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NUR2790 (Exam #1) > Oncological Emergencies COPY > Flashcards

Oncological Emergencies COPY Flashcards

1
Q

How are most chemo regimens delivered?

A

On a 3 weekly basis

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2
Q

What is the most common side effect of chemo?

A

Neutropenia

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3
Q

When does neutropenia tend to occur during chemo?

A

Around day 7-14 of each 3 weekly cycle

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4
Q

What is the normal neutrophil count?

A

> 1.5x10^9

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5
Q

At what neutrophil level is there an increased risk of infection?

A

<1x10^9

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6
Q

Noting the risk of neutropenia that comes along with chemo, what should you advise patients?

A

To monitor for symptoms of infection, e.g. flu like symptoms, fevers, or focal infections (UTI, sore throat etc.)

Advise to monitor temp, and medical assessment is req. if 1 recording >38.5/<36C or 2 recordings >38C 2 hours apart

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7
Q

What are the criteria for diagnosis of neutropenic fever?

A

A. febrile
B. neutropenia <1x10^9
C. no haemodynamic compromise

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8
Q

Define neutropenic sepsis

A

Evidence of sepsis (hypotension, tachycardia…) + neutrophils <1x10^9 with or without fever

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9
Q

What are the most common microbes causing neutropenic sepsis?

A

85% endogenous flora (e.g. gut, biliary tract, urinary tract)
75% gram -ve bacilli
Fungal infections in prolonged neutropenia (esp. haematological malignancies)

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10
Q

What symptoms might patients with neutropenic sepsis describe?

A 
Anorexia
Malaise
Lethargy 
Sweats
Fevers, rigors, chills
Symptoms related to site of infection
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11
Q

What should you ask in your history if you suspect neutropenic sepsis?

A

Symptoms related to chest infections, GI tract, urinary tract, CNS infections, skin infections, abscesses, sore throat, recent interventions (e.g. dental work)

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12
Q

What should you do in your examination if you suspect neutropenic sepsis?

A 
Temperature
Pulse
BP
O2 sats
RR
Full ex
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13
Q

What investigations should you do if you suspect neutropenic sepsis?

A 
FBC, UE, LFTs, bone profile, CRP
Coagulation screen if DIC suspected
Blood cultures
MSSU
Stool culture if diarrhoea
Throat swab, sputum culture, skin swabs if appropriate
CXR
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14
Q

How do you manage neutropenic sepsis?

A

Supportive care, e.g. fluids, O2 if indicated
Broad spectrum antibiotics - tazocin 4.5g IV 6hrly + gentamicin 7mg/kg IV
Consider G-CSF to boost neutrophil count

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15
Q

What alternative antibiotic can you give for penicillin allergy for neutropenic sepsis?

A

Ceftazidime + gentamicin if mild

Vancomycin + gentamicin +/- metronidazole if severe

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16
Q

What two things is tazocin?

A

Pipercillin + tazobactam

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17
Q

What monitoring should be done in neutropenic sepsis?

A

Temp, pulse, BP, O2 sats
UO
Check for positive cultures, optimise antibiotic therapy
FBC, UE, CRP daily

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18
Q

When should you switch to stage 2 antibiotics in neutropenic sepsis?

A

If patient remains febrile after 48h of stage 1 antibiotics

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19
Q

What is stage 1 antibiotics?

A

Tazocin

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20
Q

What is stage 2 antibiotics?

A

Meropenem 1g IV 8hrly

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21
Q

When can you switch to oral antibiotics in neutropenic sepsis?

A

After completion of antibiotic course (3d IV) if improving + no longer neutropenic can swap to oral ciprofloxacin (unless culture suggests something else may be better)

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22
Q

In which cancers is malignant spinal cord compression most commonly seen?

A

In cancers which typically spread to bone (breast, carcinoma of bronchus, prostate, myeloma, renal)

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23
Q

What may cause MSCC?

A

Vertebral collapse

Extradural metastases

24
Q

Where is the commonest site of MSCC?

A

Thoracic spine

25
Q

What are the typical features of MSCC?

A

Pain
Sensory/motor symptoms - e.g. weakness/sensory loss
Autonomic symptoms, e.g. urinary incontinence/retention, faecal incontinence
Spinal tenderness
UMN findings
Reduced anal tone

26
Q

What are the typical features of pain due to MSCC?

A

Thoracic, radicular in distribution (i.e. radiation along dermatome), worsening over weeks/months, worse with cough, sneezing, wt bearing

27
Q

Give examples of UMN findings

A

Hypertonia
Hyper-reflexia
Clonus
Upgoing plantars

28
Q

How might sensory disturbances present in MSCC?

A

Loss of sensation below dermatomal level of compression

29
Q

What is the gold standard investigation for suspected MSCC?

A

MRI spine (allows diagnosis, confirms level of compression, allows safety assessment)

30
Q

Why might someone need a CT to diagnose MSCC?

A

If MRI is CI (e.g. pacemaker)

If no prev. diagnosis of cancer, to identify a primary site

31
Q

What other investigation should you do in MSCC?

A

Serum Ca

32
Q

How do you manage MSCC?

A 
Supportive
Steroids
Surgery 
Radiotherapy
Chemotherapy
33
Q

What supportive measures should be put in place for MSCC?

A

Keep patient lying flat until stability of spine determined
Urinary catheter if in retention
Monitor bowel function + commence bowel regimen if req. (e.g. laxatives/enemas)
Physio
Prophylactic dalteparin if bed bound

34
Q

What steroid + dose should be used for MSCC?

A

Dexamethasone 8mg bd oral

35
Q

Why are steroids used in MSCC?

A

To reduce swelling around lesion

36
Q

What should be prescribed along with a steroid and what extra investigations should be done while a patient is on steroids for MSCC?

A

Gastroprotection, e.g. omeprazole

Daily BG measurements

37
Q

What is the best treatment for MSCC?

A

Surgery followed by radiotherapy

38
Q

When is surgery preferred for MSCC?

A

If fit, no volume met disease, life expectancy >3m
Isolated posterior cord compression
Good sensory/motor function prior to episode
No prior hx of cancer
Remainder of spine is sufficiently strong to allow stabilisation

39
Q

When should surgery be avoided in MSCC?

A

Frailer patients with lots of mets + poor mobility

Anterior compression

40
Q

What should be given to treat MSCC if the patient cannot have surgery?

A

Radiotherapy alone

41
Q

How is radiotherapy given for MSCC?

A

Targeted at level of spinal cord compression

4 fractions given over 4 consecutive days

42
Q

When might chemo be used for MSCC?

A

If primary tumour is highly chemosensitive, e.g. lymphoma/germ cell tumours
Surgery/RT CI

43
Q

What are the most common malignant causes of SVCO?

A 
Bronchogenic carcinoma (usually small cell) 
Lymphoma
Metastatic tumours, e.g. renal cancer, germ cell
44
Q

What are some rarer benign causes of SVCO?

A

SVC thrombosis

Mediastinal fibrosis

45
Q

What is a typical history of SVCO?

A

Facial swelling/fullness of head
Arm swelling
Dysphagia, dyspnoea

46
Q

What might you find on examination in SVCO?

A 
Distention of neck/chest wall veins
Fixed (i.e. non pulsatile), elevated JVP
Facial oedema/puffiness
Oedema of arms
Plethora of face
Peripheral cyanosis
47
Q

What investigations should be done in suspected SVCO?

A

CXR
CT
Superior venocavogram
Bronchoscopy if lung primary suspected

48
Q

What is involved in the management of SVCO?

A 
Steroids, supportive
Radiotherapy
Chemo
Stenting of SVC
Thrombolysis + anticoagulation if SVCO due to thrombosis
49
Q

What steroids should be given for SVCO and what dose?

A

Dexamethasone 8mg bd with gastroprotection and daily BMs

50
Q

What advice should you give to patients with SVCO re. their position in bed?

A

Sit up - oedema worse when lying flat

51
Q

What is the definitive Rx for SVCO?

A

Chemo/radio depending on tumour

52
Q

How do you manage catheter induced SVC?

A

Remove catheter
Thrombolysis
Anticoagulation

53
Q

What is the normal serum Ca level?

A

2.2-2.6mmol/L

54
Q

What causes hypercalcaemia in malignancy?

A

Bone mets

Para-neoplastic syndrome - production of PTH-rp

55
Q

What cancers most commonly produce PTH-rp?

A

Squamous cancers

HTLV-1 related T cell lymphomas

56
Q

What are the clinical features of hypercalcaemia?

A

Osmotic features - dehydration (polydipsia, polyuria)
Cognitive impairment, lethargy, fatigue, psychosis
Constipation, NV
Renal failure
Cardiac arrhythmias

57
Q

How should you manage hypercalcaemia in malignancy?

A

Check PTH (PTH suppressed if PTH-rp producing tumour)
Rehydration (saline)
Bisphosphonates (zoledronic acid)

Rarely: Calcitonin, Steroids

NUR2790 (Exam #1) (17 decks)

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