Examples of mechanical emergenciesq
PE, spinal cord compression, SVC syndrome, urinary obstruction, carcinomatous meningitis, malignant effusion
Metabolic emergencies
tumor lysis, hypercalcemia, SIADH, hyperuricemia, adrenal insufficiency
hematologic emergency
cytopenias, febrile neutropenia, hyperviscosity, bleeding clotting
key buzzwords for SVC case study
facial swelling, puffiness of eyes, cough, no smoking history, URI for a week, felt faint while coughing, right side pleural effusion , plethora of face, dilated veins over thorax
SVC extends from the..
R and L innominate veins into the RA and completely encircled by lymph nodes
Besides cancers what else can cause SVC syndrome?
10% cases: indwelling catheter, infectious: TB, histo
horners syndrome
found with SVC, when nerves to eye are compressed as well
horner’s syndrome triad
pstosis, loss of hemifacial sweating, constricted pupil
what diagnostic test is required for SVC syndrome?
biopsy prior to starting therapy, usually order a CXR and MRI or venogram to see if clot is present
6 stages of SVC treatmnet
- radiation 2. chemo 3. anticoag (if central line and /or no response) 4. steroid 5. stent 6. surg
spinal cord compression buzzwords
mid thoracic back pain increasing worse with standing, mild weakness in legs
what are the two most common onc emergencies
spinal cord compression and SVC syndrome
What cancers typically cause spinal cord compression
breast, lung, thyroid, kidney, prostate
what does weakness with SCC mean?
URGENT intervention!
what is typically present at diagnosis with SCC
back pain, bowel and bladder dysfunction
what 2 diagnostic test best SCC
plain x ray and MRI of spinal cord
SCC treatment
- suspicious? give dexamethasone, 16 mg dialy IV/PO q 6 hours wean over 2wks 2. send to consutl neurosurg and radiation onc
what is most significant prognostic variable for SCC
severity of weakness, and then rapid onset of neuro sx and rapid progression = poor prognosis
non ambulatory without proximal gravity leg function..
only 5% regain ambulatory function
what percent of brain metasis are solitary?
50%
incidence of brain metastases
30% of cancer patients
what is presentation brain metases
increased fatigue, N/V, edema, early morning headaches, sizures can be first sign (melanoma 50%!!), hemorrhage common (with melanoma, gestational cancer, and testicular cancer)
what are 2 images brain metastases
- Head CT noncontrasted make sure they are not bleeding, contrast? 2. MRI contrast ..best for location number and metastatic staging..
what 3 areas of brain is the MRI with contrast best at seeeing
cerebellum, temporal lobes, and brain stem
Brain metastases treatment
- steroids (edema) - decadron 2. consolt radiation (WBRT, SRS) 3. Surgery/NSU: solitary lesions 4. anticonvulsant therapy not indicated routinely
if brain metastases seems to be worsening what test order?
CT: looking for CNX leptomeminingeal dz
what 5 cancers associated with carcinomatous meningitis
lymphoma, leukemia, breast, lung, melanoma (BLLLM)
buzzwords carcinomatous meningitis
facial numbness, HA, spinal cord compression sx,
DX of carcinomatous meningitis
LABS: CSF cytology: elevated CSF pro, WBC with lymphocytosis. Low glucose *key lumbar puncture has high opening pressure above 160 mm
treat carcinomatous meningitis
intrathecal chemotherapy, radiation
intrathecal chemo
chemo injected between layers of meninges .. hence for carcinomatous meningitis
buzzwords malignant pericardial effusion
see: mediastinal widening, cardiac silhouette enlarged, dilated neck veins CP retrosternal, tamponade
what are the 3 tests used to differentiate between pleural effusion and pericardial?
CXR, Echo, chest CT
Pleural effusion
dypnea, CP, cough, percussion = dull
treat pericardial effusion
pericardiocentesis, pericardial window
pleural effusion treatment
thoracentesis, chest tube or thoracoscopy with pleural sclerosis or pleurex. cath (pt can drain their cath till stops draining) KEY: malignant effusions continue to reoccur until get scarring of pleural cavity
PE/DVVT treatment
anticoagulation: warfarin option.. but hard with diet and chemo so probably Lovenox (LMWH Enoxaparin)
PE/DVT diagnosis
US for DVT, VQ scan, spiral CT
what NHL med has cardiotoxitiy properties
doxorubicin
equation for Ca corrected
calcium + ((4- albumin bound ca) X0.8)
key hypercalcemia signs
constipation, frequent urination, short QT, dry mucous membranes, muscle weakness, fatigue, coma fofusion, N/V stomach pain
4 main hypercalcemia tx
- IV fluids: 1.5-3 L per 24hrs
- bisphosphonates: Zolendronate or Pamidronate
- Calcitonin: slows bone resorption and increase pee out calcium
- Consider furosemide
when admit a pt with hypercalcemia?
when Ca is over 12 - worry about altered mental status, low renal function , arrhythmias, lives alone and or poor ER access
what is number one most common onc ER?
hyponatriemic condition, especially with small cell lung cancer
4 main causes of low sodium
- left perihilar mass
- multiple low attenuation liver lesions
- FNA liver lesion: spread from small cell lung cancer
- SIADH
SIADH
ectopic ADH..keep way too much water, associated with SCLC
what is main concern with low na?
cerebral overhydration! .. see progression of altered mental status, obtundation, coma, respiratory arrest
low na treatment
treat underlying malignancy, water restriction, demeclocycline, hypertonic saline if severe
how could febrile neutropenia present?
diffuse myalgias, chills, temp 102, WBC 0.3
When does febrile neutropenia most commonly occur
during or after 1st cycle of chemo..caused by bacterial, viral or fungal exposure with low WBC
Dx criteria for febrile neutropenia
- single temp above 38.5 (101.3)
- 3 temps over 38 or 100. 4 within 1 day (4 hr apart)
- ANC less than 500/mm or 500-1000 with downward trend
mortality rate of neutropenia
95%
timeframe for treatment of febrile neutropenia
4 hours for abx for gram negative rod (worry about sepsis)
BLT kosher pickle
cancer associated with SCC: breast, lung, thyroid, kidney, prostate
4 steps of febrile neutropenia workup
- CXR
- UA and culture
- Blood cultures - 2 sets!
- peripheral and central venous line - examine other sites: sinuses, perianal, skin mucous membrane
febrile neutropenia tx
- empiric broad spectrum abx: cefepine, ceftazadine, impipenim, meropenem
- 2-3 days still bad.. MRSA? vancomysin
- if longer than 5 days consider antivirals or antifungals
Post febrile neutropenic episode tx
transition to oral abx: ciprofloxacin or augmentin, consider preventative measures (GF: filgrastim, pegfilgrastim)
buzzwords sepsis/ SIRS (systemic inflammatory response syndrome caused by infection)
Fever more than 38.3 (100.9), AMS (measles..rash appears delayed), hyperglycemic but low BP, tachy pnea and cardia
Sepsis / SIRS tx
- IV abx 2. IV fluids 3. vasopressors, blood products, 4. treat organ failure (ie hemodialysis), 5. mechanical ventilation
risk factors small bowel obstruction
post op adhesions, tumor, begning (inflammatory lesion, vascular tumors, )