Oncological Emergencies Flashcards
What are the 3 main criteria for diagnosing neutropenic sepsis?
Patient undergoing anticancer treatment
Neutrophils <0.5x10˄9/L
Temperature >38
How many days after chemotherapy does neutropenic sepsis tend to occur?
7-14 days
Give 4 risk factors for neutropenic sepsis
Active chemotherapy Extensive field radiotherapy Haematological malignancy Infection risk increased ie. increased exposure to pathogens Autoimmune predisposition
Give 3 examples of pathogens that commonly are the cause of neutropenic sepsis
80% are endogenous flora Staph. aureus Staph. epidermidis Enterococcus Streptococcus MRSA
How does neutropenic sepsis present?
Tachycardia Hypotension Tachypnoea Fever Drowsy Confused Sx related to site of infection eg. cough, painful line
What scoring system is used to score neutropenic sepsis?
MASCC
Score out of 26, if >21 then low risk
What investigations will be done for a patient with neutropenic sepsis?
FBC U+Es LFTs Lactate CRP Blood culture Urine culture Sputum culture Line/wound swab ABG Imaging --> CXr, AXr, CAP CT
How is neutropenic sepsis managed?
Empirical IV broad spectrum Abx within the hour –> Tazocin or Meropenem
IV fluids –> 0.9% saline 500ml over 1 hour
Catheterise
Escalate to senior
What other longer term management can be given to patients with neutropenic sepsis?
Granulocyte Colony Stimulating Factor (GCSF) makes bone marrow produce WBCs
How can neutropenic sepsis be prevented?
Patient education
Antibiotic prophylaxis
Decrease dose of further chemotherapy cycles
Describe the pathophysiology of metastatic spinal cord compression
Caused by the collapse or compression of a vertebral body that contains metastatic disease or the growth of a primary tumour. This results in compression of the spinal cord.
Over time this leads to vascular injury, cord necrosis and permanent damage .
Which cancers commonly metastasise to bone?
Breast Prostate Lung Myeloma Lymphoma
What are the clinical features of metastatic spinal cord compression?
Back pain --> radicular, prolonged, exacerbated by straight leg raise, coughing, sneezing or straining. Limb weakness Sensory loss (dermatomal) Bladder and anal sphincter dysfunction
Describe the features of cauda equina
Bilateral sciatica Impotence Bladder dysfunction Saddle anaesthesia Loss of anal tone Weakness of gluteal muscles
What is the main investigation needed in metastatic spinal cord compression?
MRI Spine within 24 hours
How is metastatic spinal cord compression managed conservatively?
Bed rest with log-rolling Bladder care Physiotherapy OT VTE prophylaxis
How is metastatic spinal cord compression managed medically?
Dexamethasone 16mg + PPI protection
Analgesia
Laxatives
How is metastatic spinal cord compression managed surgically?
Surgery –> relieves compression, removes tumour, stabilises spine
How is metastatic spinal cord compression managed palliatively?
Radiotherapy
What is the pathophysiology of superior vena cava obstruction?
Obstruction of blood through the SVC causing occlusion which leads to reduced venous return to the heart.
Give 2 causes of extrinsic superior vena cava obstruction?
Right sided lung tumour
Superior mediastinal lymphadenopathy –> lymphoma, thymoma, germ cell tumour
Give 2 causes of intrinsic superior vena cava obstruction?
Thrombosis
Foreign body (central venous catheter)
Tumour
Give 4 features of superior vena cava obstruction
Shortness of breath Swelling of face, neck and arm Choking sensation Headache Lethargy Cough Chest pain Dysphagia Distended neck and chest wall veins
What investigations are required in superior vena cava obstruction?
Chest x-ray
CT chest with contrast (urgent)
Angiography
How is acute superior vena cava obstruction managed?
Sit patient up
IV access
100% O2
Dexamethasone 8mg BD
How is stable superior vena cava obstruction managed?
Chemotherapy
Radiotherapy
Stent
What cancers are commonly associated with malignant hypercalcaemia?
Breast Squamous cell lung cancer Prostate Lymphoma Myeloma Leukaemias
What are the 3 main pathological mechanisms of malignant hypercalcaemia?
Tumour secretion of parathyroid hormone related peptide
Osteolytic metastases with local cytokine release
Tumour production of vitamin D metabolites
Give some clinical features of malignant hypercalcaemia
*Very non-specific* Fatigue Drowsiness Anorexia Dehydration Weakness Depression Seizures Nausea Vomiting Polyuria Postural hypotension Constipation
What investigations are required in diagnosing malignant hypercalcaemia?
FBC U+Es Ca2+ (corrected) PTH/PTHrP Phosphate Myeloma screen ECG
How is malignant hypercalcaemia managed?
Rehydration –> 0.9% saline 3-6L in 24 hours
Monitor U+Es
Bisphosphonates –> 30-60 mg Pamidronate IV over 24 hours
Treat underlying malignancy
Describe the pathophysiology of Tumour Lysis Syndrome
Massive lysis of rapidly proliferating tumour cells resulting in the release of intracellular contents into the circulation. Occurs 3-7 days after chemotherapy
What cancers are commonly associated with Tumour Lysis Syndrome?
High grade lymphoma ALL Myeloma Germ cell tumour Breast cancer
Give 5 metabolic abnormalities associated with Tumour Lysis Syndrome
Hyperuricemia Hyperkalemia Hyperphosphatemia Hypocalcaemia Hypomagnesaemia
Leads to metabolic acidosis
What 3 characteristics of a tumour are most likely to predispose to Tumour Lysis Syndrome?
Large tumour
Large tumour burden
High proliferation rate
Give 5 clinical features of Tumour Lysis Syndrome
N+V Diarrohea Flank pain Arrythmias Lethargy Confusion Haematuria Syncope Hallucinations Seizures Oedema Oliguria Coma Muscle cramps Heart failure Anorexia
What investigations will be carried out to diagnose Tumour Lysis Syndrome?
FBC U+Es Ca2+ Phosphate Magnesium Urate ABG ECG LDH --> tumour burden assessment
How is Tumour Lysis Syndrome managed?
Urgent correction of hyperkalaemia (with calcium gluconate, insulin)
Monitor fluid balance via U+Es
Need for haemodyalysis
How is Tumour Lysis Syndrome prevented?
Identify high risk patients early
Keep well hydrated
Low risk –> allopurinol 300mg PO od
High risk –> rasburicase 200 micrograms/kg OD
