Oncology Emergencies Flashcards
Define neutropenic sepsis?
Fever of >38 or features of sepsis in a patient with a neutrophil count <0.5 x10 ^9/L
What are the severities of neutropenia?
General neutropenia = absolute neutrophil count <1.5
Severe neutropenia = ANC <0.5
What are some of the clinical features of neutropenic sepsis?
- Temp >38 or <36
- Acute confusion
- HR >90
- RR >20
- BP <90 mmHg
- Urine output <0.5ml/kg/hour
- Other specific features of infection; cough, dysuria
- non specific generally unwell
What investigations would you do for suspected neutropenic sepsis
- ABG (lactate)
- Bloods: FBC for neutrophils, LFT, U&E, CRP
- Blood culture
- Culture of any lines
- Urine culture
- Sputum MC+S
- Stool MC+S
- Wound swab
- CXR
How do you manage neutropenic sepsis?
- Blood Cultures
- Lactate
- High flow oxygen
- IV fluids 0.9% saline over 15 mins
- Antibiotics
- Monitor urine output
What is the antibiotic of choice in managing neutropenic sepsis?
Empirical penicillin/ Tazobactam (Tazocin) 4.5g TDS for minimum of 5 days
What is the antibiotic of choice in managing neutropenic sepsis if patient is penicillin allergic?
Meropenem 1g TDS
Consult local micro
What is the MASCC risk index?
A scoring system for helping decide management of neutropenic sepsis patients
Score >21 = low risk, consider outpatient management with oral antibiotics
Score <21 = high risk, inpatient management and IV abx
What is tumour lysis syndrome?
A metabolic disruption arising from the breakdown of malignant cells
Can occur with any tumour but higher risk with haematological malignancies
What metabolic disturbances do you see in tumour lysis syndrome?
Hyperkalaemia
Hyperphosphateaemia
Hypocalcaemia
Hyperuricaemia
What are some of the consequence of metabolic disturbance in tumour lysis?
- AKI
- Arrhythmia
- Sudden death
What are some of the risk factors associated with a high risk of tumour lysis syndrome?
- High proliferation rate of tumour
- Chemosensitivity
- Large tumour burden
- Pre-existing metabolic disturbance
- Renal impairment
What are some of the signs and symptoms of tumour lysis syndrome?
- lethargy
- syncope
- N&V
- diarrhoea
- Anorexia
- Muscle cramps/ weakness
- Pruritis
- seizures
- dysrhythmia
- fluid overload
- cardiac arrest
- bronchospasm (wheeze)
- Tetany and Paraesthesia
- Haematuria
What investigations would you do for suspected tumour lysis syndrome?
- U&E
- Serum urate
- ECG
- Cardiac monitoring
- LDH
- lactate
- urine microscopy
What is the name of the definition system for determining tumour lysis syndrome?
Cairo- Bishop Definition
Splits into clinical and lab diagnosis
What Lab values are needed to diagnose tumour lysis syndrome?
2 or more of within 7 days of treatment:
- Uric acid >476 or 25% increase
- K of >6 or 25% increase
- Phosphate of >1.45 or 25% increase
- Calcium of <1.75 or 25% decrease
What clinical diagnosis of the cairo- bishop score is needed to diagnose tumour lysis?
Presence of 1 of the following that cannot be attributed to a therapeutic agent:
- Serum creatinine >1.5 x upper limit of normal
- Cardiac arrhythmia / sudden death
- Seizure
What urate lowering agents are used in treatment of tumour lysis syndrome?
Allopurinol - Prevents conversion of hypoxanthine to uric acid (but does not act on pre-existing uric acid)
Rasburicase - recombinant urate oxidase, metabolises uric acid –> allatonin
Can be used as prophylaxis and treatment
What is rasburicase contraindicated in?
G6PD deficiency
Aside from urate lowering agents, how is tumour lysis treated?
- Hyperphosphateaemia: hydrate, diet restriction, phosphate binders in severe cases
- Hyperkalaemia: ECG monitor and calcium gluconate, insulin/ dextrose and nebuliser salbutamol
- Hypocalcaemia: - only treat if symptomatic as may cause calcium deposits in kidneys- treated with calcium gluconate
Which malignancies most commonly cause SVCO?
- Lung , NSCLC most common
- Non Hodgkin’s lymphoma (due to mediastinal nodes)
What 4 collateral systems develop in SVCO?
- Azygous
- Internal mammory
- Long thoracic (femoral and vertebral)
What are the clinical features of SVCO?
- Pemberton’s sign +
- Blurred vision
- Headache
- Oedema of upper limb
- Engorged veins in neck and chest wall
- Chest pain
- Dyspnoea
- Cough
- Cyanosis
- Confusion
- Coma
How is SVCO investigated?
- CXR - 80% show abnormality and helps rule out other causes
- Contrast enhanced CT makes definite diagnosis
- Duplex USS used in patients with indwelling catheter
What is the general management of SVCO?
Conservative: elevate bed, O2 sats optimised
Stenting
Radiotherapy
Chemotherapy
What is the emergency management of SVCO? (rare)
Only if causing respiratory distress or cerebral oedema
- consider steroids and diuretics
- definitive management is end-vascular stunting, shunt or thrombolysis
What is the significant in terms of outlook for patients SVCO?
Negative prognostic factor
Average 6 months life expectancy
Short term relief of symptoms is mainstay
Define spinal cord compression
Radiological evidence of indentation of the thecae sac secondary to cancer
Thecae sac = component of dura mater
Which cancers most commonly cause spinal cord compression?
Lung Breast Kidney Thyroid Prostate
Where do most spinal cord compressions occur?
60% thoracic
30% lumbar
10% cervical
What are the clinical features of spinal cord compression?
- Pain (95% cases) usually prices neurological symptoms by several werks
- Weakness - 85% cases, typically symmetrical, progressive
- Hyperreflexia if UMN involved
- Paraesthesia
How would you investigate/ diagnose malignant spinal cord compression?
MRI investigation of choice
How do you manage malignant spinal cord compression?
- Surgical Emergency
- 16mg stat of dexamethasone + PPI (avoid after midday)
- Monitor BMs (due to steroids)
- Analgesia
- VTE prophylaxis
- Bed rest with log rolls
What is the definitive management of malignant spinal cord compression?
- External beam radiotherapy (adjuvant or stand alone) for 5 consecutive days
- Stereotactic radiotherapy (high dose) in renal cell carcinoma or sarcoma
- Decompression and reconstruction or vertebroplasty surgery)
What level of serum calcium is classified is malignant hypercalcaemia?
> 2.6 mmol/L
What are the different severities of malignant hypercalcaemia?
Mild = 2.6-3.0 mmol/L Moderate = 3.0-3.5 mmol/L Severe = >3.6 mmol/L
What are the 3 main mechanisms that cause malignant hypercalcaemia?
Osteolytic metastasis (20% cases) most common in breast PTH related PTHrP secretion (80% cases) Increased 1,25 dihydroxyvitamin D production (leads to increased calcium absorption from GI enterocytes)
What are the clinical features of hypercalcaemia?
Stones: kidney and gallbladder Thrones: polyuria Bones: pain Groans: constipation and muscle weakness Psychiatric overtone: depression and confusion
What investigations do you do for suspected malignant hypercalcaemia?
Serum adjusted calcium
Confirm malignancy if diagnosis not already known: examination, CT, myeloma screen
How do you manage malignant hypercalcaemia
If mild: oral fluids
If moderate or severe:
- Admit
- IV hydration 3L of 0.9% NaCL over 24 hours
- Bisphosphonates (Pamidronate or Zoledronic acid) takes 2-4 days to start lowering calcium
What important consideration must you give when prescribing bisphosphonates for hypercalcaemia
Can be nephrotoxic
Need to hydrate well first with 3L of fluids
Give bisphosphonate in 4th bag
