ORALS - HEME/ONC Flashcards
BLOOD TRANSFUSION CASE
CASE: Patient receiving transfusion, now with fever
CLINICAL: chills/rigors, tachy, BP low / SOB / CP, DIC
- Notify patient re: complication
=> identify concern (acute hemolytic rxn / bacterial contamination) - STOP transfusion
=> change all IV lines
=> donor blood back to blood banks to test
=> CONSULT heme / med doc - MGMT
IVF for UO 1-2cc/kg/hr
BW: CBC + diff, coombs test, DIC w/o (PT/PTT/INR, fibrinogen), Cr, urea, blood cultures
benadryl
follow up questions
- List types of transfusion reactions
=> immune mediated
ABO incompatible
febrile
allergic/anaphylaxis
TRALI
delayed ABO incompatibility
GVHD
=> Non immune mediated
TACO (>70, low EF)
sepsis
hypothermia
biochemical abnormalities
chronic (HIV, hep B/C) - Hypotension + dyspnea ddx (transfusion rxn)
=> hypotension (ABO, TRALI, sepsis, bradykinin mediated, anaphylaxis)
=> SOB (TRALI, TACO, anaphylaxis, ABO, sepsis, GVHD) - List complications of blood transfusion
acute hemolytic transufion (ABO)
febrile reaction (febrile non hemolytic)
allergic reaction
TRALI (WBC antibodies react w recipients WBC)
TACO
biochemi - hypoglycemia, K, Ca
hypothermia
DIC/coagulopathy
bacterial contamination - Definition of TRALI
=> b/l pulm edema AND
=> hypoxemia (PF less 300, SaO2 less 90%)
AND
=> WITHIN 6H of transfusion
Define: MTP
10U / 24H
>6U X1
>4U in 1H
peds >10% TBV /min
- What are the contents in an MTP
- How can you predict need for MTP
RABT score (penetrating, SI >10, +FAST) score >2 - Contents of MTP
box 1 - 4RBC, 2FFP
box 2 - 4RBC, 4FFP, 1PLT, calcium, send INR/fibrinogen
box 3 - 6RBC, 6FFP, 1PLT, +4g, fibrinogen - Complications of MTP
Hypothermia
hypoCa/Mg
hyperK
hypothermia
coag / DIC
thrombocytopenia - Peds blood dosing
blood 10cc/kg
FFP 10cc/kg
PLT 10cc/kg
Cryo 1U/kg
MTP >40cc/kg of blood
TRANSFUSION REACTIONS
- PPE/MOVID
- MGMT (STRIC)
stop transfusion
take vitals / physical exam
replace IV tubing and maintain IV access
ID - check patient and blood product
Call blood bank / send back blood
tylenol, pain control
+/- CXR
FOLLOW UP QUESTIONS
- List indications for platelet transfusion
non immune thrombocytopenia less (10)
procedures not assocaited w sig blood loss (10)
on AC (can’t be stopped) (30)
LP/epidural (50)
ITP + life threaten (50)
neurosurgery (100) - What blood products contain fibrinogen
FFP
Cryoprecipitate - Contents of cryoprecipitate
F8/F13
VWF
Fibrinogen - Indications for cryoprecipitate
bleeding with fibrinogen less 1
massive bleeding fibr less than 2
ICH post TPA fibr less than 2
vWD / hemophilia A if DDAVP + factor concentrates unavailable - Contents of PCC / Octaplex
2,7,9,10, C, S,
citrate, heparin - Indications for Octaplex
reversal of vit K antagonists / DOACS
*don’t give if HITT hx - Why is PCC better than FFP
no cross match required
less vol
less infection rates
lower INR faster
no need to thaw - List common transfusion reactions
febrile non hemolytic transfusion reaction
febrile hemolytic reaction (intravascular)
extravascular hemolysis
mild allergic reaction
anaphylaxis
TRALI
TACO
Graft vs host
electolytes - hyperK, hypoCa, hypoMg
hypothermia
bacterial infection (yersinia)
acidosis
coagulopathy
HIV/HBV/HCV
HOW to CONSENT for BLOOD
Assess capacity (KAC)
Voluntary
informed to specific treatment
understand risks/benefits and options
RISKS include: immune reactions (ABO, fever, allergic/anaphylaxis, GVHD, TRALI) + non immune (electrolyte abnormal, TACO, sepsis, HIV, hep C/B)
BENEFITS (improved O2 delivery, volume status, symptomatic relief, decr mortality)
RISKS of no tx = death
DDX: Anemia
- DDX (microcytic) - TAILS
Thalassemia
ACD
Iron def
lead tox
sideroblastic - DDX (normocytic) - ABCD
Acute blood loss
Bone marrow fail (cancer, lymphoma, leukemia, MM)
Chronic dz (ACD, RF, liver dz, hypothyroid)
Destructive
Hyperproliferative:
=> recovery from bled
=> nutrient def
=> hemolytic: MAHA (schistocytosis), spherocytes, autoimmune - DDX (macrocytic) - FAT RBC
Folate
ETOH
Thyroid
Retics - bleeding
B12 def (eTOH, vegetarian)
Cirrhosis, liver dz - Causes of hemolysis
intrinsic (extravascular) - G6PD, spherocytosis, thalassemia, SCD
extrinsic (intravascular) - ABO, TTP, DIC, AIHA, drugs, toxins
SCD CASE
CLINICA CASE: SCD with acute chest syndrome + infiltrate
- ddx includes ACS, PE, PNA PTX + acute chest syndrome
BW - trop/CK, blood cultures, HgBS level - MGMT
analgesia
supplemental O2, goal >95% (decr sickling)
incentive spirometry
bronchodilators
IVF (avoid dehydration)
ABX for encapsulated organisms = CTX, Vanco
GOALS (for stroke) - HgB 100 / HbS 30%
=> TPA
=> consider exchange transfusion - CONSULT
hematology for admission
+/- transfusion vs exchange transfusion
+/- hydroxyurea
follow up questions
1. list encapsulated organisms
strep pneumo
neisseria
haemophilus
salmonella
- List clinical manifestations of SCD
acute chest syndrome
aplastic anemia, splenic sequestration
vaso-occlusive episodes
neuro - TIA/CVA
VTE
Osteonecrosis
gallstones
priapism (ASPEN) - How would an aplastic crisis present
abrupt stop in RBC production (usually 2’ infection)
consult HEME - Indications for exchange transfusion
acute stroke
acute chest syndrome
acute multi system organ failure
HEMOPHILIA CASE
- determine patient factor activity (send in BW)
- classify minor / intermediate / major
- MGMT
give factor replacement
=> HEME A => F8 (% incr /2 = dose /kg)
Consider CRYO (F8) OR FFP (if no F8)
=> HEME B => F9 (% incr = dose /kg)
Octaplex (if no F9)
Give TXA
DDAVP
FIEBA if on inhibitors
Consult heme
follow up questions
1. examples of minor / intermediate / major bleed
=> minor - abrasions, superficial lac, early hemarthrosis
=> intermediate - oral lac, dental extraction, soft tissue hematoma
=> major - ICH, thoracic bleed, vaginal
- What is this was VWD
Determine type
MGMT:
mild (DDAVP 0.3mcg/kg SC/IV + TXA)
severe (F8, DDAVP, VWF concentrate, FFP, TXA)
Skin wound - consider lido w epi
ANTICOAGULANT REVERESAL
- heparin
=> protamine 1mg / 100U heparin in last 4H (MAX dose 50mg) - LMWH (dalt / enox)
=> andexant alfa
=> ^ if not => 1mg protamine / 1mg of LMWH - Warfarin
=> vitamin K 10mg
=> 4F - octaplex 2000U => rpt if INR still >1.5 after 15min - Xa inhibitors (riva, apix)
=> adexanet alfa
=> ^ if not => PCC - Dabigatran
=> praxbind 2.5mg IV Q15min
HUS / TTP CASE
CLINICAL presentation - FAT RN (fever, anemia, thrombocytopenia, renal failure, neuro) (HUS more renal than neuro)
- recognize patient
b/w - CBC w diff, hemolysis w/o (haptoglobin, bili, LFT), renal function - MGMT
IVF
plt for life threatening bleeding / required procedure (but will be used up)
FFP - if needing transport (3-4U pending PLEX)
Plasmapharesis (definitive tx) = removes ADAMS13
Steroids 1mg/kg/day
rituximab (if refractory) - CONSULTS
heme
follow up questions
1. ddx for DIC
pregnancy
infection
trauma
transfusion
burns
hepatic failure
ECMO
CLINICAL (HUS)
kid - bloody diarrhea, bloodwork: anemia, thrombocytopenia
MGMT
supportive - IVF
if neuro involvement - PLEX (unless HUS confirmed, then NO PLEX, no ABX)
DIALYSIS
tx HTN
- ddx for HUS (MAHA, uremia, AKI, low plt)
STEC (shiga toxin producing E coli)
Shigella
S pneumo
HIV
drugs
idiopathic
THROMBOCYTOPENIA CASE
CASE: life threatening ITP
- Consent patient
- platelet transfusion
- 15mg/kg solumedrol
- IVIG (0.7mg/kg)
- consult hematology; may require splenectomy
follow up question
- ddx for thrombocytopenia
decr production => toxin ETOH, malignancy, thiaxide drugs
destruction (HUS, TTP, DIC, ASA, ITP, SLE)
sequestration - Features of HITT
Thrombocytopenia (>50% fall / less than 100)
timing of drop(d5-10)
thrombosis (>50% of cases)
Test (HITT assay)
oTher cause
>6 = high probability
TLS CASE
CASE:
1. BW - uric acid, VBG + lactate
- MGMT
IVF 2L bolus
HYPERURIC => 1) allopurinol 800mg (RF dependent) 2) Rasburicase
HYPERK => CaCl 2g, D50 / insulin R10U, ventolin, bicarb
HYPERPHOS - Aluminum hydroxide, low phos diet
HYPOCA - don’t correct unless symptomatic / unstable
consider HD - CONSULTS
oncology
Nephro - consider HD for hyperphos
Follow up questions
1. list risk factors for devloping TLS
pre-exist renal dysfunction, volume deplete
post treatment renal failure
acidotic urine
concentrated urine
incr LDH
young age
advanced dz + abdo involvement
acute leukemia
high grade NHL
bullky solid tumors
- 4 associated biochem abnormalities (2/4 in same 24H period)
hyperPHOS = Protein breakdown (>1.45)
hyperKAL = Cytosol breakdown (>6)
hyperURIC = DNA breakdown (>475)
hypoCA = phosphate complex (LESS 1.75) - Mechanism of allopurinol + rasburicase
allopurinol (prevent uric acid production = break downs nucleic acid
rasburiase (converts uric acid => allantoin)
FEBRILE NEUT CASE
- B/W - blood + urine cultures
- MGMT
pip/taz 4.5g + vanco 15mg/kg
IVF + fluid resiscitation
CT abdo - if suspect abdo pathology - MGMT
oncology
medicine for admission
follow up questions
1. define febrile neutropenia
Temp >38.3 OR 38.1
ANC less than 500 or 1000 + expected drop to 500
- Risk factors for febrile neutropenia
recent chemo
dehydration / malnutrition
indwelling lines
disruption in mucosal membranes
steroids - indications for empiric vanco (ABCSSS)
Already on fluoroquinolone
blood cultures +gram poisitive
colonization with MRSA
shock
severe mucositis
serioes catheter related infection
HYPERVISCOSITY CASE
CASE: mucosal bleeding, blurred vision, neuro syptoms
- BW - DIC panel, type and screen / blood
- MGMT
IVF
phlebotomy
diuresis
plasma/leukapheresis
hydroxyurea
chemo
follow up questions
1. What is hyperviscosity syndrome
elevation of paraproteins / cellular blood components = decr microcirculation
- Causes of hyperviscosity syndrome
MM
leukemias
SCD
cryoglobulinemia
Waldenstomr’s macroglobulinemia
HYPERCALCEMIA CASE
- b/w - pth / pthrp
EKG => QT, osborne J waves - MGMT
Ca excretion => IVF
Block release =>
=> Bisphosphonates:
pamidronate / bisphos 90mg (inhibit osteoclast)
=> calcitonin 4U/kg SC (urine excretion)
Decr GI absorption
=> Glucocorticoid (methylpred / dex); 1,25 OH2 inhibition
HD (if renal failure)
consider lasix (only if overloaded)
FOLLOW UP QUESTIONS
1. List 5 cancers + 5 non cancers associated with hypercalcemia
MM
lung, kidney, breast CA
leukemia
TB
sarcoid
pagets
osteogenesis imperfecta
milk alkali syndrome
HYPERKALEMIA
MGMT
CaGlc 1g IV (if CaCl - central access)
10U insulin + 1amp d50
ventolin 10mg neb
+/- bicarb if acidotic / arrest
VBG Q30min
**FOLLOW UP QUESTIONS **
1. Causes of hyperkalemia (RISE)
Renal failure - acute/chronic, HD
iatrogenic (drugs - BB, Dig, ACEi, NSAIDs)
Source - rhabdo, TLS, HD
End/MET - DKA, adrenal insufficiency
- EKG features
peaked T waves
Widened QRS, long qTC
STE
tachy/brady arrythmias - DDX for peaked T waves
HyperK
hyperacute T waves
ACS
de winter T waves
BER
LBBB
LVH
HyperCa
