F sustained temp >100.4 for 1 hr ANC <1000

how to calculate ANC?

ANC = [(WBC)(%Neut + % Bands)]x10 ANC from absolute number is: ANC = (absolute polys + absolute bands)(1000)

normal ANC?

>1000

severe neutropenia ANC?

<500

when is febrile neutropenia most commonly seen?

during Nadir after chemotherapy

what is Nadir?

when give chemo and when counts hit rock bottom (drop in the counts)

when does Nadir occur and how long does it last?

5-10 days after the last dose of chemo and lasts for about 5 days

febrile neutropenia sx's?

ranges from asymptomatic to severe sepsis atypical presentation - UTI pt w/out pyuria

what must you pay special attention to with febrile neutropenia?

to the skin, oral cavity, perianal area, catheters

avoid what if pt has febrile neutropenia?

sticking fingers in holes b/c don't want to introduce bacteria into their blood since already neutropenic

labs for febrile neutropenia?

CBC, blood Cx (x2), urine cx, sputum cx and stain stool, CSF cx if indicated (if no diarrhea then no stool sample)

CXR may be what in febrile neutropenia?

normal

consider what dx tool in febrile neutropenia if respiratory complaints?

what should all febrile neutropenic pts receive upon presentation?

ANTIBIOTICS - VANCOMYCIN AND CEFEPIME

what is the goal time of getting febrile neutropenic pts abx when they present?

<1 hr from door to abx

what abx do you use for febrile neutropenia?

Vancomycin and cefepime

should febrile neutropenia be admitted?

YES!!! - if pt on chemo presents with fever, ADMIT THEM!!!

if febrile neutropenic pt has been vomiting what do you want to cover for and what abx to give them?

cover for anaerobes give Flagyl

if persistent febrile neutropenia (>72 hrs), what meds do you give?

anti-fungals fluconazole, ketoconazole

what else may febrile neutropenic pts have in addition to neutropenia?

bacteremia

Neutropenia + Bacteremia is what?

a true medical emergency b/c short-term mortality

risk of infection if neutropenic increases with what?

- duration of neutropenia - severity of ANC <100 - comorbidities - central lines - hepatic or renal insufficiency

what is G-CSF? what does it do?

Granulocyte Colony Stimulating Factor speeds up resolution of neutropenia (stimulates production or neutrophils)

when to use G-CSF for febrile neutropenia?

- profound neutropenia, shock, co-morbidities - worsening clinical course and expected prolonged neutropenia - pt not responding to abx

in what time frame is G-CSF given after chemo?

given 48hrs after starting chemo

how long does it take G-CSF to work? how long do you have to wait to give it again?

works in 5-7 days must wait 7-14 days to give it again

if pts neutrophil counts are not recovering and expect them to have a prolonged neutropenia, what do you give them?

G-CSF

if neutropenic pt is afebrile, how do you treat them?

- continue initial abx until blood cx available, then adjust abx based on culture/sensitivities - treat for 5-7 days of IV and consider PO if ANC >1000

need to be sure what is negative before discharge neutropenic pt?

that cultures are negative

if neutropenic pt is febrile after 4 days of abx treatment how do you treat them?

anti fungal - ketokonazole or fluconazole

when can a febrile neutropenic pt be discharged home?

if ANC has recovered (>1000), afebrile for 24hrs, and cx negative

what is tumor lysis syndrome?

metabolic complications which occur after tx of bulky chemo-responsive malignancies

metabolic complications that occur in tumor lysis syndrome?

- hyperphosphatemia - hypocalcemia - hyperkalemia - hyperuricemia -also acute renal failure

when does tumor lysis syndrome occur?

6-72hrs after initiation of chemo rx or radiation rx

what is tumor lysis syndrome due to?

rapid release of cell contents into bloodstream after chemo or radiation

etiologic factors of tumor lysis syndrome?

large tumor burden, high growth fraction, high preRx serum LDH or uric acid, pre-existing renal insufficiency

main life-threatening problems of tumor lysis syndrome?

- hyperkalemia - hyperuricemia - hyperphosphatemia with secondary hypocalcemia - can result in acute renal failure and arrhythmias

tx for tumor lysis syndrome?

STOP THE CHEMO - HOLD ANY FURTHER LYSIS Aggressive IV hydration NS/diuresis +/- alkalinize urine to pH7 with bicarb (NaHCO3) CaCl2, NaHCO3, glucose/insulin, kayexalate for hyperkalemia emergency hemodialysis Rasburicase

treating tumor lysis syndrome pt with bicarb does what?

alkalinizes the urine to pH7 -decreases uric acid, but may worsen hypocalcemia tetany

what to give hyperkalemic pt?

CaCl2, NaHCO3, glucose/insulin, kayexalate

emergency dialysis for tumor lysis syndrome when?

if K > 6, uric acid > 10, Cr >10, or unable to tolerate diuresis

when is allopurinol used in tumor lysis syndrome?

for prevention pre and post chemo

what is rasburicase and when is it used?

used in tumor lysis syndrome -very expensive med that can rapidly degrade uric acid so you pee it out immediately

other etiology of malignant pericardial tamponade besides tumors?

radiation pericarditis

signs and sx's of malignant pericardial tamponade?

- hypotension/narrow pulse pressure - dyspnea - JVD - muffled heart tones - pulsus paradoxical >10mmHg

heart tones in malignant pericardial tamponade?

muffled heart tones

what is the EKG like for malignant pericardial tamponade?

low QRS voltage +/- pulses alternans

dx of malignant pericardial tamponade

echocardiography

what can occur in malignant pericardial tamponade?

a pericardial effusion

malignant pericardial tamponade tx

needle catheter pericardialcentesis, pericardial window, radiation, pericardiectomy

what chemo can you add for malignant pericardial tamponade?

intrapericardial chemo or sclerosis | -add if fluid keeps building up in the heart

normal ANC range

1500-8000