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