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First Aid & Emergency Medicine > Oncology emergencies > Flashcards

Oncology emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What are primary spinal tumors? - what oncological emergency can they cause?

A

Tumors that originate in the spinal segments (RARE)

Epidural spinal cord compression

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2
Q

What are secondary spinal tumors?- what oncological emergency can they cause?

A

Tumors originate elsewhere in the body and metastasize to the spine. (Make up the MAJORITY of epidural spinal compression- 95%)

Epidural spinal compression

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3
Q

Which primary cancers are most likely to metastasize to the spine? (3)

A

Breast
Prostate
Lung

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4
Q

What level of the spine is pain most commonly seen in a spinal cord compressions?

A

Thoracic level

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5
Q

What signs and symptoms are seen in a spinal cord compressions?

A
  • Cancer patients with complaints of NEW ONSET BACK PAIN
  • Pain may be localized
  • Pain may be radicular
  • Pain is usually worsened by movement
  • Pain is usually unimproved with rest
  • PAIN THAT WORSENS WHEN PATIENT IS LYING DOWN or with PERCUSSION OF VERTEBRAL BODIES!!!!!!!!
  • pain is worsened with cough or bearing down to have a bowel movement.
  • Urinary and bowel incontinence may develop
  • eventually can lead to loss of sensory functions, or paraplegia
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6
Q

New back pain in patients with cancer suggest what condition?

A

Epidural spinal cord compression

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7
Q

Epidural spinal cord compressions is caused by a _______ compressing the _____ _____.

A

tumor, dural sac

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8
Q

True or False: epidural spinal compression can cause permanent damage even treatment is delayed for only a few hours.

A

True

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9
Q

What are the exam findings in epidural spinal compression? (5)

A
  • the quality of pain is often mimicked by percussion over the affected vertebra
  • the intensity of the pain is often worsened upon valsalva maneuver.
  • DTR’s may be increased
  • Lower extremity spasticity may develop
  • Babinski’s sign may be positive
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10
Q

What is cauda equine syndrome?

A

A subset of spinal cord compression:

Occurs when the nerve roots in the the lumbar spine are compressed, disrupting sensation and movement. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage.

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11
Q

What are signs and symptoms of cauda equine syndrome?

A
  • lower extremity weakness
  • DIMINISHED DTR’s
  • lower extremity FLACCIDITY may develop
  • patient may develop leg and perianal sensory loss
  • look for symptoms of URINARY RETENTION and constipation
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12
Q

What imaging is indicated in a case of suspected spinal chord compressions?

A
  • Plain film (may miss things)
  • MRI (soft tissue) or CT(bone)
  • Lumbar puncture may be necessary
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13
Q

What is seen on plain film with an epidural compression fracture?

What is limiting about an Plain film in this instance?

A
  • may reveal lytic changes consistent with metastatic lesions
  • may MISS para-spinal lesions impinging on neuronal foramina
  • may mis intra-spinal tumor metastasis.
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14
Q

What is a pathologic fracture?

A

A fracture caused by pathology.

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15
Q

If neurologic symptoms are present in a patients with suspected spinal cord compression, the initial treatment includes_____ ________.

If diagnosis is confirmed, most patients will need __________ or ________.

A

IV steroids (this treatment should not be delayed while awaiting diagnostic study results).

radiation, surgery

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16
Q

Asymptomatic patients with spinal chord compressions should be considered for immediate _______ therapy and patients with progressive symptoms despite radiation therapy should be considered for _________ intervention

A

radiation, surgical

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17
Q

What are some signs and symptoms of brain tumors? (7)

A
  • NEW ONSET OF HEADACHE OF HEADACHE WITH A PATTERN OF INCREASING INTENSITY OF FREQUENCY!!!!
  • altered mental status
  • visual field changes
  • focal neurologic deficits such as weakness, diminished function or sensation
  • Persistent nausea and vomiting
  • strokes
  • SEIZURES
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18
Q

If someone gets their first seizures in their 30’s or 40’s without any other obvious conditions like diabetes or alcohol withdrawal, what disease may you be suspicious of?

A

A brain tumor.

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19
Q

What do you think of when a patent tells you they have new onset of headache or headache with a pattern of increasing intensity or frequency

A

Brain tumor!

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20
Q

What is the most common tumor found in the brain?

A

Brain metastases

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21
Q

What are the most common cancers that lead to brain metastasis? (5)

A
  • lung
  • breast
  • renal cell
  • colon
  • melanoma
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22
Q

What is superior vena cava syndrome/ superior vena cava obstruction?

A

Usually the result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall by lung cancer.

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23
Q

Which cancer is the most common cause of SVCS and SVCO?

A

bronchogenic carcinoma (lung cancer)

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24
Q

Other than a malignancy, what can cause SVCS?

A

Thrombosis around an indwelling catheter

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25
Q

What are the signs and symptoms of SVCS (6)

A
  • Shortness of breath (most common)
  • edema of the face, neck, upper extremity, especially upon rising (2nd most common)
  • JVD
  • headache
  • lightheadedness
  • cough
  • varicosities over chest wall
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26
Q

How is SVCS difference than Horner’s syndrome?

A

Horners includes:

  • anhydrosis, unilateral
  • ptosis
  • myosis (small pupil size)

SVCS include?

  • Shortness of breath (most common)
  • edema of the face, neck, upper extremity (2nd most common)
  • JVD
  • headache
  • lightheadedness
  • cough
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27
Q

What is Trousseau’s sign of malignancy and how does it differ from Trousseau’s sign of hypocalcemia?

A

Malignancy: Episodes of vessel inflammation due to blood clot (thrombophlebitis) which are recurrent or appearing in different locations over time. The location of the clot is tender and the clot can be felt as a nodule under the skin.

Hypocalcemia: Blood pressure cuff around arm, inflated, induces spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.

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28
Q

If SVCS is not treated, worsened symptoms can develop including

A
  • cerebral edema
  • altered state of consciousness
  • seizures
  • airway obstruction
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29
Q

What is used to Dx SVCS?

A

MRI with or without contrast

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30
Q

What is used to treat SVC syndrome?

A
  • steroids
  • diuretics
  • bed rest with elevation of head
  • chemotherapy with or without radiation therapy to tumor mass
  • treatment with intravenous stunts is becoming increasingly common.
31
Q

What are the classical cardiac tamponade signs?

A

Beck’s triad

  • muffled heart sounds
  • JVD
  • hypotensions
32
Q

Why does hypotension occur in cardiac tamponade?

A

There is a decreased stroke volume

33
Q

Why does JVD occurs in cardiac tamponade?

A

impaired venous return to the heart.

34
Q

Why do diminished heart sounds occurs in cardiac tamponade?

A

fluid inside the pericardium and heart is trapped in the pericardial sac.

35
Q

What will show on a CXR in the case of cardiac tamponade?

A
  • Cardiomegaly, most often with clear lung fields

- AKA “water bottle heart)

36
Q

What does US reveal in the case of cardiac tamponade?

A
  • pericardial effusion

- restricted heart wall motion

37
Q

What does EKG classically show in cardiac tamponade?

A
  • Electrical alternans

- low voltage of T waves (diminished height)

38
Q

What is the most common cause of pericardial effusions?

A

malignancy - any neoplasm (breast, lymphoma, leukemia, melanoma, GI)

Sarcoma is most common malignancy that causes it.

39
Q

________ ________ is one of the most common complications related to cancer treatment, particularly chemotherapy.

A

Febrile neutropenia.

40
Q

_________ infections are common in patients with febrile neutropenia but _____ sources of sepsis are increasingly prevalent.

A

Bacterial, fungal

41
Q

What is the appearance of electrical alternans on EKG?

A

QRS segments alternate in heights from beat-to-beat.

These findings are strongly suggestive of pericardial effusion.

42
Q

In which EKG leads can electrical alternates best be seen?

A

V2 to V4 - suggesting pericardial effusion of cardiac tamponade

43
Q

Symptoms of febrile neutropenia include a temp of ____or more AND and absolute Neutrophil count (ANC) less than ____.

A

101 F, 500

44
Q

Patients with cancer presenting with fever soon after chemotherapy should receive inpatient treatment with empiric ________ until the ANC reaches a level of > or = _____ for ___ days.

A

antibiotics, 500, 3 days

45
Q

The treatment of cardiac tamponade includes:

A
  • removal of fluid from pericardial space (pericardiocentesis)
  • sclerotic therapy
  • surgical placement od a pleuropericardial window or pericardiectomy
  • low dose radiation therapy
46
Q

True or false: Hypercalcemia only results from one kind of pathological process in cancer

A

False: Hypercalcemia may result from different pathologic processes dependent upon the type of malignancy.

47
Q

What are the three pathological processes resulting in hypercalcemia in cancer?

A

1) Bone lysis and resorption - most common in metastatic breast and prostate cancer
2) Cytokine production - multiple myeloma
3) Tumor production of Parathyroid hormone related protein (PTG-rP)

48
Q

What is the main cause of hypercalcemia in the inpatient setting?

A

malignancy

49
Q

What is the most common cause of hypercalcemia in the outpatient setting?

A

Hyperparathyroidism

50
Q

The effects of hypercalcemia include: (5)

A

Stones, Bones, Groans, Thrones, and Psychiatric Overtones.

Stones - kidney and gallstone
Bones - bone pain
Groans - abdominal pain, nausea, vomiting
Thrones - constipation, polyuria
Psychiatric Overtones - depression, anxiety, cognitive dysfunction, coma

51
Q

What is paraneoplastic syndrome?

A

A syndrome that is a consequence of cancer where there is a tumor that secretes hormones….like parathyroid hormone related protein

52
Q

Which cancers are Parathyroid hormone relate protein most commonly associated with? (3)

A

Lung
breast
kidney

53
Q

Parathyroid hormone related protein functions in the same way as which hormone and how?

A

Parathyroid protein by interaction with PTH receptors.

54
Q

True or False: Hypercalcemia of malignancy is usually a grave diagnosis

A

True

55
Q

The diagnosis of hypercalcemia of malignancy may indicate a patient surveil time of

A

1-2 months or less

56
Q

What is included in the treatment of hypercalcemia? 3

A
  • Vigorous saline infusion to correct the dehydration that is almost always present
  • IV Lasix to promote renel excretion of calcium
  • Bisphosphonates i.e. Alendronate that serve to blunt osteoclast production and function which serves to block bone resorption.
57
Q

Syndrome of Inappropriate Anti-diuretic hormone (SIADH) is due to _______ production of ________ (which hormone?)

A

ectopic, ADH aka vasopressin

58
Q

SIADH is most commonly caused by which cancer?

A

Small cell carcinomas of the lung?

59
Q

What is the hallmark electrolyte finding of SIADH?

A

Hyponatremia

60
Q

In hyponatremia due to SIADH, excessive concentration of _____ due to ADH effect is compounded by renal ______loss.

A

urine, sodium

61
Q

Cancer patients with hyponatremia due to SIADH with lowered sodium levels usually note marked ________ and an initial symptom followed by altered _______ ______.

A

fatigue, mental status

62
Q

The treatment of SIADH includes: 3

A
  • fluid intake restriction
  • demeclocycline, and ADH antagonist
  • treat the underlying cancer
63
Q

What 3 things characterize tumor lysis syndrome?

A

Circulating lysed tumor cells that result in:

  • hyperuricemia (uri acid)
  • hyperkalemia (K+)
  • hyperphosphatemia (PO4)
64
Q

Tumor lysis syndrome occurs in cancer patient with large _____ burden that is very sensitive to ___________.

A

tumor, chemotherapy

65
Q

What is a major risk factor for tumor lysis syndrome?

A

Pre-existing renal dysfunction.

66
Q

Deep venous thrombosis is defined as:

A

Thrombosis within the deep veins of the clan, thigh, or pelvis.

67
Q

The classic pain of DVT is describes as:

A

A dull, deep aching pain

68
Q

The pain of DVT is made worse by what?

A

Standing or walking or when the left is in a dependent position

69
Q

What are the classic signs of DVT? 3

A
  1. Swelling, tenderness, and redness in the calf thigh or groin.
  2. A palpable cord is an added bonus
  3. Homan’s sign - discomfort in the calf or behind the knee on dorsiflexion of the foot.
70
Q

What is Homan’s sign?

A

For DVTs. - discomfort in the calf or behind the knee on dorsiflexion of the foot.

71
Q

What are the risk factors for DVT? (7)

A
  • obesity
  • smoking
  • use of HRT
  • recent travel with long periods of sitting
  • local trauma
  • recent surgery to the hip of knee
  • history of a prior DVT
72
Q

True of false: the risk factors for pulmonary embolism are similar to those for DVT especially after hip fracture of if malignancy is present.

A

True

73
Q

True or False: In at least 50% of cases of pulmonary
embolism, no signs of peripheral
thrombosis are evident, even though the
iliofemoral system has been the source of
the blood clot.

A

True

74
Q

What are common presenting symptoms of a pulmonary embolism? (8)

A
  • shortness of breath
  • chest pain (pleuritic in nature that is made worse with deep inspiration or cough)
  • patients are often apprehensive
  • tachypnea is usually present
  • tachycardia is usually present
  • hemoptysis is present in less than 30% of cases
  • A pleural rub may be found

First Aid & Emergency Medicine (10 decks)

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