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Y4 Cancer Care > Oncological emergencies > Flashcards

Oncological emergencies Flashcards

1
Q

What is the definition of neutropenic sepsis

A
  • pt undergoing systemic anticancer treatment
  • with a temp of >38
  • and neutrophil count of <0.5x10^9g/L
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2
Q

Describe the clinical features of neutropenic sepsis

A
  • variable depending on source- cough, sob, abdo pain, meningism, dysuria
  • may present generally unwell w/ reduced GCS, fever, confusion etc
  • often have tachycardia/ opnoea, hypotension
  • check indwelling catheters, central lines, skin wounds and mouth ulcers for source
  • staph a, staph e, enterococcus and strep are usual causes but 30% have no source identified
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3
Q

When are neutrophils lowest after chemotherapy (and so at highest risk of neutropenic sepsis)

A
  • 10-14 days post chemo

- important to consider in all that have had chemo in the last 6 weeks

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4
Q

What investigations should be done when neutropenic sepsis is suspected

A
  • FBC, U&E, LFT, lactate, CRP
  • Blood (central and peripheral), urine, sputum cultures
  • lines and wound swabs
  • ABG
  • CXR, AXR, CT/ MRI, LP if clinically indicated
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5
Q

Give 3 differentials for neutropenic sepsis

A
  • malignancy related fever
  • PE
  • chemo related fever
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6
Q

How should neutropenic sepsis be managed?

A
  • empiric IV abx within an hour- give piperacillin and tazobactam, dont wait for FBC to confirm neutropenia
  • fluid resus
  • consider catheter
  • may switch to oral abx after 48 hrs if low risk
  • consider granulocyte colony stimulating factor if profoundly septic/ neutropenic
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7
Q

How can neutropenic sepsis be avoided/ harm be reduced

A
  • written and oral pt info on when and how to contact 24hr specialist oncology advice and emergency care
  • antibiotic prophylaxis
  • dose reduction, prophylactic GCSF and stoppage of chemo may be considered
  • avoid IM injections
  • barrier nursing and strict handwashing when in pt
  • all pts get alert card
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8
Q

What cancers most commonly cause spinal cord compression

A
  • breast
  • prostate
  • lung
    account for 60% of cases
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9
Q

By what mechanism can cancer cause spinal cord compression

A
  • vertebral collapse
  • compression of vertebral body
  • only 10% caused by direct tumour extension into vertebral column
  • initially causes oedema, venous congestion and demyelination which is reversible, prolonged compression causes vascular injury, cord necrosis and permanent damage
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10
Q

Describe the clinical features of cord compression

A
  • 90% have back pain for a couple months before other symptoms
  • Pain is spinal or radicular pain exacerbated by SLR, cough, sneeze or straining, night pain, worry if thoracic or cervical
  • Most have limb weakness
  • Many have sensory level (not in CES)
  • Some have bladder and bowel dysfunction, saddle anaesthesia
  • Spasticity (increased tone, clonus, hyperreflexia) below MSCC
  • Plantar reflexes
  • Palpable bladder due to urinary retention
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11
Q

How should spinal cord compression be managed?

A
  • If pain suggestive of mets MRI within 1 week
  • If signs suggestive of MSCC MRI within 24 hrs
  • Admit
  • Bed rest with log rolling
  • Dexamethasone 16mg + PPI
  • Radiotherapy is commonly used to treat and must be given within 24hrs
  • Decompressive surgery is preferred if fit and good prognosis
  • Chemo is used rarely for cancers which are very responsive
  • If motor function hasn’t returned within 48hrs of treatment, it is unlikely to
  • Analgesia, laxatives, bladder care, BM monitoring, VTE prophylaxis, physio and OT all have a role also
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12
Q

Which cancers respond well to chemo, and so it can be used to treat MSSC

A
  • lymphoma
  • SCLC
  • teratoma
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13
Q

How can malignancy cause hypercalcaemia?

A
  • PTHrp production by tumour (usually lung, oesophagus, skin, cervix, breast, kidney)
  • Local osteolysis around mets due to cyotokine release eg with myeloma
  • Tumour production of calcitriol eg with lymphomas
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14
Q

Describe the clinical features of hypercalcaemia

A

(Decrease NMJ excitibility)

  • weakness, constipation
  • N+V
  • Anorexia
  • Thirsty
  • Polydipsia and polyurea
  • Fatigue and weakness
  • Confusion
  • Poor concentration
  • Drowsy
  • Seizure
  • Coma
  • stones
  • bone pain
  • arrhythmias- asytole
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15
Q

Describe the management of hypercalaemia

A
  • Aggressive rehydration for first 24 hrs
  • Bisphosphonates (IV zolendronic acid) can then be used but can cause renal failure so need to be properly rehydrated first and take up to a week to work
  • Denosumab can be used for refreactory hypercalcaemia
  • Definitive management is better systemic treatment of the malignancy
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16
Q

How can malignancy cause SVO obstruction?

A
  • 90% extrinsic compression from intrathoracic primary eg lung ca, mesothelioma or mediastinal lymphoma/ met
  • 5% due to occlusion of SVC by thrombus on central catheter
  • Rarely due to fibrosis from radiotherapy
17
Q

Describe the clinical features of SVCO

A
  • Breathlessness
  • Swelling of face and neck, trunk and arms
  • Chocking sensation
  • Fullness in head
  • Headache
  • Lethargy
  • Distended chest and neck veins
  • Chest pain, cough, dysphagia less common
18
Q

How should SVCO be investigated?

A
  • CXR

- CT contrast

19
Q

How should SVCO be managed?

A
  • sit up with high flow O2
  • 16mg IV dexamethasone (poor evidence but usually given anyway)
  • balloon valvuloplasty and SVC stenting if not radio or chemo sensitive or need rapid relief
20
Q

How is bowel obstruction managed?

A
  • drip and suck
  • give ++ fluids and stabilise as much as possible
  • emergency bowel resection and stoma creation
21
Q

What is tumour lysis syndrome?

A
  • massive tumour lysis leading to release of K=, phosphate and uric acid
  • leads to AKI from uric acid and calcium phosphate crystals in the renal tubules
  • and hypocalcaemia due to hyperphosphateaemia
22
Q

When does tumour lysis syndrome most commonly occur?

A
  • usually in haematolgical maligancies which respond very well to treatment- eg lymphoma, leukaemia, myeloma
  • renal disease, hypovolaemia, high LDH and uric acid pretreatment will predispose to it
23
Q

How does tumour lysis syndrome present?

A

3-7 days post chemo with N+V, diarrhoea, anorexia, lethargy, haematuria/ oliguria, heart failure and arrhythmias

24
Q

How can tumour lysis syndrome be prevented?

A
  • vigorous hydration before and during treatment
  • monitoring of electrolytes and and fluid balance
  • prophylactic rasburicase and allopurinol if high risk
25
Q

How is tumour lysis syndrome treated?

A
  • allopurinol and rasburicase used to reduce uric acid levels
  • dialysis if refractory
  • cardiac monitoring
  • calcium gluconate if hypoglycaemia

Y4 Cancer Care (6 decks)

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