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Flashcards in Heme-Onc Deck (31):
1

Sickle Cell Emergencies

Review Evernote

2

How to supplement Iron

Iron supplementation:  50 mg elemental Fe QHS with 500 mg vitamin C. Avoid taking with tea. Better taken with bloody red meat. More is not better unless severely deficient.
 


Ferrous gluconate 300 mg = 35 mg elemental Fe
Ferrous sulfate 300 mg = 60 mg elemental Fe
Ferrous fumarate 300 mg = 100 mg elemental Fe
FeraMAX 150 mg = 150 mg elemental Fe

3

PERC Rule

1. Pretest probability of PE

2.

Hormone use (estrogen)

Age > 50

DVT/PE Hx

Coughing blood

Leg swelling

O2 sat

Tachycardia > 100 BPM

Surgery/Trauma (within 4 weeks)

4

Explain the prothrombotic effect of Warfarin at initiation of therapy

  • protein C has short half-life (7 hours)
  • 10, 9, 7, 2 have longer half-lives (up to 60 hours)
  • thus, on balance, the initial effect for the first 24-36 h is prothrombotic (hence bridging with LMWH)

5

Drugs that increase/decrease INR

  • Drugs that increase INR
    • NSAIDS
    • TMP-SMX
    • macrolides (but not azithro)
    • quinolones
  • Drugs that decrease INR
    • anticonvulsants
    • antipsychotics
    • sedatives (haldol, trazodone)

6

Warfarin Reversal and nomogram

  • Life-threatening bleeding
    • Vitamin K 5-10 mg slow IV bolus
    • Octaplex IV
      • INR > 6: 50 units/kg (max 5000)
      • INR 4-6: 35 units/kg (max 3500)
      • INR <4: 25 units/kg (max 2500)
    • FFP (instead of PCC)
      • 10-15 mL/kg IV
      • restores INR to 1.7-1.8
    • rFVIIa (instead of FFP/PCC)
      • 80 mcg/kg slow IV bolus
  • Minor/no bleeding, INR > 10
    • Vitamin K 2 mg PO
    • hold 1-2 doses
  • Minor/no bleeding, INR 4.5-10
    • Vitamin K 2 mg PO if high risk
    • hold 1-2 doses
  • Minor/no bleeding, INR 3-4.5
    • lower dose by 15% or omit 1 dose if high risk

7

Dabigatran

Class

Reversal

  • direct thrombin inhibitor
  • reversal
    • hemodialysis
    • aPCC > rFVIIa > PCC may work
    • idarucizumab

8

Rivaroxaban, Apixaban

Class

Reversal

  • FXa inhibitors
    • reversal
      • dialysis not effective
      • FFP, PCC, rFVIIa

9

UFH Reversal, side-effects of reversal

  • protamine
  • 0.2% incidence anaphylaxis

10

HIT (read through)

  • normal for plt to fall 10-20%
  • (no lower than 100 k) 2-3 d after starting tx, recover within 4 days
  • check plt 24h after starting UFH + Q2-3 days
  • HIT is IgG/IgM aggainst heparin + platelet factor 4
    • low plts + thrombosis
  • usually 5-10 days after starting treatment
    • may be immediate if received heparin before
    • plt fall of > 50%
    • tx
      • stop all heparin
      • give fonda or bivalirudin if strongly suspicious
      • platelets recover within 4-6 days

11

LMWH Reversal

  • protamine (partial)

12

ASA

  • effect duration
  • treatment of bleeding

  • lasts ~7 d
  • treatment (may need to repeat daily)
    • platelet transfusion to increase count by 50 k +
    • desmopressin

13

Plavix, Ticagrelor, Prasugrel

Class

Treatment of bleeding

  • Adenosine Diphosphate Receptor Agents
  • supportive +- platelet transfusion +- desmopressin

14

Febrile Neutropenia Definition

  • ANC < 500 or ANC < 1000 with predicted decline
    • nadir 5-10 days post-chemo
  • single oral T >=38.3 or miltiple >= 38.0 separated by > 1h

15

ITP (read through)

  • immune thrombocytopenia (ITP)
    • 80% self-limited, resolve within 6 mo.
    • incidence life-threatening bleeding <0.5%
    • > 3 mo. is persistent, >12 mo. is chronic
    • usually isolated thrombocytopenia, bruising, after viral illness
    • speak with heme
    • sometimes prednisone (only if leukemia excluded), anti-Rh (D), IVIG
    • admit if bleeding, IV meds, or plt < 20 k
    • transfuse only if life-threatening bleeding

16

Afebrile Neutropenia

  • ANC < 1.5 sometimes normal in infants and also blacks/middle easterners
  • ANC < 1.0 always abnormal
  • Fx + ANC < 1.5, always Abx even if not on chemo
  • if higher counts and looks well or no fever/infection then outpatient peds

17

Definition of Massive Transfusion

  • > 6 units PRBC in 4h
  • rapid blood loss (>1500 mL)

18

Labs to send in Massive Transfusion

  • Initial
    • Cross-match
    • CBC
    • INR
    • aPTT
    • fibrinogen
    • ROTEM (if trauma patient)
    • lytes, Cr
    • ionized calcium
    • VBG, lactate
  • Subsequent
    • ABG/VBG, ionized calcium, lytes Q 15-30 min

    •  

      CBC, INR, aPTT, fibrinogen Q1h

19

1st Round Massive Transfusion

  • 6 units PRBC (x-matched, or grouped, or Group O)
  • 4 units FFP (grouped or AB if unknown)

20

Massive Transfusion Targets

  • FFP to INR < 1.5 and/or aPTT < 1.5x normal
  • cryo to fibrinogen > 1.5 g/L
  • plt to > 50k during bleeding or > 100k if CNS bleeding/TBI
  • RBC to Hb > 80

21

Spherocytosis vs. schistocytosis

  • spherocytosis: extravascular hemolysis (spleen takes bite out of RBC membrane, making it more spherical)
  • schistocytosis: intravascular hemolysis

22

TTP Pentad

pentad (present in 5% of patients)

  • fever
  • CNS problems (sz/CVA/LOC)
  • renal failure
  • MAHA
  • thrombocytopenia (often < 20k)

23

Aquired Hemolytic Anemias

Read Through

24

Warfarin Management

Review Evernote

25

Febrile Neutropenia Definition & Management

  • ANC < 1.0 + T > 38.3 (100.9F) on one occasion or > 38  (100.4) > 1h
    • severe neutropenia is ANC < 0.5
  • nadir is 5-10d post-chemo, recovers within 5d afterwards
  • labs
    • CBC, eGBCL, LFT's
    • BC x 2 + 1 for each cath site
    • wound/sputum cultures if applicable
    • CXR
    • no DRE until after IV abx (if necessary)
  • dispo
    • MASCC score
    • > 21 is generally safe for outpatient treatment
    • < 21 should be admitted
  • tx
    • treat ANC < 0.5, or < 1 and falling/concerned/evidence of infection
    • median duration of fever after starting empiric abx is 2 days in low-risk patients and 5-7 days in high-risk patients
    • therefore wait 2-4 days before adjusting therapy unless clinical deterioration
    • continue until infection resolved or ANC > 0.5
    • outpatient: cipro/levo + clavulin
    • daily medical assessments for initial 3d
  • inpatient: cefepime 2g IV Q8h or pip-tazo 4.5 g IV Q6h, add vanco if HD instability, catheter infection, pneumonia; add Flagyl if abdominal symptoms present

26

Hyperviscosity Syndrome

  • most often from Waldenstrom's or IgA myeloma or leukemia
  • fatigue, AP, HA, altered LOC, thrombosis/bleeding
  • lab measurement of plasma/serum viscosity will not identify hyperviscosity from polycythemia/leukemia
  • rouleaux bodies on smear
  • tx: IVF, 1L phlebotomy with 2-3L NS replacement if coma (discuss with heme)

27

Tumor Lysis Syndrome

  • usually heme malignancy, usually after treatment
    • AKI (precipitation of uric acid and CaPO4 in tubules, sz, arrhythmias
    • hyperuricemia, hyperK+, hyperPO4, hypoCa2+
  • tx
    • aggressive IVF
    • HD
    • careful with Ca in hyperK as may cause worse AKI from precipitation (only use if unstable/ECG changes)

28

Hypercalcemia of Malignancy

  • rarely needs tx if asymptomatic and total serum Ca < 3.5
  • tx
    • tend to be intravasc deplete because of calcium related diuresis, 1-2 L NS bolus --> 250 mL/h
    • lasix if CHF/renal insufficiency to help with volume

29

Hemophilia

Review Evernote (Bleeding Disorders)

30

Selection of anticoagulants in renal impairment

See Evernote "Antithrombotics"

31