Oncology Emergencies Flashcards
Types of Emergencies: Systems Approach:
- Neurological? 3
- Cardiopulmonary? 2
- Metabolic? 3
- Hematological? 3
- Cord Compression,
- CNS metastases,
- Vascular Events: Hyperviscosity/Leukostasis
- Cardiac Tamponade,
- SVC Syndrome
- Tumor Lysis,
- Hypercalcemia,
- SIADH
- Neutropenic Fever,
- Severe Thrombocytopenia,
- Overanticoagulation
Types of Emergencies: Urgency Approach
1. Right Now This Minute? 4
- Today? 6
- If Not Today, Tomorrow? 4
- Neutropenic fever,
- tamponade,
- cord compression,
- CNS metastases with symptoms
- coagulopathies,
- tumor lysis,
- leukostasis,
- hyperviscosity,
- severe thrombocytopenia,
- INR over 9
- SVC Syndrome,
- most hypercalcemia,
- most CNS mets without edema,
- INR 5-9
Neurological: Cord Compression
1. In most patients it presents as what?
- What process cause this? And how will it feel?
- Autonomic dysfunction __________ motor/sensory!
- Usually occurs in diseases with what kind of mets?
- What kind of deterioration predicts a worse outcome?
- In most patients, presents as back pain
- Inflammation & paresthesias
- FOLLOWS
- vertebral body mets, not hematogenous dural mets
- Rapid deterioration (days) predicts worse outcome than longer (weeks)
Dx for cord compression?
Tx? 3
- You need to get:
- MRI / CT [+/- myelogram] of the WHOLE spine - -Decadron
(4-6 mg q4-6 hrs, PO or IV – but some studies suggest 24 mg q 6 after a 100 mg bolus)
-Neurosurgery in most circumstances (especially no dx or very rapid onset)
-XRT (Radiation Therapy IF multiple levels)
Neurological: Brain Metastases
1. Presentation? 4
- Most commonly from what kinds of cancer if no prior known primary? 2
- If no dx, isolated to brain conider what? 2
- What kind of therapy for isolated mets improves survival vs. either alone?
- Presentation:
- headache,
- seizures,
- altered mental status, or
- focal deficits - Most commonly from
- lung or
- breast cancer if no prior known primary - lymphoma,
- HIV
- Surgery plus radiation therapy
Neurological: Brain Metastases
You need to get?
4
(two meds, two studies, one procedure)
- Decadron into the patient if there is edema, focal sx
- Dilantin into the patient only if seizure witnessed/suspected
- Good imaging of the whole brain: MRI if at all possible
- Neurosurgery if no diagnosis, or clearly an isolated met
Neurological: Vascular Events Hyperviscosity/ Leukostasis 1. Presentation? 2. Hyperviscosity mostly with what? But can be from? 2 3. Serum viscosity usually > \_\_\_ cP? 4. In PV, Hgb usually > \_\_\_\_\_\_\_? 5. In ET, platelets well over \_\_\_?
- Relatively nonspecific sx’s:
- somnolence,
- headache,
- blurry vision,
- dizziness - Hyperviscosity mostly with Waldenström’s.
- Polycythemia Vera,
- rarely Essential Thrombocytosis - Serum viscosity usually > 5 cP
- 19 or 20
- 10^6
What is Waldenstoms?
Waldenstrom macroglobulinemia (WM) is a type of non-Hodgkin lymphoma (NHL) . The cancer cells make large amounts of an abnormal protein (called a macroglobulin). B cell originates.
Neurological: Hyperviscosity
You need to get:
4
- The patient HYDRATED
- Apheresis for IgM, plus chemotherapy.
- -You will need a Hem/Onc for chemo - Phlebotomy for PV: replace units with NS, want Hgb ~ 15
- Hydroxyurea and aspirin for ET
What cancers are most likely to go to brain?
5
- Lung
- breast
- kidney
- colorectal
- melanoma
Neurological: Vascular Events
Hyperviscosity/ Leukostasis
1. Leukostasis mostly in ____ with WBC > _______
- Presentation? 2
- Complications? 2
- When may it worsen during treatment?
- What often do they die from? 2
- AML,ALL 100,000 (most common)
- -CLL, CML uncommon even with WBC >300,000
- Extrememly elevated lymphoblasts. Can’t even profuse. - Altered mental status,
- coma common, but other organs also involved
- Hypoxia,
- renal insufficiency
- May worsen during induction chemo for AML
- Brain infarction or Respiratory infarction
Neurological: Leukostasis
You need to get what?
4
- The patient HYDRATED
- Quinton access (Renal) and Chemotherapy (Onc)
- An LP for cytology to rule in / out CNS leukemia
- Steroids may help here, too
Cardiac Tamponade
1. Malignant effusions are common, just not commonly _______?
- Mortality probably will be from what?
- WHat are the most common primaries that cause this? 2
- EKG will show? 3
- Presents how? 3
- symptomatic
- other aspects of patient’s disease
- Breast and Lung
- Electrical alternans, Low voltage, tachy
- Presents with
- left or right sided failure,
- pulsus paradoxus,
- big heart on CXR
In multiple myeloma what cells are you making too many of?
What is Beck’s triad?
If they are just having pericarditis what should you give them?
Plasma cells
- Hypotension
- Distended neck veins
- Distant muffled heart sounds
NSAIDS
Cardiac Tamponade
You need to get what?
5
- An Echo and cytology from pericardiocentesis
- Catheter drainage of the pericardial space
- Medical management
- Oncology input re: chemotherapy
- CV surgery input re
- What kind of CV surgery input?
- This is esepcially for who?
- What area of the lung does a pancoast tumor present?
- subxiphoid pericardial window or balloon pericardiotomy,
- especially for recurrent effusions in patients with good performance status
- Apex of the lung
Cardiopulmonary: SVC Syndrome
- Usually from what cancer?
- Others that can cause it? - Presentation? 3
- How urgent is this?
- Usually from lung cancer (bronchiogeneic carcinoma)
- lymphoma,
- breast cancer,
- mediastinal tumors also possible - Facial edema,
- symmetric or asymmetric upper extremity edema common
- Shortness of breath common, but not hypoxic
- Only a relative emergency, even with CNS symptoms
Which SVCS obstruction is more severe?
Infra-azygos SVC obstruction
over supra-azygos obstruction
Manifestations of supra-azygos SVC obstruction?
4
- Distended arm and neck veins
- Edema of neck, face, and arms
- Congested mucous membranes (mouth)
- Dilated, tortuous vessels on upper chest and back
Manifestations of Infra-azygos SVC obstruction?
2
- More severe symtpoms but all of the features for obstruction distal to the entrance of SVC
- Dilation of collateral vessels on anterior and posterior abdominal wall with downward blood flow into IVC, then back to the heart.
Cardiopulmonary: SVC Syndrome
You need to get?
6
- Pulse Ox / CXR
- Chest CT to outline the mass that will need therapy
- Oncology involved
- -chemotherapy for small cell, lymphoma, germ cell - Radiation for almost all else
- Heparin or corticosteroids
- Call IR? New area of interest: stenting
Metabolic:
Tumor Lysis Syndrome
1. Occurs in tumors with what characteristics? 2
- What two kind of cancers are common?
- Usually its due to what so you know the diagnosis already?
- May occur on what timeline?
- Clinical symtpom? What its due to?
- Occurs in tumors with
- high body burden and
- high chemosensitivity - Usually high-grade
- lymphomas or
- leukemias
- -Small cell, germ cell less common - Usually due to therapy, so you know the diagnosis already
- May occur at onset of therapy, or after a day or two, up to 5 days
- Few clinical symptoms other than being ill with obvious lab abnormalities due to renal failure
Metabolic:
Tumor Lysis Syndrome will cause what electrolyte abnormalities?
4
What is this due to?
- HYPERURICEMIA
- HYPERKALEMIA
- HYPERPHOSPHATEMIA
- HYPOCALCEMIA
Due to rapid turnover of tumor cells (with or without anti-tumor therapy)
Metabolic: Tumor Lysis Syndrome
Pre-treatment, you need to do what?
7
- Fix conditions that will make effects worse:
- Get baseline labs
- Alkaline diuresis: D5•1/2NS with 2 or even 3 amps NaHCO3/l at 200+ cc/hr,
- keep urine pH > 7
- Keep urine output high
- Allopurinol 600 mg load, then 300/day
- Rasburicase? [recombinant urate oxidase $2500/d]
What are conditions that will make effects worse for tumor lysis syndrome? 3
What baseline labs should you get? 6
How should we keep the urine output high? 2
Why do we give allopurinol?
- Dehydration,
- renal obstruction,
- IV contrast
- K,
- Ca,
- Phos,
- Uric Acid,
- LDH,
- Cr
- lasix,
- mannitol
to keep uric acid production down
Metabolic:
Tumor Lysis Syndrome
During treatment you need to?
5
- Remember high K+ and low Ca++ kill people
- Keep alkaline urine output high
- Check BID lytes,
- Try to keep phosphate less than 7, Ca > 6, K less than 6
- If Ca low, remember to give Mg, too
What lytes should you check BID during treatment for tumor lysis?
5
- phos,
- UA,
- Ca,
- LDH,
- Cr
Metabolic:
Tumor Lysis Syndrome
1. If phosphate >7, switch NaHCO3 to NS to prevent what? What helps with this?
- Acute __ Rx is always good,
- but ________ preferred over IV Calcium if Ca-P product high.
- What may they need?
- Ca-PO4 deposits in kidney,
- Oral phosphate binders (Amphogel) help - K
- insulin/D-50. Kayexalate fine (reverses your hyperkalemia)
- May need dialysis
Metabolic: Hypercalcemia
1. Most common causes? 3
- Squamous cancers from multiple sites often make _____, even without bony mets
- Describe the presentation? 5
- Breast,
- lung,
- multiple myeloma most common causes
- PTH-rP
- Usually gradual in onset
- Fatigue,
- N/V, constipation, anorexia,
- apathy,
- decreased consciousness most common
- Pathologic role of PTH-rP (fake PTH made by the tumor)?
- Patients always volume depleted due to what?
- What tumor likes to secrete PTH-rP?
- PTH-rP stimulates elevated Ca+ concentrations and reabsorption of it by the kidney
- calcium-induced renal tubular defects
- Non-hodgkins lymphoma
Metabolic: Hypercalcemia
What do you need to do? 2
Hypercalcemia predicts what kind of survival?
You need to:
- VOLUME REPLETE the patient
- Furosemide
- IV Pamidronate (Aredia)90 mg over 3-4 hrs
know that hypercalcemia predicts short survival (but better than in the past; now > 5 mos vs 2 mos)
If renal function of hypercalcemia pt is ok what can we treat with instead of IV Pamidronate?
What things can be used as adjunctive therapy? 3
-Or if renal function okay, IV Zoledronic (Zometa) acid 4 mg over 15 minutes
- know that dialysis,
- calcitonin (Miacalcin), &
- steroids are not as effective, but can be used as adjunctive treatment.
Metabolic: SIADH
1. Is most common in what type of cancer?
- Clinical presentation if -Serum sodium less than 120 meq/L? 6
- Clinical presentation if Serum sodium less than 110 meq/L? 4
- __ BUN & serum osmolarity
___ Urine Osmolarity & Sodium levels
- Small cell lung cancer
- Anorexia
- Irritability
- N/V
- Constipation
- Muscle weakness
- Myalgia
- Seizure
- Coma/Death
- Abnormal Reflexes
- Papilledema
- ↓, ↑
Metabolic: SIADH
What do you need to do?
5
- Treat underlying tumor!!
- Limit fluid intake to 500-1000 ml/day
- Furosemide
- Parenteral sodium replacement w/ severe neurological symptoms
- Monitor lytes
Which lytes should you monitor for SIADH caused by tumor?
3
- Mag,
- K+,
- Ca++
Hematologic: Neutropenic Fever
- Describe its progression? 3
- Duration of neutropenia predicts organisms
- Short term = ?
- Long term (weeks) = ? 3 - Most patients are neutropenic due to what?
- Most neutropenia occurs ___ days after chemotherapy is given
Top of the “right now, this minute” list***
- May initially be very subtle, then rapid development of
- hypotension,
- dyspnea,
- sepsis - Duration of neutropenia predicts organisms
- Short-term = gram-negative»_space; gram-positive
- Long-term (weeks) = fungal, viral, opportunistic - Most patients are neutropenic due to chemotherapy, not malignancy in the marrow
- 10-15 days after chemotherapy is given
- -Top of the “right now, this minute” list
Hematologic: Neutropenic Fever
You need to do what?
- Fully evaluate the patient for a source
- If there’s a suspected source, treat it
- If there’s NOT a suspected source, treat empirically for gut flora
What things would we do to evaluate the patient for the source of neutropenic fever?
6
- Blood,
- CXR,
- sputum,
- urine,
- skin,
- LP
How would we treat empirically for gut flora for neutropenic fever?
4
- Cefipime,
- Moxifloxacin,
- Pip/Gent,
- Aztreonam
Add coverage for lack of response
“Platelets of 2” – stat page from the lab
1. Most cases of isolated profound thrombocytopenia are what? 2
- Symptoms vary but include?
5
- idiopathic,
- immune
- Asymptomatic
- Mucosal bleeding most common
- Cutaneous bleeding
- Menorrhagia
- CNS bleeding least common
Musocosal bleeding in thrombocytopenia commonly presents how?
3
Cutaneous bleeding will present how? 2
- epistaxis,
- gingival bleeding,
- bullous hemorrhages
- petechiae,
- ecchymoses
Name the coresponding Platelet Defect and Clotting Factor Deficiency with the following Clinical Characteristic:
- Site of bleeding?
- Bleeding after minor cuts?
- Petechiae?
- Ecchymoses?
- Hemarthrosis, muscle hematomas?
- Bleeding after Surgery?
PLATELET DEFECT CLOTTING FACTOR DEFICIENCY 1. -Skin, mucous membranes -Deep in soft tissue 2. -Yes -Not usually 3. -Present -Absent 4. -Small, superficial -Large, palpable 5. -Rare -Common 6. -Immediate, mild -Delayed, severe
When a patient is bleeding what labs should you get?
6
Fibrinogen LDH PT, PTT Smear CBC Pregnancy
Platelets of 2
1. What do we need to rule out? 4
- Assess pt for what?
- When should we transfuse?
- What should we give is the patient is well (plt rise = days)?
- If the patient is ill what should we give them (plt rise = hours)?
- How does the presentation and prognosis differ in kids and adults?
- Be sure it’s not:
- TTP
- DIC
- HIT (heparin induced)
- HELLP (pregnant lady) - Assess the patient for ACTIVE bleeding
- Transfuse if patient is ACTIVELY bleeding (or if you know the problem is platelet production)
- Prednisone 1mg/kg/d if patient well (plt rise = days)
- IV-IG x 2 days if patient ill (plt rise = hours)
- Know that in kids, most will remit; in adults, most will relapse & require splenectomy
Overanticoagulation
For patients on warfarin, You need to?
6
- Assess whether there is significant bleeding
- Assess for head trauma
- Assess whether the patient should be anticoagulated again in the future
- Give FFP (2 units) and 5 mg IV 5. Vitamin K for significant bleeding [note risk of anaphylaxis!]
- Give PO (2-5 mg) Vitamin K for INR > 9 w/o bleeding
- –Avoid SQ Vitamin K, if the patient is to be anticoagulated in the future!
Overanticoagulation
For patients on non-warfarin agents, You need to? 4
- Assess for bleeding and head trauma
- Identify the specific agent and call pharmacy / hematology
- For significant bleeding, consider protamine sulfate for heparin or LMWH (slow administration). Dose requires pharmacy help (FFP, Protomine)
- For all significant bleeding, especially with fondaparinux (Arixtra), consider recombinant activated Factor VII
