OSCE emergencies (Cancer care) Flashcards
Presentation of bowel obstruction
- Stomach pain- colicky
- Constipation
- Vomiting Occurs early in upper GI obstruction and later in lower GI
- Abdominal distension
investigations for bowel obstruction
- Abdominal X ray
o Central- upper
o Peripheral- lower - CT scan (best)
- Barium enema
management of BO
depends on stage and what is appropriate
management of BO
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
superior vena cava obstruction presentation
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
Pemberton sign
- Ask patient to raise both arms above head
- Normal: nothing
- SVC syndrome: facial and neck swelling, cough, SoB, cyanosis
investigation for SVCO
CT scan with contrast
Management of SVCO
Mild
- Head elevation and diuretics
- Endovenous stents
Palliative care
- Cryotherapy
- Diathermy
- Bronchial stents for central airway
- Endobronchial radiotherapy
hypercalcaemia causes in cancer
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
hypercalcaemia presentation
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
investigations for hypercalcaemia
Bedside
- Neurological examination
- Urinalysis
- ECG
Laboratory
- Bloods: PTH, blood calcium, UEs
management of hypercalcaemia
- Rehydration (24 hours of normal saline)
- Steroids
- Bisphosphonates (inhibit osteoclasts)
- Systemic treatment of malignant
- Dialysis if kidney failure
Refractory
- Denosumab
VTE background and cancer
- 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
DVT presentation
- Redness
- Tenderness
- Swelling
- Pitting oedema
- Collateral superficial veins
PE presentation
- SoB
- Pleuritic chest pain
- Cough
- Tachycardia
- Cyanosis
- Dizziness and fainting
- Sweating
investigations for DVT/ PE in cancer patients
- D-dimer raised in cancer so not used as a predictor
- DVT- US
- PE- CTPA
(wells score??)
Management of DVT/PE
DOACS
- Apixaban
- Dabigatran
- Edoxaban
- Rivaroxaban
LMWH
- Dalteparin
- Enoxaparin
Reducing risk of blood clots whilst in hospital
- Anticoagulants
- Antiembolic stockings
- Compression devices
- Keeping moving
- Stopping COCB or HRT
- Keeping hydrated
status epilepticus definition
It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.
management of status epilepticus
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
metastatic spinal cord compression presentation
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
commonest site of metastatic spinal cord compression
thoracic vertebrae
lumbar for spinal cord compression
investigations for MSCC
oncological emergency and requires rapid imaging and management.
- MRI of whole spine
- Blood tests: group and save, clotting (high risk of surgery being required)
referral with signs of MSCC
- Pain suggestive of spinal mets – MRI within1 weeks
- Signs MSCC, MRI within 24 hours
management of MSCC
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
Radiotherapy and MSCC
- 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
cauda equina
- 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
Presentation of cauda equina syndrome
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
investigations for cauda quina syndrome
Investigations
- PR examination
- Post-void bladder scan
- Lumbar-sacral spine MRI
cauda equina mangement
Management
- Surgical decompression
- Radiotherapy and/or chemotherapy
neutropenic sepsis definition
- 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
Presentation neutropenic sepsis
- 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
investigations for neutropenic sepsis
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
management of neutropenic sepsis
Call for senior help
- Empiric IV broad spectrum antibiotics within the hour: Piperacillin with tazobactam (tazocin)
- Fluid resuscitation
- Oxygen
- Consider catheterisation
Prophylaxis for neutropenic sepsis
- 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
tumour lysis syndrome background
triggered by the initiation of cytotoxic therapy- metabolic emergency
key biochemical markers of tumour lysis syndrome
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
highest risk cancers for tumour lysis syndrome
o High grade lymphoma
o Leukaemia
o Myeloma
TLS presentation
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
management of tumour lysis syndrome
- 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
investigations for tumour lysis syndrome
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.
complication of TLS
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
