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Clin Therapeutics II (Spring 2018) > Exam 1: Malignant emergencies > Flashcards

Exam 1: Malignant emergencies Flashcards

1
Q

SVC Syndrome can be caused by what type of catheter?

A

Thrombosis from indwelling catheter (IV cath)

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2
Q

Most common sx of SVC Syndrome?

A

Dyspnea

Followed by cough and orthopnea

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3
Q

What are the two most frequent signs of SVC syndrome?

A

Neck vein distension (JVD) AND facial swelling/fullness

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4
Q

What do the arm veins, neck veins, and face look like in SVC Syndrome?

A

Distended arm and neck veins. Facial swelling/fullness.

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5
Q

What is an ominous sign of SVC syndrome that represents a true emergency?

A

Papilledema

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6
Q

What is compressed or occluded in SVC Syndrome?

A

Superior Vena Cava

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7
Q

Dx to confirm SVC Syndrome?

A

CXR first, confirm with Chest CT with contrast

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8
Q

Tx of SVC Syndrome? (Hint: position? meds? remove?)

A
  • keep in head-up position (to make fluid go down)
  • IV steroids (shrinks tumor swelling)
  • IV diuretics (Torsemide)
  • Anticoagulants or thrombolytics (if clot in SVC)
  • Emergent mediastinal radiation
  • remove central IV catheter if present
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9
Q

Acute Spinal Cord Compression usually results from extension of what?

A

Extension of spinal bony metastases

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10
Q

Where do mets most commonly occur in Acute Spinal Cord Compression?

A

Thoracic spine

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11
Q

What are the 4 most common tumors causing spinal cord compression

A 
Breast
Lung
Prostate
Renal cell
All 4 hide in bone

Other tumors include lymphomas, MM and sarcomas which destroy bone

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12
Q

Sx in Acute Spinal Cord Compression?

A

Localized back pain (most common) +/- tenderness (may be absent with lymphomas)

  • paraparesis/paraplegia
  • distal sensory deficits
  • gait disturbance
  • urinary incontinence
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13
Q

Dx of choice for Acute Spinal Cord Compression? What other studies can you do ?

A

MRI STUDY OF CHOICE

cervical, thoracic, or lumbar spine films (but neg films don’t rule out SCC)

radionuclide bone scan (>90% sensitivity, except for multiple myeloma)

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14
Q

Tx for Acute Spinal Cord Compression? What is key tx?

A

Spine immobilization. Emergent decompressive Laminectomy.
Key tx=radiation!

+/- IV steroids / diuretic / mannitol for swelling
Foley cath for incontinence

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15
Q

What are the most common tumors causing hypercalcemia

A

Metastatic breast, lung or prostate ca

Multiple myeloma

NHL

Head+neck scc

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16
Q

2 most common types of Hypercalcemia of Malignancy?

A
  1. Humoral hypercalcemi of malignancy via PTHrP
  2. Local bone destruction

Less commonly Tumor production of Vit D analogues

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17
Q

Sx of Hypercalcemia of Malignancy?

A

Moans, bones, stones, groans, psych undertones.

Vague malaise/weakness, polydipsia, anoexia, nausea, confusion

Can lead to seizures

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18
Q

Lower the albumin what happens to calcium levels?

A

Lower albumin, higher calcium

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19
Q

Formula for Corrected Calcium? What is dangerous?

A

Corrected Ca2+ = Total Ca + {0.8 X (4.0-albumin)}

>12 is dangerous

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20
Q

Low Serum ___ can indicate Hypercalcemia of Malignancy?

A

Low Serum Cl-

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21
Q

QT in Hypercalcemia of Malignancy?

A

Short QT

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22
Q

PR in Hypercalcemia of Malignancy??

A

Long PR

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23
Q

Voltage in Hypercalcemia of Malignancy?

A

Low voltage

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24
Q

IV hydration until when in Hypercalcemia of Malignancy?

A

Voiding 150-200 mL/hr

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25
Q

Once euvolemic what to give in Hypercalcemia of Malignancy?

A

Loop diuretics

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26
Q

Which diuretic to avoid in Hypercalcemia of Malignancy?

A

Thiazide!

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27
Q

What to avoid in Hypercalcemia of Malignancy?

A

PO Phosphate

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28
Q

What to discontinue in Hypercalcemia of Malignancy? (hint: 4)

A
  1. Calcium
  2. VitD
  3. Thiazides
  4. NSAIDs
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29
Q

Meds to control high Ca2+ in Hypercalcemia of Malignancy?

A

SC/IM Calcitonin, Bisphosphonates, corticosteroids, dialysis, AVOID ORAL PHOSPHATE

Calcitonin quickly lowers serum calc levels
Bisphosphonattes block osteoclasts bone resorption
Corticosteroids most effective (elevated Vit D)
HD for renal/heart failure

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30
Q

Which bisphosphonates to avoid in renal failure?

A

Zoledronic acid

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31
Q

Which two bisphosphonates are IV. Which one is SQ

A

Pamindronate 60-90mg IV over 60 minutes

Zolendronic Acid 4mg IV over 15 minutes
- don’t use in renal failure

Denosumab 120 mg sc

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32
Q

Normal ANC?

A

> 1000

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33
Q

Neutropenic ANC?

A

500-1000

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34
Q

Severe neutropenia?

A

<500

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35
Q

How to calculate ANC?

A

ANC=(WBC)(% neutrophils + % bands)

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36
Q

What is ANC if WBC=6000; Seg=30%; Band=3%

A

ANC=(6000)(0.30+0.03)

ANC=2000

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37
Q

When does Febrile Neuropenia most commonly occur?

A

During nadir after chemo

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38
Q

When is nadir in Febrile Neuropenia?

A

5-10 days after chemo. Lasts 5 days.

39
Q

Which gram bacteria from central lines in Febrile Neuropenia?

A

Gram positive

40
Q

Which gram are enteric bacteria in Febrile Neuropenia?

A

Gram negative

41
Q

Sx of Febrile Neuropenia?

A

ASx to severe sepsis

UTI without pyuria (no WBCs in urine)

42
Q

What exam should you try to avoid in febrile neutropenia

A

Internal rectal exam

Don’t want to compromise mucosa

43
Q

Single PO temp above what in Febrile Neuropenia?

A

> 101.3F

44
Q

Sustained temp above ___ for how long in Febrile Neuropenia?

A

> 100.4 for 1 hour

45
Q

How many blood cultures in Febrile Neuropenia? Where?

A

2x peripheral

1x from catheter

46
Q

What is involved in febrile neutropenia work up

A

Blood Cx (2 sets one from Peripheral vein and one from catheter)
Urine Cx
Sputum Cx and gram stain
Stool, CSF Cx if inficated
CXR –may be nl, consider a CT if respiratory complaints

47
Q

Which 2 abx for Febrile Neuropenia?

A

Vanco=staph and strep

Cefepime=gram + and pseudomonas

48
Q

What time frame to give abx in Febrile Neuropenia?

A

Within 1 hour of presentation

49
Q

Tx if afebrile Neuropenia? (Hint: based on ANC)

A

IV Abx for 5-7 days then PO Abx when ANC >1000

  • continue initial abx until blood cx available, then adjust abx based on culture/sensitivities
  • treat for 5-7 days of IV and consider PO if ANC >1000
50
Q

Tx for febrile Febrile Neuropenia?

A

IV Abx for 5-7 days.

50
Q

When to add antifungal in Febrile Neuropenia?

A

After 4 days (>72h)

Fluconazole and ketoconazole

51
Q

What medication makes neutrophils? What dose?

A

G-CSF.

5mcg/kg/day SC . (300-480mcg/day)

52
Q

When to D/C (discharge) tx in Febrile Neuropenia? (3 criteria)

A
  1. ANC normal >1000
  2. Afebrile for 24h
  3. Cx negative
53
Q

Most common tumors causes of tumor lysis syndrome

A

Leukemia’s with high WBCs
Lymphomas
Small cell ca
Metastatic adenoca

55
Q

What is tumor lysis syndrome? What happens to cancer cells in Tumor Lysis Syndrome?

A

Rapid destruction of CA cells after chemo or radiation

metabolic complications which occur after tx of bulky chemo-responsive malignancies

55
Q

When does Tumor Lysis Syndrome happen?

A

6-72 hours after chemo or radiation

57
Q

What sort of complications occur with Tumor Lysis Syndrome?

A

Metabolic complications from release of cell contents into serum

58
Q

metabolic complications that occur in tumor lysis syndrome?

What 3 things are elevated? what is low?

A

HyperK,
Hyperuricemia,
Hyperphophatemia
Hypocalcemia. (D/t precip of calc phosphate)

Can lead to Acute renal failure and arrhythmias

59
Q

Etiologic factors of TLS. What two elevated labs are attributed with acute tumor lysis

A

High preRx serum LDH or uric acid

large tumor burden, high growth fraction, high preRx serum LDH or uric acid, pre-existing renal insufficiency

60
Q

What to do with chemo and radiation in Tumor Lysis Syndrome?

A

STOP THEM!

61
Q

How hydrate in Tumor Lysis Syndrome?

A

Aggressively with diuresis

62
Q

How to treat elevated uric acid in Tumor Lysis Syndrome?

A

Alkalize urine to pH 7 with NaHCO3 (bicarb)

63
Q

How to treat HyperK in Tumor Lysis Syndrome?

A

CaCl2, NaHCO3, Glucose/Insulin, Kayexalate

64
Q

When to do emergent hemodialysis in Tumor Lysis Syndrome? (hint: K, uric acid, Cr, peeing)

A
  1. K>6
  2. Uric Acid >10
  3. Cr >10
  4. or can’t tolerate diuretics
65
Q

Which med to prevent uric acid build up in Tumor Lysis Syndrome?

A

Allopurinol

66
Q

Which med to rapidly decrease uric acid in Tumor Lysis Syndrome?

A

Rasburicase

Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin so it can be secreted.

67
Q

All treatments for tumor lysis

A

Stop the chemoRx, hold any further lysis

Aggressive IV hydration NS/ diuresis

+/- alkalinize urine to pH 7 (NaHco3)
–Decreases uric acid but may worsen hypocalcemic tetany

CaCl2, NaHCO3, glucose / insulin, kayexalate for hyperkalemia

Emergency hemodialysis
–If K > 6, uric acid > 10, creat. > 10, or unable to tolerate diuresis

Can use allopurinol for prevention pre & Post Chemo

Rasburicase – rapid degredation of uric Acid

67
Q

What happens to the kidneys with tumor lysis

A

Proteins and nuclei acids broken down by xanthine oxidase to uric acid

Excess uric acid accumulated in kidney and results in uric acid Nephropathy and AKI

elevates phosphate causes dec urine output. Binds to serum calc which also precip in kidney

68
Q

How often is Malignant Pericardial Temponade an early sign of malignancy?

A

Rarely!

70
Q

Heart tones in Malignant Pericardial Temponade?

A

Muffled/decreased

70
Q

JVD in Malignant Pericardial Temponade?

A

Yes they will have JVD

72
Q

Pulsus paradoxis in Malignant Pericardial Temponade?

A

> 10mmHg

73
Q

QRS complex in Malignant Pericardial Temponade?

A

Low voltage

74
Q

Most common causative tumors in pericardial tamponade

A 
Melanoma
HL
acute leukemia
Lung ca
Breast ca
Ovarian ca

Radiation pericarditis

75
Q

Friction rub in Malignant Pericardial Temponade?

A

Rarely

76
Q

what is the EKG like for malignant pericardial tamponade?

A

low QRS voltage +/- pulses alternans

77
Q

Dx of choice for Malignant Pericardial Temponade? What will it show?

A

Echo! Will show equalization of heart chamber pressures.

78
Q

Tx for Malignant Pericardial Temponade?

A

MC Needle catheter pericardiocentesis.

Others=pericardial window, pericardiectomy, radiation, intrapericardial chemoRx or sclerosis

80
Q

Si/sx of malignant pericardial tamponade

A

–Dyspnea / weakness +/- chest pain
-Hypotension / narrow pulse pressure
-Friction rub rare –Jugular venous distention
-Muffled (decreased) heart tones
-Pulsus paradoxicus > 10 mm Hg
-Low EKG QRS voltage +/- pulsus alternans
+/- cardiomegaly on CXR

81
Q

causative tumors of SVC syndrome

A
  • small cell (oat cell) lung cancer
  • squamous cell lung cancer
  • lymphoma
  • anaplastic mediastinal cancer
82
Q

what can form in spinal column and cause acute spinal cord compression?

A

epidural abscess/hematoma

83
Q

what IV steroid is given for tx of acute spinal cord compression?

A

Decadron aka dexamethasone

-decreases swelling of tumor

84
Q

what is key in tx of acute spinal cord compression? what does it do?

A

radiation - shrinks the tumor pressing on the cord

85
Q

When and why do you do a corrected calcium

A

Done in setting of hypO albuminemia. Low albumin = less ionized Ca bound to albumin = pseudohypOcalcemia.

The labs for calcium drawn measure the ionized calcium, and thus will report a false low. Your patient may have hypercalcemia but without a corrected value may appear normocalcemic.

86
Q

What IV fluid is tx of choice for hypercalcemia?

A

Normal saline

87
Q

what needs to be given immediately to pts with hypercalcemia?

A

HYDRATION - IV FLUIDS -> TO PEE OUT THE CA

-Normal Saline is of choice

88
Q

How do bisphosphonates work?

A

block osteoclastic bone resorption

89
Q

when would hypercalcemic pt go on dialysis?

A

pt with renal or heart failure

not life-long, just for acute episode

used b/c fluid will start to back up -> CHF

90
Q

what is febrile neutropenia defined as?

A

single oral temp >101.3 F

sustained temp >100.4 for 1 hr

ANC <1000

91
Q

risk of infection if neutropenic increases with what?

A
  • duration of neutropenia
  • severity of ANC <100
  • comorbidities
  • central lines
  • hepatic or renal insufficiency
92
Q

when to use G-CSF for febrile neutropenia?

A
  • profound neutropenia, shock, co-morbidities
  • worsening clinical course and expected prolonged neutropenia
  • pt not responding to abx
93
Q

what is G-CSF? what does it do?

A

Granulocyte Colony Stimulating Factor

speeds up resolution of neutropenia (stimulates production or neutrophils)

93
Q

how long does it take G-CSF to work? how long do you have to wait to give it again?

A
  • profound neutropenia, shock, co-morbidities
  • worsening clinical course and expected prolonged neutropenia
  • pt not responding to abx

Clin Therapeutics II (Spring 2018) (11 decks)

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