Oncology & Hematologic Emergencies Flashcards
Right This Minutes Emergencies
Neutropenic Fever
Cardiac Tamponade
Cord Compression
CNS metastasis with symptoms
Emergencies for Today
Coagulopathy
Tumor lysis
Leukostasis
Hyperviscosity
Severe Thrombocytopenia (<20,000)
INR >9
Urgent Emergencies - by tomorrow
SVC Syndrome
Hypercalcemia
CNS metastasis without edema
INR 5-9
Spinal Cord Compression
Prostate, Breast, Multiple Myeloma to bone
Sx: Back pain -> inflammation, paresthesias, ANS dysfunction late
Rapid deterioration (days) predicts worse outcome
Usually vertebral metastasis
Dx: MRI/CT
Tx: Decadron (steroids), neurosurgery - especially w/ rapid, radiation
CNS Metastasis with symptoms
Lung or breast cancer - adult (most common adult CNS tumor)
Kids = carcinoma, neuroblastoma, germ cell tumor
Sx: HA, seizure, AMS, focal deficits
Dx: MRI
Tx: Decadron for edema or focal sx
- Dilantin w/ seizure
- Surgery + radiation improves survival
Vascular event - hyperviscosity
Waldenstom’s Macroglobulinemia most common
-also Polycythemia Vera (PV) or Essential Thrombocytosis (ET)
Sx: nonspecific - somnolence, HA, blurry vision, dizzy
Serum viscosity >5 w/ Wald; Hgb >19/20 PV; Platelets >106 ET
Tx: Hydrate, IgM + Chemo
-PV = phlebotomy; ET = hydroxyurea + ASA
Vascular Event - Leukostasis
AML/ALL with wbc >100,000 common - CLL/CML rare
Sx: AMS, coma, hypoxia, renal insufficiency
-May worse w/ induction chemo in AML
Tx: Hydrate, chemo for rapid cytoreduction
-Have to watch for tumor lysis syndrome
Cardiac Tamponade
Lung & Breast Cancer common - malignant effusions common
Becks Triad: low BP, JVD, muffled heart sounds
Sx: R/L side failure, pulses paradoxus, pericardial rub
EKG: electrical alternans, diffuse ST elevation
Dx: Immediate echo
Tx: Drainage + chemo or CT surgery for chronic
-Simple effusion - NSAIDs and watch for a few days
SVC Syndrome
Usually lung cancer - bronchogenic carcinoma
-Also thymoma, breast, mediastinal lymphadenopathy
Sx: Facial edema, asymmetric/symmetric UE edema, SOB w/ hypoxia
Pancoast tumor (apex of lung) presents w/ this
Dx: CT
Tx: Chemo, radiation, heparin/steroids, consider stent
Tumor Lysis Syndrome
Tumors w/ high burden/chemosensitivity - leukemia, lymphoma
Or directly related to chemotherapy
Cause HYPERuricemia, HYPERkalemia, HYPERphosphatemia, and HYPOcalcemia - get gout and renal tubule injuries
Sx: N/V/D, anorexia, hematuria, cardiac arrhythmias (Ca and K)
Tx: Hydrate, bicarb for urine pH >7; CMP baseline and monitoring
Treating Hypokalemia
Insulin + D50 for quick reversal
-pushes potassium back into cells, D50 to prevent hypoglycemia
Kayexalate binds to potassium in gut and excretes
- takes time to work, pts develop a tolerance
- Also treatment for constipation?
Consider dialysis as last-resort
Hypercalcemia
Breast, lung, MM common cancers
Can also get PTHrP production - Squamous cell, NHL most common
Sx: Gradual onset - fatigue, N/V/C, anorexia, apathy, decreased consciousness
Tx: volume replete - furosemide
-IV Pamidronate or IV Zoledronic (GFR ok) to prevent bone breakdown
Predicts short survival if w/ cancer
SIADH
SCLC most common
Causes dilutional hyponatremia w/ water retention
Labs: Decreased BUN and serum osmolarity with increased urine osmolarity and sodium
Tx: Treat tumor, water restriction, furosemide, parenteral Na replacement if severe
SIADH Na <120 Symptoms
Anorexia
Irritable
N/V
Constipation
Muscle weakness
Myalgias
SIADH Na <100 Symptoms
Seizure
Coma
Death
Abnormal reflexes
Papilledema
Neutropenic Fever
Usually a result of chemo rather than marrow malignancy
Sx: Subtle then rapid development HOTN, dyspnea, sepsis
Short-term more likely gram negative; Long-term fungal, viral, opportunistic
Tx: IMMEDIATE, admit w/ empiric Abx, look for source
- No suspected source = empiric for gut flora
- Cefepime, Moxifloxacin, Pip/Gent, Aztreonam
Severe Thrombocytopenia
Usually idiopathic or immune w/ isolated case
Labs: CBC, PT/PTT, INR, D-dimer, LDH, Fibrinogen, heparin
Tx: Transfuse w/ active bleeding or platelets <7, prednisone
-Possible splenectomy in children to prevent recurrence
Platelet Defect Clinical Characteristics
Bleeding site
Minor cut bleeds
Petechiae
Ecchymoses
Hemarthrosis/muscle hematomas
Bleeding after surgery
Bleeding site: skin, mucous membranes
Minor cut bleeds: yes
Petechiae: Present
Ecchymoses: Small, superficial
Hemarthrosis/muscle hematomas: rare
Bleeding after surgery: Immediate, mild
Clotting Factor Deficiency Clinical Characteristics
Bleeding site
Minor cut bleeds
Petechiae
Ecchymoses
Hemarthrosis/muscle hematomas
Bleeding after surgery
Bleeding site: Deep in soft tissue
Minor cut bleeds: Not usually
Petechiae: Absent
Ecchymoses: Large, palpable
Hemarthrosis/muscle hematomas: Common
Bleeding after surgery: Delayed, severe
Distinguishing
TTP
DIC
HIT
HELLP
TTP: thrombotic thrombocytopenia -normal PT/PTT, neuro sx & fever - platelet deficiency
DIC: Prolonged PT/PTT & INR with increased D-dimer - bleeding & clotting @ same time
HIT: Heparin-induced
HELLP: Pregnancy -hemolysis, elevated LFTs, low platelets
Factor 5 Leiden
Von Willebrand disease
Hemophilia A & B
Factor 5 Leiden: inherited hypercoagulopathy - factor 5 resistant to breakdown by activated C protein
Von Willebrand disease: vWF deficient - no factor 8 degradation
-ineffective platelet adhesion - bleed @ dentist
Hemophilia A & B: A = 8, B = 9 factor deficient
Overanticoagulation
Cancer pts clot easily - often on Warfarin but INRs difficult to stabilize
Coumadin (Warfarin) is Vitamin K dependent (2,7,9,10-extrinsic)
- Monitor w/ PT & INR
- Vitamin K + FFP for quick reversal
Non-warfarin agents
- LMWH = FFP+Protamin
- Fondaparinux = recombinant active Factor 8
