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Clinical Therapeutics 2 > Oncologic Emergencies - Exam 1 > Flashcards

Oncologic Emergencies - Exam 1 Flashcards

1
Q

what catheter can cause SVC syndrome?

A

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

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2
Q

what is SVC syndrome?

A

compression of the SVC

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3
Q

SVC syndrome sx’s

A

-dyspnea, cough, orthopnea

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4
Q

SVC syndrome signs

A

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

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5
Q

what sign of SVC syndrome represents a true emergency?

A

Papilledema (means more severe case of SVC syndrome)

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6
Q

SVC syndrome dx

A

CXR

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7
Q

confirm SVC syndrome with what test?

A

Chest CT with contrast

MRI

Contrast venography

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8
Q

SVC syndrome treatment

A
  • 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
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9
Q

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

A

anticoagulants or thrombolytics (heparin drip)

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10
Q

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

A

epidural abscess/hematoma

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11
Q

what must be evaluated urgently in acute spinal cord compression?

A

neuro status - as to predict the functional outcome

-a lot of neuro deficits are not reversible

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12
Q

what does acute spinal cord compression usually result from?

A

extension of spinal bony metastases

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13
Q

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

A

thoracic spine

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14
Q

sx’s of acute spinal cord compression

A
  • localized back pain +/- tenderness (may be absent with lymphomas)
  • paraparesis/paraplegia
  • distal sensory deficits
  • gait disturbance
  • urinary incontinence
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15
Q

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

A

MRI

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16
Q

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

A

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

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

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17
Q

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

A

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

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18
Q

acute spinal cord compression tx

A
  • spine immobilization
  • Foley catheter (for urinary incontinence)
  • IV steroids (Decadron)/diuretic/mannitol (decreased CSF pressure)
  • emergency decompressive laminectomy or radiation rx
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19
Q

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

A

Decadron aka dexamethasone

-decreases swelling of tumor

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20
Q

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

A

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

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21
Q

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

A

radiation - shrinks the tumor pressing on the cord

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22
Q

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

A

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

Local Bone Destruction

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23
Q

sx’s of hypercalcemia of malignancy?

A

MOANS, GROANS, STONES, PSYCHIATRIC UNDERTONES

  • lethargy/confusion
  • constipation
  • back pain (b/c destruction of vertebrae)
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24
Q

hypercalcemia of malignancy dx

A
  • total and ionized Ca (need albumin to calculate corrected Ca)
  • check Cr, electrolytes, all phos
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25
Q

low level of what can indicate hypercalcemia of malignancy?

A

low serum Cl-

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26
Q

what does EKG in hypercalcemia show?

A

short QT intervals, low voltage, and long PR intervals

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27
Q

work-up for what in hypercalcemia?

A

skeletal lesions

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28
Q

what level of serum Ca is considered dangerous?

A

> 12

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29
Q

what needs to be given immediately to pts with hypercalcemia?

A

HYDRATION - IV FLUIDS -> TO PEE OUT THE CA

-Normal Saline is of choice

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30
Q

what IV fluid is of choice for hypercalcemia tx?

A

normal saline

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31
Q

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

A

IV loop diuretics

AVOID thiazides - cause hypercalcemia

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32
Q

what diuretics to avoid in hypercalcemia?

A

thiazides b/c cause hypercalcemia

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33
Q

other meds for tx of hypercalcemia?

A

bisphosphonates

-Pamindronate, Zoledronic acid (don’t use in renal failure), Denosumab

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34
Q

what should you D/C in hypercalcemia?

A

Ca, Vit D, thiazides, and NSAIDs

-Example: tums (have a lot of Ca)

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35
Q

how do bisphosphonates work?

A

block osteoclastic bone resorption

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36
Q

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

A

SubQ or IM Calcitonin (lower serum Ca levels)

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37
Q

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

A

150-200cc/hr

38
Q

when would hypercalcemic pt go on dialysis?

A

pt with renal or heart failure

not life-long, just for acute episode

used b/c fluid will start to back up -> CHF

39
Q

what to AVOID in hypercalcemia?

A

PO Phosphate

40
Q

what is febrile neutropenia defined as?

A

single oral temp >101.3 F

sustained temp >100.4 for 1 hr

ANC <1000

41
Q

how to calculate ANC?

A

ANC = [(WBC)(%Neut + % Bands)]x10

ANC from absolute number is:

ANC = (absolute polys + absolute bands)(1000)

42
Q

normal ANC?

A

> 1000

43
Q

severe neutropenia ANC?

A

<500

44
Q

when is febrile neutropenia most commonly seen?

A

during Nadir after chemotherapy

45
Q

what is Nadir?

A

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

46
Q

when does Nadir occur and how long does it last?

A

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

47
Q

febrile neutropenia sx’s?

A

ranges from asymptomatic to severe sepsis

atypical presentation - UTI pt w/out pyuria

48
Q

what must you pay special attention to with febrile neutropenia?

A

to the skin, oral cavity, perianal area, catheters

49
Q

avoid what if pt has febrile neutropenia?

A

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

50
Q

labs for febrile neutropenia?

A

CBC, blood Cx (x2), urine cx, sputum cx and stain

stool, CSF cx if indicated (if no diarrhea then no stool sample)

51
Q

CXR may be what in febrile neutropenia?

A

normal

52
Q

consider what dx tool in febrile neutropenia if respiratory complaints?

A

CT

53
Q

what should all febrile neutropenic pts receive upon presentation?

A

ANTIBIOTICS - VANCOMYCIN AND CEFEPIME

54
Q

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

A

<1 hr from door to abx

55
Q

what abx do you use for febrile neutropenia?

A

Vancomycin and cefepime

56
Q

should febrile neutropenia be admitted?

A

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

57
Q

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

A

cover for anaerobes

give Flagyl

58
Q

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

A

anti-fungals

fluconazole, ketoconazole

59
Q

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

A

bacteremia

60
Q

Neutropenia + Bacteremia is what?

A

a true medical emergency b/c short-term mortality

61
Q

risk of infection if neutropenic increases with what?

A
  • duration of neutropenia
  • severity of ANC <100
  • comorbidities
  • central lines
  • hepatic or renal insufficiency
62
Q

what is G-CSF? what does it do?

A

Granulocyte Colony Stimulating Factor

speeds up resolution of neutropenia (stimulates production or neutrophils)

63
Q

when to use G-CSF for febrile neutropenia?

A
  • profound neutropenia, shock, co-morbidities
  • worsening clinical course and expected prolonged neutropenia
  • pt not responding to abx
64
Q

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

A

given 48hrs after starting chemo

65
Q

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

A

works in 5-7 days

must wait 7-14 days to give it again

66
Q

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

A

G-CSF

67
Q

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

A
  • 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
68
Q

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

A

that cultures are negative

69
Q

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

A

anti fungal - ketokonazole or fluconazole

70
Q

when can a febrile neutropenic pt be discharged home?

A

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

71
Q

what is tumor lysis syndrome?

A

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

72
Q

metabolic complications that occur in tumor lysis syndrome?

A
  • hyperphosphatemia
  • hypocalcemia
  • hyperkalemia
  • hyperuricemia

-also acute renal failure

73
Q

when does tumor lysis syndrome occur?

A

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

74
Q

what is tumor lysis syndrome due to?

A

rapid release of cell contents into bloodstream after chemo or radiation

75
Q

etiologic factors of tumor lysis syndrome?

A

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

76
Q

main life-threatening problems of tumor lysis syndrome?

A
  • hyperkalemia
  • hyperuricemia
  • hyperphosphatemia with secondary hypocalcemia
  • can result in acute renal failure and arrhythmias
77
Q

tx for tumor lysis syndrome?

A

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

78
Q

treating tumor lysis syndrome pt with bicarb does what?

A

alkalinizes the urine to pH7

-decreases uric acid, but may worsen hypocalcemia tetany

79
Q

what to give hyperkalemic pt?

A

CaCl2, NaHCO3, glucose/insulin, kayexalate

80
Q

emergency dialysis for tumor lysis syndrome when?

A

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

81
Q

when is allopurinol used in tumor lysis syndrome?

A

for prevention pre and post chemo

82
Q

what is rasburicase and when is it used?

A

used in tumor lysis syndrome

-very expensive med that can rapidly degrade uric acid so you pee it out immediately

83
Q

other etiology of malignant pericardial tamponade besides tumors?

A

radiation pericarditis

84
Q

signs and sx’s of malignant pericardial tamponade?

A
  • hypotension/narrow pulse pressure
  • dyspnea
  • JVD
  • muffled heart tones
  • pulsus paradoxical >10mmHg
85
Q

heart tones in malignant pericardial tamponade?

A

muffled heart tones

86
Q

what is the EKG like for malignant pericardial tamponade?

A

low QRS voltage +/- pulses alternans

87
Q

dx of malignant pericardial tamponade

A

echocardiography

88
Q

what can occur in malignant pericardial tamponade?

A

a pericardial effusion

89
Q

malignant pericardial tamponade tx

A

needle catheter pericardialcentesis, pericardial window, radiation, pericardiectomy

90
Q

what chemo can you add for malignant pericardial tamponade?

A

intrapericardial chemo or sclerosis

-add if fluid keeps building up in the heart

91
Q

normal ANC range

A

1500-8000

Clinical Therapeutics 2 (11 decks)

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