Oncologic Emergencies Flashcards Preview

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Flashcards in Oncologic Emergencies Deck (56):
1

define ocologic emergency:

any clinical oncologic situation that requires rapid diagnostic attention and therapeutic intervention

2

Hyponatremia in a smoker- think what disease?

SIADH from lung cancer

3

Silhouette sigh on x-ray is when?

aortic knob disappears

4

Large mediastinal mass in a smoker w/ facial swelling and periorbital edema?

Lung cancer! & SVC smashed due to the mass = superior venacava syndrome = cant drain from head and neck

5

Superior vena cava syndrome:
-what is it?

-any condition that is (benign or malignant) caused by obstruction of blood flow through the SVC = emergency!

6

What fraction of body blood does the SVC return to the heart?

What happens when obstructed?

1/3 of venous return to heart

Venous collaterals return blood to the heart via the inferior vena cava or azygous venous systems

7

SVC syndrome -
Signs and symptoms:

1) presence of venous collaterals/venous dilation
2) edema of head, neck, arms, upper chest, **LARYNX**, and **BRAIN**
3) shortness of breath
4) Head fullness
5) cyanosis
6) cough
7) chest pain
8) headaches
9)**CONFUSION**
10) ***COMA***

*** = emergency!!!!

8

Etiology of SVC syndrome:

1) malignancy in 70% of cases - usually lung and NHL
2) benign:
a) SVC stenosis or thrombosis due to intravascular devices (**central venous catheters**, pacemaker wires)
b) fibrosing mediastinitis - ex) hitoplasma capsulatum

9

SVC syndrome diagnostic studies:

-Chest X-ray
***-CT scan - contast**** BEST CHOICE IF MALIGNANT OBSTRUCTION
***-venography*** - BEST CHOICE IF THROMBOSIS FROM IV CATHETER OR PACEMAKER
-MR
-histologic diagnosis for malignancy (Biopsy)

10

SVC treatment:

**1) alleviate symptoms - SVC endovascular stents** BEST** - BETTER WITHIN HOURS!
2) treat underlying disease - Malignancy: RT (depends on tumor type), Chemo, steroids, diuretics

11

neutropenic fever:
definition of:

-single temp >38.3C/101F - oral
-sustained temp for >1hr >38C/100.4F
-some may not have fever especally those on glucocorticoids - these patients have hypotension, tachycardia, tachypnea, changes in metal status and or hypothermia
-abs neutrophil count (ANC-bands +PMNs) less than 500cells/microliter. Total WBC count X%of PMN+BANDS
-neutropenia >7 days is greater risk for infection

12

Types of neutropenic fever syndromes

1) microbiolocially documented infection - neutropenic fever with a clinical focus of infection and an associated pathogen
2) Clinically documented infection- neutropenic fever with a clinical focus (pneumonia, mucositis) but without isolation of an associated pathogen
3) unexplained fever - neutropenic fever without a clinical focus or an isolated pathogen

13

Neutropenic fever is usually induced by?

chemo therapy! - this Tx suppresses myelopoiesis and affects the integrity of the GI mucosa = bacteria and fungi can cross intestinal mucosa

14

What is promptly used in all neutropenic fever patients?

*Empiric antibiotics - DO NOT WAIT FOR CULTURES

15

Neutropenic fever - patient evaluation procedure:

1) meticulous history and PE DAILY (HE SAYS TO DRAW BLOOD FIRST AND IMMEDIATELY GIVE ANTIBIOTICS while slide written opposite)
2) Lab: CDC with differential, LFTs, CMP, cultures of blood, urine, sputa, anything suspicious
--> IMMEDIATELY GIVE ANTIBIOTICS --> THEN PE and Hx (inspect all IV sites, catheters, skin surfaces - NO RECTAL EXAM)
3) Radiology: ***CXR***, CT chest, anything suspicious

16

Pathogenesis of Neutropenic fever:

-direct effect of chemo on mucosal barriers and immune system - from mouth to anus = mucous = its affected - chemo induces mucositis occurs (everywhere) = seeding of the bloodstream from endogenous flora = major cause of episodes
-obstruction of lymphatics, bilary tract, GI, or GU w/ or w/o indwelling catheters
-breeches in host defenses due to the underlying malignancy itself

17

How often is infectious source found in neutropenic fever?

What is only evidence of infection in most patients?

WHere do we hink 80% of documented infections are from?

-only 20-30% of time

- bacteremia in 10-25% of patients

-infections arise from the patient's endogenous gut flora

18

Most often give what to Tx neutropenic fever?

-3rd generation cephalosporin (broad spectrum)-
-DO NOT give vancomycin which is only good against G+

19

What are the pathogens in neutropenic fevers?

More often is which class of pathogens??

1) gram + (staph, strep, Staph epidermidis is most common) --- USUALLY GRAM +
2) gram - (E Coli, Pseudomonas)
3) fungal (candida, aspergillus)
4) viral (HSV, Herpes zoster, CMV, EBV)

20

which organism class most often causes Neutropenic fevers?

GRAM + organism _ staph epidermidis

21

When do we begin to think fungal for neutropenic fever?

risk inc with duration and severity of neutropenia, prolonged antibiotic use and number of chemo cycles

22

Rarely is the INTIAL cause of neutropenic fever...

fungal

23

What pathogen is most common in central venous catheter associated neutropenic fever?

Candida - fungal

24

Neutropenic fever treatment:

-broad spectrum antibiotics immediately after blood draw/cultures - WITHIN 1 hr!
-antifungals as needed
-remove infected devices
-G-CSF not usually needed

25

narrow pulse pressure?

lack of perfusion in general

26

pulsus paradoxus definition:

variable pulse with respiration: - disappears with inspiration and reappears with expiration

27

electrical alternans is what?

seen in pericardial effusiion and tamponade - have alternating large and small QRS

the heart moves in the pericardial sac (due to above two conditions) and so on certain beats it is further or closer to the chest leads

28

Signs/Symptoms of pericadial tamponade:

-JVD
-narrow Pulse pressure
-pulsus paradoxis
-electrical alternans (on EKG)
-cough
chest pain
-shortness of breath
weakness
-tachycardia
-diminished heart sounds
-friction rub

29

Pericadial tamponade effects on body?

hypotension
Dec CO

bc heart cant open and close properly

30

Diagnosis of pericardial tamponade?

EKG is test of choice for suspected pericardial effusion and tamponade

NOT CT!!!

31

Appearance of heart on Xray with pericardial tamponade or effusion?

"old waterbottle" look

32

Tx of pericardial tamponade:

drain fluid:
-pericardiocentesis - BEST CHOICE
-pericardial window surgery for recurrent effusions

33

Test of choice for Malignant spinal cord compression (MSCC)?

MRI

34

Definition of malignant spinal cord compression?

- compression of the spinal cord or cauda equina by an extra dural tumor = spinal cord injury/compromsed blood flow-ischemia = spinal cord infarct

35

Cancers that could metastasize and cause MSCC?

lung
breast
prostate
multiple myeloma

36

Most frequent site of MSCC?
Second? Third most?

thoracic spine
lumbosacral
cervical

37

signs and symptoms of MSCC?

-localized back pain: worse with movement, coughing, supine position
-radicular component: pain down limb
-Lhermitte sign - feeling of electric shock down the spine with neck flexion
-Motor - weakness, spasticity, reflexes, typically symmetric and greates with thoracic lesions
-sensory findings - numbness, paresthesias
-bladder and dowel dysfunction (late)

38

First symptom in most MSCC patients?

localized back pain - worse with movement coughing, supine position

39

Lhermitte sign - is...

feeling of electric shock down the spine with neck flexion

40

MSCC - cauda equina syndrome - signs and symptoms:

-low back pain
-decreased sensation over butt, posterior thigh and perineum (saddle distribution)
-bladder and bowel dysfunction
-decreased patella and achilles reflex
-lower extremity weakness

41

MSCC diagnostic test? Why would you maybe have to pick a different test?

-MRI - is test of choice - see difference bw bone and soft tissue

-if patient has pacemaker use CT myelogram

42

intramedullary tumor vs leptomeningeal tumor?
differentiate how diagnostically? And Tx for each?

- use MRI

-intra=tumor part of the spinal cord itself - SURGERY OR CHEMO DEPENDING ON WHERE AND SHAPE
-lepto=tumor spread to megninges - CHEMO

43

goal for MSCC treatment:

relieve pain and maintenance and or recovery of neurologic function

44

TUmor lysis syndrome:
-how happens?

syndrome caused by rapid death (following chemo) or cell turnover of a large volume of rapidly proliferating cells

45

**Tumor lysis syndrome (TLS)
-characteristics?

-hyperkalemia
-hyperuricemia
-hyperphosphatemia
-hypocalcemia
-metabolic acidosis
-acute kidney injury - 1-5 day onset - (AKI - from uric acid crystal deposition in the renal tubule)

46

TLS is most common with which diseases?

lymphomas and leukemia (hematologic malignancies)

47

General Pathophysiology of TLS?

-cancer cells die --> releaee of potassium, phosphorus and nucleic acids --> metabolized to hypoxanthine --> metabolized to xanthine--> to uric acid

---> PPT of uric acid = PPT of calcium phos and Vice versa ==========vicious cycle!

-release of cytokines from tumor cells = systemic inflammation = multisystem organ failure

48

Issues with hyperphosphatemia in TLS?

-causes secondary HYPOcalcemia = neuromuscular instability, seizures, and dysrhythmia
-can PPT calcium phosphate crystals in organs - especially bad if in cardiac tissues = more dysrhythmias

49

Issue with hyperkalemia in TLS?

fatal dysrhythmias!

50

Issue with hyperuricemia in TLS?

= acute kidney injury
1) precipitates in tubules
2) induces renal vasoconstriction
3) impaired autoreg
4) dec RBF
5) oxidation
6) infammation

51

Main thing to look at with tumor lysis syndrome???

Risk of acute kidney injury! want to prevent it from happening!

52

***High risk group for TLS?***

-pre-existing chronic renal insufficiency
-oliguria
-volume depletion
-hypotension
-acidic urine

53

***Prevent TLS by?***

1) HYDRATION!!!!! - KEEP THEM PEEING!!
2) allopurinol (xanthine oxidase inh) - block conversion of xanthine and hypoxanthine to uric acid
3) rasburicase (urate oxidase)- oxydizes urin acid to more water soluble allantoin ----- EXPENSIVE!!!

4) DIALYSIS

54

Signs and symptoms of pulmonary emboli:

-non-specific but most commoN:
--dyspnea with exertion or at rest
--pleuritic chest pain
--cough
--calf or thigh pain or swelling

--tachypnea
--tachycardia
--rales
--JVD

----Frequently asymptomatic!

55

Diagnosis - pulmonary embolus:

-chest xray but really poor sensitivity and specificity-- will see pleural effusion and atelectasis

-V/Q scan - only when there is contraindication to IV contrast ex) kidney issues

***-CT pulmonary angiogram - CTPA- BEST TEST! - really good for excluding Pulmonary Emboli

56

Tx for PE?

1) resuscitation - respiratory and hemodynamic
2) diagnostic studies when the patients are stable
3)initiation of anti-coagulation with low molecular wieght heparin (LMWH) if there is no contraindciation to anticoagulation