Oncology emergencies Flashcards
Patient on chemotherapy with fever - what should you do?
admit urgently to hospital
IV antibiotic within 1 hour of getting to hospital
(treat as neutropenic sepsis until proven otherwise)
Neutropenic sepsis management
urgent hospital assessment
IV antibiotic within 1h of arrival
bloods and full septic screen - sepsis 6
admission for further IV antibiotic therapy and close monitoring if confirmed neutropenia
if proven neutropenic, treat even if patient seems relatively well
What neutrophil count is considered definitely neutropenic?
<1
What platelet counts are acceptable in patients on chemotherapy?
not septic, accept >10
septic, accept >20
What haemoglobin is acceptable in chemotherapy patients?
> 80 generally fine as long as not symptomatic
What antibiotics are used for neutropenic sepsis?
Tazocin (tazobactam + piperacillin) or Meropenem
+/- gentamicin (good for gram -ve = gut/urine)
+/- vancomycin (skin/soft tissue/MRSA/line infection)
anti-fungal prophylaxis - fluconazole
pneumocystis jirovecii prophylacis if lymphopenic - co-trimoxazole (eg. in HIV patients)
What is G-CSF and what is it used for?
granulocyte colony-stimulating factor
recombinant human haematopoietic growth factor:
- stimulates maturation of existing immature neutrophils
- does not stimulate production of new neutrophils per se
SC injection
recommended in neutropenic sepsis in some patients
Which patients with neutropenic sepsis might be given G-CSF?
generally considered in critical care patients
higher risk features:
- prolonged neutropenia >7 days
- hypotension
- fungal infection
- pneumonia
- enterocolitis
What will happen to a patient’s next dose of chemotherapy if they’ve had neutropenic sepsis?
do not give patient chemo if actively neutropenic - delay until recovered
reduce next dose
add prophylactic G-CSF +/- antibiotics with next chemo (generally done if chemo has curative intent)
discontinue chemo (generally palliative patients)
Spinal cord compression presentation
back pain
altered sensation in legs
difficulty walking
urine retention
Which investigation must be done for suspected spinal cord compression?
urgent MRI whole spine within 24h
Spinal cord compression management
‘time is spine’
high dose steroid until definitive treatment
- reduces oedema surrounding tumour
- dexamethasone 16mg per day (16mg stat, then 8mg BD at morning + lunch)
- PPI for gastroprotection
urgent MRI whole spine
Why is whole spine MRI done in suspected spinal cord compression?
symptoms cannot accurately predict level of compression
may be more than one level of compression
What does a spinal cord compression look like on MRI?
no CSF visible around spinal cord at level of compression
Spinal cord compression management
fit patient + some or all neurological function preserved:
- decompression surgery (single level) or radiotherapy (multiple levels)
frail patient/complete paralysis/poor prognosis:
- radiotherapy or supportive care
What does a urea that is relatively higher than creatinine suggest?
dehydration
Hypercalcaemia of malignancy management
IV fluid - 3L normal saline over 24h
bisphosphonate - zoledronic acid (dose reduce in mild-moderate renal impairment)
RANKL inhibitor - denosumab (can be used in severe renal impairment)
monitor renal function, calcium and phosphate
Investigation of cancer-associated venous thromboembolism
D-dimer = not helpful in cancer pts as often raised due to malignancy
ultrasound = limb deep vein thromboses
CTPA = look for pulmonary emboli
Which anticoagulant is used in cancer patients with a DVT?
dalteparin
(or DOACs, just not dabigatran as not studied)
SVCO presentation
noisy and laboured breathing
facial swelling and redness
prominent veins over upper chest wall
SVCO and upper airway obstruction management
ABCDE
- secure airway (ENT/anaesthetics)
- oxygen
steroids? (not in lymphoma as can make biopsies inconclusive)
SVC stenting (relives symptoms)
need urgent biopsy if tumour
Tumour lysis syndrome prophylaxis
IV fluid
allopurinol - prevents uric acid formation
rasburicase - clears uric acid already formed
Patient with small cell lung cancer presents with generalised seizure and hx of headache and weakness - what test should be done?
CT head - looking for cerebral metastasis
Brain metastasis management
high dose steroid - dexamethasone 8mg BD with PPI cover
levetiracetam is anti-epileptic of choice in brain metastases
neurological observations
surgery?
stereotactic radiosurgery?
supportive care/whole brain radiotherapy?
Can patients with brain metastasis drive?
no
must inform DVLA
Large bowel obstruction management
nil by mouth
drip + suck until definitive treatment:
- large bore NG to decompress GI tract
- IV fluids
definitive:
- surgery
- endoscopic stenting
Which anti-emetic should be avoided in bowel obstruction?
metoclopramide (as pro-kinetic)
