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Year 4 exams > OSCE emergencies (Cancer care) > Flashcards

OSCE emergencies (Cancer care) Flashcards

1
Q

Presentation of bowel obstruction

A
  • Stomach pain- colicky
  • Constipation
  • Vomiting Occurs early in upper GI obstruction and later in lower GI
  • Abdominal distension
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2
Q

investigations for bowel obstruction

A
  • Abdominal X ray
    o Central- upper
    o Peripheral- lower
  • CT scan (best)
  • Barium enema
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3
Q

management of BO

A

depends on stage and what is appropriate

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4
Q

management of BO

A

Supportive
- NG decompression/ venting gastrostomy (PEG)
- IV fluids to prevent rehydration
- Buscipan- stop muscle spasms and reduce pain
- Strong painkillers
- IV antibiotics
- Antiemetics
- Octreotide
o Reduces fluid that building up in GI tract
- Steroids to reduce inflammation in bowel

Surgery
Tends to be palliative to relieve pain
- Resection of damaged bowel-> stoma
- Stent insertion

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5
Q

superior vena cava obstruction presentation

A

can be due to a tumour pressing on SVC -> stops blood draining from bveins in the brain to the heart

  • Tachycardia, tachypnoea, hypotension
  • Swollen, red face
  • Neck and shoulder swollen
  • Jugular venous distension
  • Pemberton sign
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6
Q

Pemberton sign

A
  • Ask patient to raise both arms above head
  • Normal: nothing
  • SVC syndrome: facial and neck swelling, cough, SoB, cyanosis
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7
Q

investigation for SVCO

A

CT scan with contrast

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8
Q

Management of SVCO

A

Mild

  • Head elevation and diuretics
  • Endovenous stents

Palliative care

  • Cryotherapy
  • Diathermy
  • Bronchial stents for central airway
  • Endobronchial radiotherapy
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9
Q

hypercalcaemia causes in cancer

A

Humoral cause -80%

  • Chemical agents released by tumour disrupt normal calcium homeostasis e.g. PTH-related protein released by certain cancers
  • E.g. paraneoplastic feature of lung cancer – SCC
  • Causes increased release of calcium from bone and increase uptake from kidneys

Bone invasion

  • Osteolytic metastases with local release of cytokines -> increased bone reportion and therefore calcium release from bone into blood

Tumour calcitriol release- Hodgkins lymphoma

Immunotherapies and hormonal therapy

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10
Q

hypercalcaemia presentation

A

Bones, moans, groans, stones, psychiatric overtones
- Nausea
- Anorexia
- Thirst
- Constipation
- Kidney stones
- Confusion
- Polydipsia and polyuria
- Fatigue and weakness
- Bone bane

Neurological
- Seizures
- Poor coordination
- Change in personality

Cardiac
- Bradycardia
- HTN
- Shortened QT interval

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11
Q

investigations for hypercalcaemia

A

Bedside
- Neurological examination
- Urinalysis
- ECG

Laboratory
- Bloods: PTH, blood calcium, UEs

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12
Q

management of hypercalcaemia

A
  • Rehydration (24 hours of normal saline)
  • Steroids
  • Bisphosphonates (inhibit osteoclasts)
  • Systemic treatment of malignant
  • Dialysis if kidney failure

Refractory

  • Denosumab
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13
Q

VTE background and cancer

A
  • Hypercoagulable state is a hallmark of cancer
  • Increased risk 2-3X the normal population
  • Complicated managing risk of thrombocytopenic bleeding and risk of clots

Pathophysiology
- Hypercoagulable state induced by specific prothrombotic properties of cancer cells that activate blood clotting

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14
Q

DVT presentation

A
  • Redness
  • Tenderness
  • Swelling
  • Pitting oedema
  • Collateral superficial veins
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15
Q

PE presentation

A
  • SoB
  • Pleuritic chest pain
  • Cough
  • Tachycardia
  • Cyanosis
  • Dizziness and fainting
  • Sweating
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16
Q

investigations for DVT/ PE in cancer patients

A
  • D-dimer raised in cancer so not used as a predictor
  • DVT- US
  • PE- CTPA

(wells score??)

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17
Q

Management of DVT/PE

A

DOACS

  • Apixaban
  • Dabigatran
  • Edoxaban
  • Rivaroxaban

LMWH

  • Dalteparin
  • Enoxaparin
18
Q

Reducing risk of blood clots whilst in hospital

A
  • Anticoagulants
  • Antiembolic stockings
  • Compression devices
  • Keeping moving
  • Stopping COCB or HRT
  • Keeping hydrated
19
Q

status epilepticus definition

A

It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.

20
Q

management of status epilepticus

A

1) Start timer
2) After 5 mins give
- Lorazepam IV or if in community midazolam buccally/rectally
3) After 10 mins
- Lorazepam IV
- Prepare second line medication
4) At 15 mins
- Phenytoin or Phenobarbital
5) At 20 mins
- Intubate or administer further alternatives to the second line drugs (Levetiracetam, phenytoin, phenobarbital)
6) If this doesnt work
- Rapid sequence induction of anaesthesia using thiopental sodium

21
Q

metastatic spinal cord compression presentation

A

THINK: prostate, lung, breast cancers

A key feature is back pain that is worse on coughing or straining.

Back pain

  • Often for 2-3 months
  • Poorly responsive to analgesia
  • Radiation around chest- band like
  • Radicular
    o Exacerbated by neck flexion, SLR, coughing, sneezing, straining
  • Pain at night/ wakes up

Motor symptoms (upper motor neuronee signs)

  • Affects >75%,
  • Reduced power, difficulty standing, walking, climbing stairs, often symmetrical
  • increased tone, clonus, hyperreflexia

Sensory loss

  • Affects >50%, but may be unaware until examined

Sphincter dysfunction
- Urinary retention with overflow
- Diminishing performance status/generally unwell

22
Q

commonest site of metastatic spinal cord compression

A

thoracic vertebrae

lumbar for spinal cord compression

23
Q

investigations for MSCC

A

oncological emergency and requires rapid imaging and management.
- MRI of whole spine
- Blood tests: group and save, clotting (high risk of surgery being required)

24
Q

referral with signs of MSCC

A
  • Pain suggestive of spinal mets – MRI within1 weeks
  • Signs MSCC, MRI within 24 hours
25
Q

management of MSCC

A

Treatments will depend on individual factors. They may include:
Admit and treat within 24 hours

  • High dose dexamethasone (to reduce swelling in the tumour and relieve compression)
  • Analgesia
  • Surgery
  • Radiotherapy
  • Chemotherapy
26
Q

Radiotherapy and MSCC

A
  • Majority receive this (due to extensive disease and poor performance status when MSCC occurs)
  • Delivered within 24 hours
  • MOA
    o Targets abnormal area plus 1-2 vertebra either side
  • Aim
    o Relieve compression of the spine and nerve roots by causing cell death in the rapidly dividing tumour tissue
    o Relives pain and stabilises neurological deficit
  • Life expectancy often measured in months
27
Q

cauda equina

A
  • Caused by compression of the spinal cord
  • Below L2
  • Peripheral nerves (LMN), containing motor and sensory fibres
  • High level of suspicion and rapid intervention required
28
Q

Presentation of cauda equina syndrome

A

Lower motor neurone signs
- Reduced lower limb sensation (often bilateral)
- Hyporeflexia
- Bladder or bowel dysfunction
o Perianal (saddle) numbness
o Loss of anal tone
o Urinary retention
- Lower limb motor weakness
- Severe back pain
- Impotence

29
Q

investigations for cauda quina syndrome

A

Investigations
- PR examination
- Post-void bladder scan
- Lumbar-sacral spine MRI

30
Q

cauda equina mangement

A

Management
- Surgical decompression
- Radiotherapy and/or chemotherapy

31
Q

neutropenic sepsis definition

A
  • Patient undergoing systemic anticancer treatment (SACT)
  • Temp >38 or over 37.5 degrees over 1 hour
  • Neutrophil count < 0.5 x 10 9per litre or <1.0 and falling
  • Patient can have infection and no fever
32
Q

Presentation neutropenic sepsis

A
  • Fever >38 or over 37.5 degrees over 1 hour
  • Tachycardia >90
  • HYPOTENSION < 90 systolic= URGENT
  • RR > 20
  • Symptoms related to a specific system e.g. cough, SOB, line, mucositis
  • Drowsy
  • Confused
33
Q

investigations for neutropenic sepsis

A

Bedside
- Basic observations

Laboratory
Blood tests
- FBC (with differential)
- U&Es
- LFTs
- ABG (lactate)
- CRP

Cultures/swabs
- Blood – central and peripheral
- Urine
- Sputum
- Wound swabs

Imaging
CXR

34
Q

management of neutropenic sepsis

A

Call for senior help
- Empiric IV broad spectrum antibiotics within the hour: Piperacillin with tazobactam (tazocin)
- Fluid resuscitation
- Oxygen
- Consider catheterisation

35
Q

Prophylaxis for neutropenic sepsis

A
  • A neutrophil count of < 0.5 x 109 as a consequence of their treatment they should be offered a fluoroquinolone
  • All patients should be issued with an alert card with 24gr contact numbers
36
Q

tumour lysis syndrome background

A

triggered by the initiation of cytotoxic therapy- metabolic emergency

37
Q

key biochemical markers of tumour lysis syndrome

A

Massive tumour cell lysis -> release of large amounts of potassium, phosphate and uric acid into the systemic circulation
- Hyperuricemia
- Hyperkalaemia
- Hyperphosphatemia
- Hypocalcaemia

AKI from uric acid and/or calcium phosphate crystals in renal tubules

38
Q

highest risk cancers for tumour lysis syndrome

A

o High grade lymphoma
o Leukaemia
o Myeloma

39
Q

TLS presentation

A

Presentation
- Normally day 3-7 post chemotherapy
- N and V
- Diarrhoea
- Anorexia
- Lethargy
- Haematuria-> oliguria -> anuric
- Fluid overload
- Cardiac arrhythmia/arrest (peaked T waves, QTc derangement)
- Muscle cramps/ tetany/ seizures

40
Q

management of tumour lysis syndrome

A
  • Vigrourous rehydration (fluid resus: 500ml normal saline over 15 mins)
  • Rasburicase to lower uric acid levels
  • Calcium gluconate for hyperkalaemia

Allopurinal to prevent i.e. give to patients at risk

41
Q

investigations for tumour lysis syndrome

A

Bedside
- Urine dip
- ECG
- Cardiac monitoring

Laboratory
Urine microscopy (e.g. uric acid crystals)
Bloods
- Serum lactate
- Lactate dehydrogenase (LDH)

Diagosis: diagnosis of TLS is based on the Cairo-Bishop definition.

42
Q

complication of TLS

A

deposition of uric acid and calcium phosphate crystals in the renal tubules may cause acute renal failure which is often exacerbated by concomitant intravascular volume depletion. These products are normally renally excreted - therefore preexisting renal failure exacerbates the metabolic derangements of tumor lysis syndrome

Year 4 exams (21 decks)

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