KC Onc and Special Pop

Question 1

*What are 2 Definitions of fever in febrile neutropenia

Answer 1

A single temperature at or above 38.3° C
A sustained temperature of at least 38.0° C for at least 1 hour

Question 2

*What are 2 Definitions of neutropenia

Answer 2

ANC less than 500 cells/mm 3
An ANC expected to drop below this threshold within 48 hours

Question 3

*4 biochemical changes in tumour lysis syndrome

Answer 3

• HYPERuricemia (i.e. high uric acid, source is DNA, which is metabolized to uric acid)
• HYPERphosphatemia (phosphate primarily intracellular electrolyte)
• HYPOcalcemia (due to binding of phosphate)
• HYPERkalemia

Question 4

*2 reasons to treat hypocalcemia in TLS

Answer 4

Hypocalcemia with 1) cardiac (e.g. dysrhythmia, heart block) 2) neurologic (e.g. seizure, coma) instability
- Can also give calcium if hyperkalemia with ECG changes

Otherwise should avoid giving calcium just for hypocalcemia; supplemental calcium will only increase calcium-phosphate deposition in the viscera

Question 5

*What are 5 non-infectious causes of fever in an oncology patient

Answer 5

VTE, drug side effect (ex. chemo), tumor burden, transfusion reaction, inflammation

Question 6

*what is the classic triad of hyperviscosity?

Answer 6

Classically presents with the triad of neurological deficits, visual changes, and mucosal bleeding.

Question 7

*Treatment of hyperviscosity

Answer 7

Plasmapheresis (temporizing measures: hydration, phlebotomy, hydroxyurea)

Question 8

*What are high risk criteria in patients with febrile neutropenia?

Answer 8

Opposite of MASCC score:
Severe symptoms
Hypotension
COPD
Heme cancer with prev. fungal infection
Dehydration
Inpatient
Over 60yo

Question 9

*What are the indications for IV vancomycin in a patient with febrile neutropenia?

Answer 9

Hypotension or CVS unstable
Clinically suspected catheter infection
Positive culture for gram+ organisms
Known colonization MRSA (or ceph resistant pneumococcus)
?other: skin/soft tissue infection, pneumonia (page 1498)

Question 10

*What is the appropriate PO antibiotic regimen for a patient with febrile neutropenia being discharged home?

Answer 10

Amox/Clav + cipro
“moxifloxacin monotherapy has shown similar outcomes”

Question 11

*Lymphoma patient on chemo presents with increasing SOB and pleuritic CP, afebrile. 5 Differential Diagnoses

Answer 11

• Pulmonary embolism
• Pericardial effusion/tamponade
• Pericarditis/myocarditis
• Pneumonia
• Pneumothorax
• Mass/airway obstruction
• Acute heart failure

Question 12

*3 treatments of tumour lysis syndrome

Answer 12

• Intravenous fluids, as high as 5-6 L daily
• Prevent/treat hyperuricemia (allopurinol and rasburicase)
• Correct other electrolytes
  consider dialysis)
  Caveats:
• Calcium: To minimize risk of calcium phosphate nephropathy, calcium should only be given in setting of cardiac (e.g. dysrhythmia, heart block) or neurologic (e.g. seizure, coma) instability
• Potassium: Management of hyperkalemia same as any other etiology, including use of calcium
• Uric acid: Allopurinol to decrease production, rasburicase to increase elimination

Question 13

List 5 features associated with low risk febrile neutropenia

Answer 13

[Box 115.1] - MASCC criteria
Hx: age <60, fever while outpatient, no hx of prior fungal infection, no hx of COPD
O/E: asymptomatic or mild symptom burden, no dehydration, no hypotension

Question 14

Which with febrile neutropenia can be treated as an outpatient

Answer 14

1) meet low risk criteria (MASCC score => 21)
2) no evidence of PNA, line infection, cellulitis, or organ failure
3) have reliable follow up with their oncologist
4) have demonstrated clinical stability during an observation in the emergency department that lasts at least 4 hours

Question 15

Which cancers are most likely to cause spinal cord compression

Answer 15

Prostate, breast, lung

Question 16

List 4 ultrasound findings of cardiac tamponade

Answer 16

pericardial fluid, RV diastolic collapse, RA systolic collapse, plethoric IVC

Question 17

What is pulsus paradoxus

Answer 17

> 10 mmHg change in systolic blood pressure between the inspiratory and expiratory phases of the cardiac cycle

Question 18

What is Kussmaul’s sign

Answer 18

paradoxically increased JVP with inspiration

Question 19

List 3 cancers associated with hypercalcemia

Answer 19

Lung, lymphomas, esophagus, head and neck, cervical, endometrial

Question 20

What diuretic should be avoided in hypercalcemia

Answer 20

Thiazides (increase calcium reabsorption)

Question 21

List 5 risk factors for tumor lysis syndrome

Answer 21

Tumor related: high proliferation rate, large tumor burden, increased WBC, bone marrow involvement, kidney involvement, high sensitivity to chemo agents
Host related: low urine output, CKD

Question 22

List 2 cancers at a particular risk for tumor lysis syndrome

Answer 22

lymphoma, leukemia

Question 23

List 2 reasons why high WBCs counts in cancer are particularly prone to causing leukostasis

Answer 23

Blast cells are larger and less deformable than WBCs leading to increased viscosity
Leukemic cells may trigger additional endothelial adhesion mechanisms

Question 24

List 3 cancers and 3 non cancerous causes of SVC syndrome

Answer 24

Cancers: lung, thyroid, breast, lymphoma
Non cancers: thyroid goiter, tuberculosis, pacemaker wires, indwelling central line, thoracic aortic aneurysms, pericardial effusion, post radiation

Question 25

List 2 medications that can be used in invasive fungal infections

Answer 25

Amphotericin B, caspofungin

Question 26

Which medications can be used to treat listeria infections

Answer 26

Ampicillin, gentamicin, Septra Vanco, cephalosporins are not effective

Question 27

Which medications can be used to treat legionella infections

Answer 27

Azithromycin or levofloxacin (respiratory fluoroquinolone)

Question 28

List 5 causes of bilateral infiltrates in the immunocompromised patient

Answer 28

Viruses: CMV, RSV, influenza Bacteria: PCP CHF, TRALI, radiation injury, chemo induced toxicity, ARDS, pulmonary hemorrhage, cancer

Question 29

List 5 causes of focal infiltrate in the immunocompromised patient

Answer 29

Bacterial: Legionella, MRSA, TB Fungi: aspergillosis, mucormycosis, PE, cancer

Question 30

List 5 side effects of corticosteroid use

Answer 30

adrenal insufficiency, peptic ulcer disease, pancreatitis, psychosis, glaucoma, poor wound healing, hyperglycemia, avascular necrosis of the bone, spontaneous fractures

Question 31

List 6 causes of functional asplenia

Answer 31

sickle cell disease, ulcerative colitis, celiac disease, sarcoidosis, amyloidosis, RA, SLE

Question 32

*Define and give two examples for different types of restraints (chemical, physical, environmental)

Answer 32

a. Chemical 1. versed 2. ketamine b. Physical 1. 4 point restraints 2. Mittens c. Environmental 1. Placing the stretcher in slight Trendelenburg with the guardrails up 2. A locked room with CCTV and security monitoring

Question 33

*5 considerations for safety when using waist restraints?

Answer 33

1. Make sure the patient doesn’t have the restraints on too tight 2. Make sure they don’t have open wounds, abdo surgical sites 3. Make sure there’s nothing compromising their ability to breath freely 4. Make sure they have normal peripheral pulses 5. Make sure they can urinate

Question 34

*5 things to consider for your own safety when seeing a violent patient?

Answer 34

1. Do not see patient if they’re actively violent 2. Let security know that you’re seeing a potentially violent patient, ask them to stand nearby 3. Leave the door slightly open, stand near the door to allow quick escape 4. Make sure the patient has been searched for weapons, devices, needles 5. Do not bring anything with you that could be potentially used as a weapon

Question 35

*List 3 classes of antipsychotic medications and give one example of each (to restrain a patient)

Answer 35

- Benzos (Midaz) - Typical Antipsychotics (Haldol) - Atypical antipsychotics (Risperdal)

Question 36

*When using waist restraints, what are 3 considerations to decrease the risk of asphyxiation?

Answer 36

- Avoid prone position - Use of chemical sedation if patient continues to struggle against physical restraint - Frequent re-assessments/Monitoring - Position changes - Remove restraints as soon as possible

Question 37

Describe 10 elements of verbal de-escalation

Answer 37

[Box 189.4] see photo

Question 38

*Name 5 causes of pneumonia in immunocompromised patients?

Answer 38

CMV Aspergillus Candida Pseudomonas Staph aureus

Question 39

*Recognize PCP, what is the prophylaxis for this condition?

Answer 39

Septra

Question 40

*When is the infectious risk highest for a transplant patient and over what period does the risk decline?

Answer 40

1-6 months, declines after?

Question 41

*What are 5 complications of lung transplant?

Answer 41

Anatomic - Anastomosis - Pneumothorax - Hemothorax - Pleural effusion - Empyema - Persistent air leaks Rejection (25% in first year) Infection - CMV most common opportunistic infection post lung transplant Drug toxicity

Question 42

List 3 bacterial, viral, and fungal opportunistic infections

Answer 42

Bacterial: pseudomonas, mycobacterium, listeria, nocardia, clostridium Viral: HIB, HBV, EBV, HCV, HSV, VZV, CMV Fungal: candida, cryptococcus, aspergillus, histoplasma, strongyloides

Question 43

List 5 medications that can interact with anti-rejection medications

Answer 43

Antibiotics: rifampin, fluoroquinolones, macrolides, aminoglycosides, fluconazole, amphotericin Anti convulsants: carbamazepine, phenobarbital, phenytoin Cardiac meds: colchicine, diltiazem, verapamil

Question 44

What are the SPICE organisms and what is their clinical relevance

Answer 44

SPICE: Serratia, providencia, indole-positive proteus, citrobacter, enterobacter Also pseudomonas and acinetobacter These bacteria have inducible AmpC Beta lactam genes that can create B lactam resistance despite apparent sensitivity Avoid third generation cephalosporins Needs 4th generation cephalosporins ex. cefepime, carbapenems, aminoglycosides, or fluoroquinolones

Question 45

List 4 categories of complications post organ transplant

Answer 45

Anatomic/surgical, rejection, infection, drug toxicity ## Footnote RAID

Question 46

List 3 vascular and 3 non vascular complications of solid organ transplant

Answer 46

Vascular: thrombosis, stenosis, AV fistula, pseudoaneurysm, bleeding Non vascular: complications to bile ducts, bronchi, ureters - leaks, obstructions from scarring or migration 

Question 47

What are the three phases to transplant rejection

Answer 47

Hyperacute: days in the peri-operative periods, occurs d/t preformed antibodies or ABO incompatibility Acute: days to week with constitutional sx Chronic: months to years with chronic rejection, fibrosis, inflammation

Question 48

List 4 categories of transplant medications, side effects, and examples of each

Answer 48

Induction agents/mono clonal antibodies ex. Alemtuzumab - risk of immunosuppression Calcineurin inhibitors ex. Tacrolimus, cyclosporin - risk of nephrotoxicity, neurotoxicity Rapanycin inhibitors ex. Sirolimus - risk of nephrotoxicity, impaired wound healing, pneumonitis Antimetabolites ex. azathioprine, mycophenolate - risk of hepatotoxicity and bine marrow depression Corticosteroids

Question 49

List 4 physiologic changes in the transplanted heart

Answer 49

Increases resting heart rate to 95-110 due to lack of parasympathetic tone Medications affecting autonomic nervous system ex. Atropine will have no use  Increased risk of silent or asymptomatic MI Donor and recipient SA nodes may show two different P waves

Question 50

What is the most common vascular complication post hepatic transplant

Answer 50

Hepatic artery thrombosis

Question 51

*5 medical interventions you would do

Answer 51

HIV PEP Hep B PEP Gono/chlam treatment Trich treatment Tetanus Levonorgestrel + antiemetic

Question 52

*4 populations at risk

Answer 52

Homeless, Those with severe disabilities (eg, serious injury, chronic disease, chronic mental health problems), Incarcerated men and women, Children. College-aged women (especially freshman), Nonheterosexuals, Those who use drugs and alcohol, Sex workers.

Question 53

*3 signs in a male

Answer 53

The anal and rectal examination should include visualization to look for potential foreign bodies and gross injury, such as tears, abrasions, bleeding, erythema, hematoma, fissures, engorgement, and friability.

Question 54

*2 reasons for urine tox screen in the sexual assault patient

Answer 54

• Period of unconsciousness • Period of loss of motor control • Amnesia or confused state with suspicion of sexual assault • Patient suspicion or belief that she or he was drugged prior to or during sexual assault And • Less than 72–96 hours since assault (depending on jurisdictional protocol)

Question 55

What is the ideal imaging in the non fatal strangulation patient

Answer 55

CTA neck +/- CT head if concerns for hypoxic brain injury

Question 56

List 5 signs on history that may suggest human trafficking

Answer 56

[Box 59.1] see photo