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Cancer Care > Oncological emergencies > Flashcards

Oncological emergencies Flashcards

1
Q

what are oncological emergencies?

A

Group of conditions, that occur as a direct or indirect result of cancer or it’s treatment that are potentially life threatening

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2
Q

name some oncological emergencies

A

neutropenic sepsis

metastatic spinal cord compression

hypercalcaemia of malignancy

superior vena cava obstruction

tumour lysis syndrome

venous thromboembolism

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3
Q

what is the definition of neutropenic sepsis?

A
  • Patient undergoing systemic anticancer treatment (SACT)
  • Temp >38
  • Neutrophil count < 0.5 x 10 9 per litre

suspect in all chemo patients who become unwell as some chemo pt cannot mount a fever

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4
Q

neutropenic sepsis is a life threatening complication of chemotherapy. how many days after chemo does it typically present?

A

7-10 days post chemo

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5
Q

what are some signs and symptoms of neutropenic sepsis?

A
  • Fever
  • Tachycardia >90
  • HYPOTENSION < 90 systolic= URGENT
  • RR > 20
  • Symptoms related to a specific system e.g. cough, SOB, line, mucositis
  • Drowsy
  • Confused
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6
Q

what are some things that increase infection risk

A
  • prolonged neutropenia >7 days
  • severe neutropenia
  • significant comorbidities - COPD, DM, renal/hepatic impairment
  • aggressive cancer
  • central lines
  • mucosal disruption
  • hospital inpatient
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7
Q

what are some causes of neutropenia?

A

genetic - congenital neutropenia, chediak-Higashi syndrome

acquired - malignancy, infection, drugs, autoimmune

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8
Q

what microbes are most frequently isolated in neutropenic sepsis?

A

Staph aureus, staph epidermidis, enterococcus and streptococcus

source identified in only 20-30% of pt and blood cultures are often negative

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9
Q

what investigations can be done from neutropenic sepsis?

A

observations

bloods - VBG/ABG, FBE, CRP, U&Es, LFTs, bone profile, clotting, fungal assays, blood borne virus screen

cultures - anything that you suspect may be causing infection - blood, line, sputum, urine, stool, viral PCR, wound swabs

imaging - CXR, LP, ECHO

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10
Q

how is neutropenic sepsis managed?

A

sepsis 6 & senior input asap

IVabx - need to be given within 1 hour of presentation, give immediately

IVF

O2

blood cultures

urine output

lactate

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11
Q

what antibiotics are given in neutropenic sepsis?

A

empirical treatment with piperacillin/tazobactam - tazocin

meropenem in pen allergic - renal function

usually need 5/7 broad spec, may switch to oral after 48 hours if low risk

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12
Q

what antibiotics can be added if a patient has central venous access in neutropenic sepsis?

A

vancomycin

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13
Q

what is the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index?

A

way of risk stratifying patients with neutropenic sepsis

  • Low risk (≥ 21) - consider oral abx, out pt care
  • High risk (< 21) - IV abx, in pt mx
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14
Q

what is metastatic spinal cord compression and what causes it?

A

when dural sac and its contents are compressed at the level of the cord or cauda equina

80-85% caused by collapse of vertebral body that contains metastatic disease

10% by direct tumour extension into the epidural space

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15
Q

how does MSCC progress?

A

initially causes oedema, venous congestion and demyelination = REVERSIBLE

prolonged compression = vascular injury, cord necrosis, permanent damage

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16
Q

which cancers is MSCC most common in?

A

breast, prostate, lung = 60% of cases

also in lymphoma, myeloma, renal & thyroid

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17
Q

what is the most common location for MSCC

A

Thoracic

30-50% have > 1 area involved

(below L2 = cauda equina)

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18
Q

how does MSCC present?

A

pain - poorly responsive to analgesia, radiating round chest or down legs, worse after lying down

motor symptoms - reduced power, difficulty standing, walking, climbing stairs, often symmetrical

sensory loss

sphincter dysfunction - urinary hesitancy, frequency, urinary retention with overflow, faecal incontinence

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19
Q

what is seen on examination of MSCC?

A
20
Q

what is the imaging of choice for MSCC?

A

MRI

21
Q

how is MSCC managed?

A

analgesia - WHO ladder

VTE prophylaxis - LMWH, TEDs

catheter to manage bladder dysfunction

Dexamethasone - 16mg acutely (monitor glucose)

Radiotherapy

Surgery

22
Q

describe some indicators for surgery in MSCC

A

treatment of choice if fit and good prognosis

good motor function at presentation

good performance status

limited comorbidity

single level spinal disease

absence of visceral mets

long interval from primary diagnosis

biopsy

stabilisation

23
Q

describe radiotherapy for MSCC

A

used in the majority of cases - extensive disease and poor physiological reserve

delivered within 24 hour of confirmation

single posterior field, pt usually supine, targets abnormal area plus 1-2 vertebra either side

24
Q

describe some supportive care measures for MSCC

A

good nursing care - pressure areas, log rolling if unstable

analgesia

laxatives

bladder care

monitor BMs

VTE prophylaxis

physio

OT

25
Q

what is malignant hypercalcaemia?

A

serum calcium >2.6mmol/L secondary to a malignant process

26
Q

what cancers is malignant hypercalcaemia most common in

A

breast

scc

renal

myeloma

lymphoma

27
Q

what are the 2 broad causes of hypercalcaemia in malignancy?

A

humoural case in around 80% - chemical agents released by tumour that disrupt normal calcium homeostasis (PTH related protein, overproduction of vit D)

bone invasion in around 20% - osteolytic metastases with local release of cytokines - increased bone resorption and calcium release from bone

28
Q

what are the symptoms of hypercalcaemia?

A

stone, thrones, bones, abdominal groans and psychiatric moans

(renal stones, bone pain, polyuria, abdominal pain, psychiatric features)

29
Q

how can malignant causes for hypercalcaemia be distinguished from primary hyperparathyroidism?

A

malignant hypercalcaemia PTH will be suppressed

30
Q

how is malignant hypercalcaemia managed?

A

rehydration - usually at least 24 hours IVF

bisphosphonates - inhibits osteoclastic bone resorption (IV pamidronate or zolendronic acid)

calcitonin - promoting urinary calcium excretion and inhibits bone resorption

nice recommends admission for any pt with serum calcium >3mmol

31
Q

what is superior vena cava obstruction?

A

obstruction of blood flow through the SVC

compression or occlusion of the SVC

can be a first time presentation of an underlying cancer diagnosis

32
Q

what are the commonest causes of SVCO?

A

extrinsic compression - intrathoracic primary lung cancer or mesothelioma

can also be mediastinal lymph nodes, metastatic or lymphoma

33
Q

what are some signs and symptoms of SVCO?

A
  • Swelling of face, neck and upper limbs
  • Distended neck and chest veins
  • Shortness of breath and cyanosis
  • Stridor
  • Hoarse voice
  • Lethargy
  • Headache and confusion
  • Conjunctival swelling and blurred vision
  • Can → to laryngeal oedema, airway obstruction, cerebral oedema and death
34
Q

what is pembertons sign?

A

when elevating both arms above head for 1-2 minutes causes congestion, cyanosis or respiratory distress = increased venous return from upper extremities exacerbating obstruction

= positive

35
Q

how is SVCO managed?

A

sit upright/elevate head

oxygen

dexamethasone

pain relief

CXR and CT

36
Q

long term management of SVCO

A

endovascular stenting - percutaneoulsy inserted

thrombolysis - if venogram confirms presence of clot, usually combined with stent insertion

radiotherapy -

chemotherapy

37
Q

what is tumour lysis syndrome?

A

metabolic emergency that presents as severe electrolyte abnormalities

caused by rapid breakdown of large numbers of cancer cells and subsequent release of large amounts of intracellular content into the bloodstream - overwhelming normal homeostatic mechanisms

38
Q

how is tumour lysis syndrome defined/classified?

A

classified as laboratory TLS - defined as presence of 2 or more of the following metabolic abnormalities:

  • hyperuricaemia
  • hyperphosphataemia
  • hyperkalaemia
  • hypocalcaemia

or clinical TLS - defined as laboratory TLS with 1 or more of the following clinical manifestations:

  • AKI
  • cardiac arrhythmia
  • seizure
  • sudden death
39
Q

what cancers is TLS most commonly associated with?

A

Most commonly associated with highly proliferative, bulky, chemosensitive haematological malignancies, particularly high-grade B-cell lymphoid malignancies

however - seen in more other malignancies due to advances in cancer Tx

40
Q

what are 2 modifiable risk factors predisposing to TLS?

A

high serum creatinine ≥ 1.5 x upper limit of normal

dehydration

41
Q

what are some risk factors for tumour lysis syndrome?

A
  • High volume/bulky disease
  • Pre-treatment LDH high
  • High circulating WCC
  • Pre-existing renal dysfunction/ nephropathy
  • Pre-treatment hyperuricaemia
  • Hypovolemia
  • Pretreatment diuretic use
  • Urinary tract obstruction from tumour
42
Q

how does TLS present?

A
  • Normally day 3-7 post chemotherapy
  • Nausea and vomiting
  • Diarrhoea
  • Anorexia
  • Lethargy
  • Haematuria → oliguria → anuric
  • Fluid overload
  • Cardiac arrhythmia/arrest (peaked T waves, QTc derangement)
  • Muscle cramps/tetany/seizures
43
Q

investigations and there results are done in TLS?

A

serum uric acid - raised

serum phosphate - raised

potassium - raised

calcium - low

elevated WBC

lactate dehydrogenase - raised

serum creatinine - raised

serum urea - raised

ECG - may have an arrhythmia

44
Q

what ECG abnormalities may be seen in tumour lysis syndrome?

A

hyperkalaemia - peaked T waves, prolonged PR and QRS, flattening P waves

hypocalcaemia - QT prolongation may be seen, predisposes to ventricular arrhythmias

45
Q

how is tumour lysis syndrome managed?

A
  • hydration
  • allopurinol prophylaxis
  • rasburicase
  • dialysis
46
Q

what is the management of a cancer related VTE?

A

DOAC for at least 6 months

Cancer Care (11 decks)

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