Flashcards in Oncologic Emergencies - Exam 1 Deck (91):
what catheter can cause SVC syndrome?
indwelling catheter - I.e. PICC line that gets thromboses and then SVC get compressed
what is SVC syndrome?
compression of the SVC
SVC syndrome sx's
-dyspnea, cough, orthopnea
SVC syndrome signs
neck vein distention, facial swelling/fullness (b/c fluid is backing up), arm vein distention
what sign of SVC syndrome represents a true emergency?
Papilledema (means more severe case of SVC syndrome)
SVC syndrome dx
confirm SVC syndrome with what test?
Chest CT with contrast
SVC syndrome treatment
-keep in head-up position (to make fluid go down)
-IV steroids (shrinks tumor swelling)
-IV diuretics (Torsemide)
-Anticoagulants or thrombolytics (if clot in SVC)
-Emergent mediastinal radiation
-remove central IV catheter if present
if SVC has clot in it, then how do you treat pt?
anticoagulants or thrombolytics (heparin drip)
what can form in spinal column and cause acute spinal cord compression?
what must be evaluated urgently in acute spinal cord compression?
neuro status - as to predict the functional outcome
-a lot of neuro deficits are not reversible
what does acute spinal cord compression usually result from?
extension of spinal bony metastases
where is acute spinal cord compression most common in the spine?
sx's of acute spinal cord compression
-localized back pain +/- tenderness (may be absent with lymphomas)
-distal sensory deficits
what is the dx study of choice for acute spinal cord compression?
what other dx imaging can you get for acute spinal cord compression?
cervical, thoracic, or lumbar spine films (but neg films don't rule out SCC)
radionuclide bone scan (>90% sensitivity, except for multiple myeloma)
dx studies for acute spinal cord compression should be done how soon and with early involvement of who?
should be in emergent time frame with early involvement of consultant (ex: neuro, radiation, etc)
acute spinal cord compression tx
-Foley catheter (for urinary incontinence)
-IV steroids (Decadron)/diuretic/mannitol (decreased CSF pressure)
-emergency decompressive laminectomy or radiation rx
what IV steroid is given for tx of acute spinal cord compression?
Decadron aka dexamethasone
-decreases swelling of tumor
what do you never want to give to someone with acute spinal cord compression? why?
bisphosphonates - b/c will bind to Ca and mess up kidney -> won't help the spinal cord compression
what is key in tx of acute spinal cord compression? what does it do?
radiation - shrinks the tumor pressing on the cord
what are the 2 most common types of hypercalcemia of malignancy?
Humoral Hypercalcemia of Malignancy (via PTHrP - allows too much Ca to be in blood)
Local Bone Destruction
sx's of hypercalcemia of malignancy?
MOANS, GROANS, STONES, PSYCHIATRIC UNDERTONES
-back pain (b/c destruction of vertebrae)
hypercalcemia of malignancy dx
-total and ionized Ca (need albumin to calculate corrected Ca)
-check Cr, electrolytes, all phos
low level of what can indicate hypercalcemia of malignancy?
low serum Cl-
what does EKG in hypercalcemia show?
short QT intervals, low voltage, and long PR intervals
work-up for what in hypercalcemia?
what level of serum Ca is considered dangerous?
what needs to be given immediately to pts with hypercalcemia?
HYDRATION - IV FLUIDS -> TO PEE OUT THE CA
-Normal Saline is of choice
what IV fluid is of choice for hypercalcemia tx?
once pt with hypercalcemia is euvolemic give them what for tx? avoid what?
IV loop diuretics
AVOID thiazides - cause hypercalcemia
what diuretics to avoid in hypercalcemia?
thiazides b/c cause hypercalcemia
other meds for tx of hypercalcemia?
-Pamindronate, Zoledronic acid (don't use in renal failure), Denosumab
what should you D/C in hypercalcemia?
Ca, Vit D, thiazides, and NSAIDs
-Example: tums (have a lot of Ca)
how do bisphosphonates work?
block osteoclastic bone resorption
injection of what that lowers serum Ca levels for tx of hypercalcemia?
SubQ or IM Calcitonin (lower serum Ca levels)
what rate of voiding do you want to aim for when treating pt with hypercalcemia with IVF?
when would hypercalcemic pt go on dialysis?
pt with renal or heart failure
not life-long, just for acute episode
used b/c fluid will start to back up -> CHF
what to AVOID in hypercalcemia?
what is febrile neutropenia defined as?
single oral temp >101.3 F
sustained temp >100.4 for 1 hr
how to calculate ANC?
ANC = [(WBC)(%Neut + % Bands)]x10
ANC from absolute number is:
ANC = (absolute polys + absolute bands)(1000)
severe neutropenia ANC?
when is febrile neutropenia most commonly seen?
during Nadir after chemotherapy
what is Nadir?
when give chemo and when counts hit rock bottom (drop in the counts)
when does Nadir occur and how long does it last?
5-10 days after the last dose of chemo and lasts for about 5 days
febrile neutropenia sx's?
ranges from asymptomatic to severe sepsis
atypical presentation - UTI pt w/out pyuria
what must you pay special attention to with febrile neutropenia?
to the skin, oral cavity, perianal area, catheters
avoid what if pt has febrile neutropenia?
sticking fingers in holes b/c don't want to introduce bacteria into their blood since already neutropenic
labs for febrile neutropenia?
CBC, blood Cx (x2), urine cx, sputum cx and stain
stool, CSF cx if indicated (if no diarrhea then no stool sample)
CXR may be what in febrile neutropenia?
consider what dx tool in febrile neutropenia if respiratory complaints?
what should all febrile neutropenic pts receive upon presentation?
ANTIBIOTICS - VANCOMYCIN AND CEFEPIME
what is the goal time of getting febrile neutropenic pts abx when they present?
<1 hr from door to abx
what abx do you use for febrile neutropenia?
Vancomycin and cefepime
should febrile neutropenia be admitted?
YES!!! - if pt on chemo presents with fever, ADMIT THEM!!!
if febrile neutropenic pt has been vomiting what do you want to cover for and what abx to give them?
cover for anaerobes
if persistent febrile neutropenia (>72 hrs), what meds do you give?
what else may febrile neutropenic pts have in addition to neutropenia?
Neutropenia + Bacteremia is what?
a true medical emergency b/c short-term mortality
risk of infection if neutropenic increases with what?
-duration of neutropenia
-severity of ANC <100
-hepatic or renal insufficiency
what is G-CSF? what does it do?
Granulocyte Colony Stimulating Factor
speeds up resolution of neutropenia (stimulates production or neutrophils)
when to use G-CSF for febrile neutropenia?
-profound neutropenia, shock, co-morbidities
-worsening clinical course and expected prolonged neutropenia
-pt not responding to abx
in what time frame is G-CSF given after chemo?
given 48hrs after starting chemo
how long does it take G-CSF to work? how long do you have to wait to give it again?
works in 5-7 days
must wait 7-14 days to give it again
if pts neutrophil counts are not recovering and expect them to have a prolonged neutropenia, what do you give them?
if neutropenic pt is afebrile, how do you treat them?
-continue initial abx until blood cx available, then adjust abx based on culture/sensitivities
-treat for 5-7 days of IV and consider PO if ANC >1000
need to be sure what is negative before discharge neutropenic pt?
that cultures are negative
if neutropenic pt is febrile after 4 days of abx treatment how do you treat them?
anti fungal - ketokonazole or fluconazole
when can a febrile neutropenic pt be discharged home?
if ANC has recovered (>1000), afebrile for 24hrs, and cx negative
what is tumor lysis syndrome?
metabolic complications which occur after tx of bulky chemo-responsive malignancies
metabolic complications that occur in tumor lysis syndrome?
-also acute renal failure
when does tumor lysis syndrome occur?
6-72hrs after initiation of chemo rx or radiation rx
what is tumor lysis syndrome due to?
rapid release of cell contents into bloodstream after chemo or radiation
etiologic factors of tumor lysis syndrome?
large tumor burden, high growth fraction, high preRx serum LDH or uric acid, pre-existing renal insufficiency
main life-threatening problems of tumor lysis syndrome?
-hyperphosphatemia with secondary hypocalcemia
-can result in acute renal failure and arrhythmias
tx for tumor lysis syndrome?
STOP THE CHEMO - HOLD ANY FURTHER LYSIS
Aggressive IV hydration NS/diuresis
+/- alkalinize urine to pH7 with bicarb (NaHCO3)
CaCl2, NaHCO3, glucose/insulin, kayexalate for hyperkalemia
treating tumor lysis syndrome pt with bicarb does what?
alkalinizes the urine to pH7
-decreases uric acid, but may worsen hypocalcemia tetany
what to give hyperkalemic pt?
CaCl2, NaHCO3, glucose/insulin, kayexalate
emergency dialysis for tumor lysis syndrome when?
if K > 6, uric acid > 10, Cr >10, or unable to tolerate diuresis
when is allopurinol used in tumor lysis syndrome?
for prevention pre and post chemo
what is rasburicase and when is it used?
used in tumor lysis syndrome
-very expensive med that can rapidly degrade uric acid so you pee it out immediately
other etiology of malignant pericardial tamponade besides tumors?
signs and sx's of malignant pericardial tamponade?
-hypotension/narrow pulse pressure
-muffled heart tones
-pulsus paradoxical >10mmHg
heart tones in malignant pericardial tamponade?
muffled heart tones
what is the EKG like for malignant pericardial tamponade?
low QRS voltage +/- pulses alternans
dx of malignant pericardial tamponade
what can occur in malignant pericardial tamponade?
a pericardial effusion
malignant pericardial tamponade tx
needle catheter pericardialcentesis, pericardial window, radiation, pericardiectomy
what chemo can you add for malignant pericardial tamponade?
intrapericardial chemo or sclerosis
-add if fluid keeps building up in the heart