oncologic emergencies

Question 1

what presentation of hyponatremia constitutes an oncologic emergency?

Answer 1

severe hyponatremia with neurologic changes

Question 2

how to treat euvolemic, severe hyponatremia from SIADH with no neurologic changes

Answer 2

free water restriction and treatment of underlying cause

Question 3

what is the max rate of sodium correction to avoid central pontine myelinolysis?

Answer 3

less than 0.5 mEg/L/h

Question 4

hypertonic saline should be reserved for what patients?

Answer 4

those with severe hyponatremia with neurologic symptoms

Question 5

what drug class bind to the v2 receptor of the collecting ducts where ADH exerts its effects, in order to cause aquaresis?

Answer 5

vaptans

Question 6

for asymptomatic and euvolemic hyponatremia, what is the recommended water restriction?

Answer 6

restrict to less than 0.5 to 1 liter per day

Question 7

to diagnose the cause of hyponatremia, what conditions must be excluded to rule out SIADH

Answer 7

hypothyroidism and adrenal insufficiency

Question 8

what urine osmolality is supportive of the diagnosis of SIADH

Answer 8

> 40 mOsm/kg

Question 9

what is the most common cause of euvolemic hyponatremia?

Answer 9

SIADH

Question 10

what is the differential for hyponatremia in the oncologic setting?

Answer 10

SIADH from tumors, brain mets, N/V, several chemotherapy drugs, imatinib, and unrelieved pain

Question 11

cisplatin, cyclophosphamide, ifosphamide, vinca alkaloids, and imatinib can all cause what condition that can affect nervous system function?

Answer 11

hyponatremia

Question 12

what is the gold standard for evaluating spinal cord compression?

Answer 12

MRI

Question 13

cancer and back pain should be considered what until proven otherwise

Answer 13

spinal cord compression

Question 14

what are the most common causes of spinal cord compression?

Answer 14

breast, lung, and prostate cancer (15-20% of cases)

Question 15

what are the less common causes of spinal cord compression?

Answer 15

renal cancer, myeloma, and hodgkin lymphoma (5-10% of cases)

Question 16

what masses can compress the spinal cord yet present with normal plain spine films and normal bone scans?

Answer 16

paraspinous masses. They invade through the intervertebral foramen, most commonly lymphomas, sarcomas, and lung cancer.

Question 17

cancer patients with back pain with a normal neurologic exam should be evaluated for spinal cord compression within what time frame?

Answer 17

24-48 hours

Question 18

cancer patients with back pain and an abnormal neurologic exam should be evaluated for spinal cord compression within what time frame?

Answer 18

immediately

Question 19

what is a key pharmacologic treatment in spinal cord compression?

Answer 19

standard dose of dexamethasone 16 mg bolus IV followed by 4-6 mg q 4-6 hours, followed by rapid taper after resection or radiation therapy

Question 20

surgical decompression and radiation therapy should be used when?

Answer 20

highly selected cases not involving radiosensitive tumors, multiple discrete lesions, only cauda equina or spinal root compression.

Question 21

what are the life-threatening symptoms of SVC syndrome?

Answer 21

central airway obstruction
laryngeal edema
coma from cerebral edema

Question 22

what imaging is indicated for suspicion of SVC syndrome when there are mild symptoms?

Answer 22

CT or MRI

Question 23

what imaging is indicated for suspicion of SVC syndrome when there are severe symptoms?

Answer 23

CT venogram

Question 24

what is the NCCN recommended approach for life threatening SVC syndrome, non-radiation/non-chemotherapy sensitive malignancies, and non-iatrogenic related SVC syndromes?

Answer 24

endovascular stent

Question 25

new onset dyspnea/orthopnea, cough, hoarse voice, stridor, syncope, and/or headaches/mental status changes are all symptoms of what serious condition?

Answer 25

SVC syndrome

Question 26

what ecg findings are strongly suggestive of pericardial effusion, and not necessarily cardiac tamponade?

Answer 26

electrical alternans

Question 27

what is the name of the classic xray finding for pericardial effusion?

Answer 27

water bottle pattern of cardiomegaly

Question 28

what echocardiogram finding is diagnostic for cardiac tamponade?

Answer 28

pericardial effusion andright ventricular collapse during diastole

Question 29

hypotension, muffled precordium, and elevated JVP are known as what finding suggestive of tamponade?

Answer 29

Beck's triad

Question 30

what test is the definitive diagnostic test for tamponade?

Answer 30

echocardiogram

Question 31

if a bowel obstruction is suspected, what findings are suggestive of a perforation?

Answer 31

fever, tachycardia, hypotension, peritoneal signs, ascites

Question 32

what physical exam finding should not be relied on to rule out bowel obstruction?

Answer 32

bowel sounds, as they can continue early in the obstruction

Question 33

what is the imaging/lab test workup for a suspected bowel obstruction?

Answer 33

CT AP with contrast, CBC, CMP, lactate

Question 34

type of obstruction which is due to insufficient or absent peristalsis

Answer 34

functional bowel obstruction

Question 35

what descriptors signify whether the obstruction is inside or outside the bowel?

Answer 35

intraluminal or extraluminal.

Question 36

what descriptor signifies that the obstruction is located within the bowel wall?

Answer 36

intramural

Question 37

tumor involvement of the enteric nervous system or the celiac plexus, paraneoplastic syndrome, or drug induced ileus can result in what type of bowel obstruction?

Answer 37

functional bowel obstruction

Question 38

what are the most common causes of bowel obstruction in patients with cancer?

Answer 38

adhesions and tumors

Question 39

what is the term for a bowel obstruction caused by two distinct points of obstruction?

Answer 39

closed-loop obstruction

Question 40

what is the term for a bowel obstruction with compromised blood flow to the bowel causing ischemic necrosis?

Answer 40

strangulated obstruction

Question 41

when is a strangulated obstruction most likely to occur?

Answer 41

in setting of complete bowel obstruction, and more common in closed-loop obstructions.

Question 42

in adults, an intussusception is usually due to what conditions?

Answer 42

instrinsic bowl tumor/metastases

Question 43

what is the most common cause of large bowel obstruction?

Answer 43

colorectal cancers. 60% are due to this.

Question 44

what is the usual treatment for large bowel obstruction?

Answer 44

stent and/or resection

Question 45

how is bowel perforation diagnosed

Answer 45

free air seen on imaging studies

Question 46

what is the treatment priority in bowel obstruction and peritonitis?

Answer 46

sepsis management. Can include microbiologic evaluation, fluid resuscitation, broad spectrum antibiotics to cover enteric pathogens, and source control (drainage of infected fluid collections and colonic resection)

Question 47

in the initial management of malignant bowel obstruction, what lab finding should raise the suspicion for bowel necrosis?

Answer 47

persistent acidosis

Question 48

what common complication of bowel obstruction makes it important to monitor urine output?

Answer 48

dehydration

Question 49

what intervention can be considered for nausea and vomiting to decrease the risk of aspiration?

Answer 49

nasogastric tube placement

Question 50

for malignant small bowel obstruction with concern for perforation, necrosis, or ischemia, what other features should prompt surgical consideration?

Answer 50

closed-loop obstruction, volvulus, intussusception, or small bowel tumor

Question 51

in medical management of malignant bowel obstruction, why is IV hydration important?

Answer 51

prevent dehydration and correct electrolyte abnormalities

Question 52

T or F: opioids may be used for pain control with bowel obstructions

Answer 52

True, a meta-analysis showed there is no difference in the rate of spontaneous resolution between patients who are treated with opioids and those who are not.

Question 53

in medical management of malignant bowel obstruction, what is recommended in addition to antiemetics to help control nausea?

Answer 53

dexamethasone to reduce bowel edema, inflammation, and distension

Question 54

in medical management of malignant bowel obstruction, what agents can be considered to reduce secretions?

Answer 54

scopolamine, h2 blockers, glycopyrrolate ( muscarinic receptor antagonist), octreotide ( mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone)

Question 55

what is the role of the NG tube in medical management of malignant bowel obstruction?

Answer 55

decompress the stomach which may facilitate resolution of the obstruction, and may prevent aspiration from gastric contents

Question 56

why monitor NG tube output?

Answer 56

to replace fluid losses, and low output (<100 mL in 4 hours) may suggest obstruction has resolved

Question 57

what are the signs and symptoms of a bowel obstruction?

Answer 57

nausea, vomiting, abdominal pain, obstipation, abdominal tenderness

Question 58

small bowel malignant bowel obstructions including closed loop, intussuception, volvulus, and small bowel tumors should all be considered for what treatment?

Answer 58

surgical resection

Question 59

malignant bowel obstruction is often a harbinger of what?

Answer 59

the transition into the terminal phase of the illness and rapid deterioration of clinical status