Oncological Emergencies Flashcards
(41 cards)
1
Q
What are the oncological emergencies?
A
- Sepsis
- Bleeding
- Tumour lysis
- Acute leukaemia
- Hyperviscosity
- Hypercalcaemia
- Hyponatraemia
- Increased ICP
- DVT + PE
- Thrombocytopenia
- Spinal cord compression
- Pain
- Airway compromise
- SVCO
- Bowel obstruction
- Graft vs host
- Rapidly progressing disease
2
Q
What are the red flags for back pain?
A
- Referred pain that is multi-segmental or band-like
- Escalating pain which is poorly responsive to treatment (including medication)
- Different character or site to previous symptoms
- Funny feeling, odd sensations or heavy legs (multi-segmental)
- Lying flat increases pain (also worse on coughing)
- Agonising pain causing anguish and despair
- Gait disturbance, unsteadiness, especially on stairs (not just a limp)
- Sleep grossly disturbed due to pain being worse at night
3
Q
What are the features of tumour lysis syndrome?
A
- Most often seen in high grade lymphomas (Burkitt), ALL, SCLC.
- Calcium less than or equal to 1.75
- Phosphate more than or equal to 2.1
- Urea >/= 8
- Potassium >/= 6
4
Q
What are the complications of tumour lysis syndrome?
A
- Too much urea > AKI
- Increase in K and decrease in Ca > seizures/arrhythmias
5
Q
What is the management for tumour lysis syndrome?
A
- High risk: IV rasburicase and IV hydration (maintain UO >100ml/m2/hr)
- Intermediate risk: IV allopurinol and IV hydration
- Intensive monitoring - repeat bloods at least twice daily
- Increased phosphate: phosphate binders
- Increased potassium: calcium gluconate then give dextrose/insulin or salbutamol
- Decreased calcium: can give calcium replacement (but only when phosphate corrected)
- In extreme cases, can use hemofiltration e.g. if hyperkalaemia not responding to treatment
6
Q
What is the action of rasburicase and allopurinol?
A
Rasburicase is good at removing pre-existing uric acid (which allopurinol can’t do very well) but comes with risk of many serious SEs and it’s expensive, so generally used in high risk only.
SEs: haemolysis in patients with G6PD deficiency; met-hemoglobinaemia, anaphylaxis
7
Q
What is the definition of neutropenic sepsis?
A
When neutrophil count <0.5x10^9/L PLUS either:
- Temperature >38 degrees celsius
- Signs or symptoms of sepsis
8
Q
How does chemotherapy cause neutropenic sepsis?
A
- Theory that chemotherapy suppresses bone marrow producing WBCs, typically neutrophils
- Chemotherapy attacks areas of high cell division. In the gut, cells replicate rapidly to overcome stresses during digestion. This overturn of cells stops bacteria (gut flora) penetrating the body, but chemotherapy attacks these cells, causing bacteria to get through gut wall and cause infection (gut flora thought to cause 80% of neutropenic sepsis).
9
Q
What are the symptoms of neutropenic sepsis?
A
- Fever/chills
- N+v
- Usually don’t present with many symptoms as immunocompromised so threshold for treatment is low
10
Q
What is the management of neutropenic sepsis?
A
- ABC
- Cannulate for bloods including blood cultures, then immediately give broad spectrum abx (within 1 hour of presenting to hospital) - don’t wait for blood results
- Usually broad spectrum abx such as Tazocin (piperacillin and tazobactam) or Meropenum
- After abx take a history, examination, further bloods, further cultures (sputum and urine), imaging (CXR), ABG, if patient has central venous access e.g. Hickmann line then take cultures. 4 hourly obs/consider fluids.
- If after 48 hours patient not improving on abx, can give meropenem +/- vancomycin, consider a fungal infection (CT chest to check for fungal infection)
11
Q
What are the features of metastatic spinal cord compression?
A
- Always consider in a cancer patient with back pain - presents in 5%
- Can result in permanent neurological damage
- In 20% of patients MSCC is their first presenting symptoms
- 60% of cases are in the thoracic spine (uncommon place for back pain)
- Other causes to bear in mind are: OA, herniated disc, RA, spinal injuries/deformities, infections e.g. abscesses
- Vertebral body most often affected first, cord compression can spread to veins/arteries and lead to ischaemia
- Most common cancers that metastasise to the spine are lung, breast, myeloma, lymphoma and prostate. Most common in children is sarcoma and neurblastoma.
- Epidural metastases mostly arise from the vertebral column or paravertebral space (anterior or anterolateral to the cord)
12
Q
What are the symptoms of MSCC?
A
- Back pain (can come several weeks before) > worse on straining, coughing, sneezing, pain during sleep
- Weakness often follow UMN pattern - increased muscle tone, reflexes, weakness
- Cauda equina syndrome»_space; decreased tone and reflexes, weakness
- Sensory loss
- Bladder and bowel dysfunction (more typical in cauda equina)
13
Q
What are signs of MSCC?
A
- Gait disturbance
- Focal weakness
- Sensory loss
- Loss of anal tone
14
Q
What is the management of MSCC?
A
- Initial measures > lie flat, neutral spine alignment
- If spine not aligned, can irritate sympathetic nerves and cause loss of tone in blood vessels > vasodilation and then pooling of blood in peripheries > hypotension
- Give venous compression stockings/prophylactic medication for DVT/PE
- High dose steroids - dexamethasone 16mg STAT and then 8mg BD (reduce oedema around compression and helps pain) - PPI and glucose monitoring
- Investigate with MRI whole spine - within 24 hours
- Blood tests - FBC, U+E, LFT, PSA, bone profile, calcium, other evidence of mets
- Organise definitive treatment - decompressive surgery (internal fixation), radiotherapy (e.g. SCC or myelomas > sensitive to radiotherapy), chemotherapy, palliative
15
Q
What are the causes of superior vena cava obstruction?
A
- Most commonly associated with lung cancer (typically non-SC (50%) + SCC) and Non-Hodgkin’s Lymphoma
- Other causes are blood clots (often due to pacemakers that sit in vena cava), TB, aortic aneurysms
16
Q
What are the signs and symptoms of SVCO?
A
- SOB (dyspnoea)
- Distended veins
- Facial swelling (due to back flow of blood) - red suffused eyes
- Blood can return via collateral veins (so may see distended veins elsewhere in the body
17
Q
What are the complications of SVCO?
A
- Cerebral oedema > ischaemia, symptoms are headaches, confusion, decreased consciousness
- Increased ICP
- Tracheal obstruction > suffocation
- SVCO usually means advanced cancer so management often palliation (symptom control) as opposed to a cure
18
Q
How do you diagnose SVCO?
A
- Clinical signs include: facial swelling, distended veins in the neck, chest
- 80% have abnormal CXR > mediastinal widening or pleural effusion
- Contrast CT > can find level of obstruction and look at collateral veins
- Biopsy and cytology (supraclavicular lymph node biopsy often easiest to access) - if biopsy hard to obtain then use bronchoscopy/mediastinoscopy
19
Q
What is the treatment of SVCO?
A
- ABC
- Sit patient up, give oxygen and analgesia if required
- Steroids > reduce inflammation (same dose as cord compression)
- If dyspnoeic: 5mg of morphine sulfate 10mg/5ml oral solution 4 hourly
- EMERGENCY > if patients have airway compromise or signs of cerebral oedema > need emergency stenting and chemotherapy/radiotherapy
- Non-emergency: histological diagnosis (choose targeted therapy), e.g. SCC or Non-Hodgkin’s very sensitive to chemo, e.g. Non-SCC is not very responsive to chemo so stent and radiotherapy
20
Q
What are the differentials of hypercalcaemia?
A
- Infection (delirium) - UTI
- Perforated viscous
21
Q
What are commonly associated cancers with hypercalcaemia?
A
- Myeloma
- Squamous cell lung cancer
- Breast
- Kidney
- Head and neck
- Prostate cancers
22
Q
What is the mechanisms of cancer increasing calcium levels?
A
- Cancer releases PTHrP (similar to parathyroid hormone) > causes increased calcium but doesn’t cause calcitriol activation, so small intestine absorption often not affected. Blood tests will show increased PTHrP, low PTH, low/normal calcitriol.
- Metastases can also cause osteolytic metastases which causes increased osteoclast activation. Blood tests typically show decreased/normal PTHrP, decreased PTH, low/normal calcitriol
- Tumour causes calcitriol release (commonly seen in lymphomas, especially Hodgkin’s)
23
Q
What are the symptoms of hypercalcaemia?
A
- Stones, thrones, groans, bones, psychiatric overtones, cardiac
- Kidney stones, polyuria, polydipsia, diabetes insipidus (increased Ca causes more water loss), clinical dehydration
- Thrones > constipation
- Groans > cardiac pain, n+v
- Bones > bone pain, muscular weakness
- Psychiatric > anxiety, depression, confusion, agitation, coma
- Cardiac > bradycardia, HTN, arrhythmias, palpitations
24
Q
What is the management of hypercalcaemia?
A
- IV fluid rehydration - monitor fluid balance and electrolytes (normal saline 2-3L)
- Calcitonin
- Bisphosphonates (zolendronate) - 2 SEs are renal failure and fatigue
- Only after rehydration - typically next day (unless Ca very high, then give straight away)
- Bisphosphonates usually take 2-4 days to work so often not 1st line - Anti-emetics
- Review medication
- Denosumab
- Calcium levels may take several days to fall so continue fluids and check electrolytes daily
- Treat malignancy
25
What are the features of hypercalcaemia?
- 30% of patients with malignancy get hypercalcaemia at some point
- Mechanism: tumour osteolytic effects on bone, humoral PTHrP, overproduction of vit D
- Hypercalcaemia can exist without bone metastases
26
What is the threshold for suspecting neutropenic sepsis?
- A patient commencing on anti-cancer therapy should be provided with information regarding neutropenic sepsis and how and when to seek emergency care.
- Neutropenic sepsis should be suspected in any patient who has received systemic anti-cancer therapy and has a fever or signs/symptoms of sepsis
- Patients at low risk of septic complications can be managed in outpatient setting. They should be assessed with a validated scoring system and by someone with competence in managing complications of cancer therapy.
27
What is the aim of MSCC treatment?
- Establish diagnosis and maintain as much function as possible
- If mobile 85% will walk again, if paraplegic <15% will walk again and survival <4 months
- Once MRI confirms options are: surgery, XRT, BSC (best supportive care)
- All hospitals taking acute admissions should have access to Acute Oncology Service and many will have a specific MSCC service and a written MSCC protocol.
28
What candidates with MSCC can have surgery?
- Patients with mechanical back or neck pain or early neurological symptoms indicating the possibility of spinal instability
- Single or limited levels of disease
- Good performance status
- Estimated prognosis > 3 months
- Tissue required for diagnosis
29
When is radiotherapy used in MSCC?
- Indicated after surgery
- Alternative to surgery if pt not eligible
- Aim to give with 24hrs of diagnosis
30
When is BSC (best supported care) used in MSCC?
- Established paralysis
- Poor prognosis
- Unable to tolerate XRT
31
What is the definition of febrile neutropenia?
Fever >38 degrees celsius for 1 hour and with an absolute neutrophil count (ANC) of <0.5x10^9/L.
32
What patients require urgent administration of abx in potential neutropenic sepsis?
Any patient who has received chemotherapy within 6 weeks of presentation is at risk. In these patients the presence of any of the following factors will result in urgent administration of abx:
- Patients with known or suspected neutropenia <1.0x10^9L
- Temperature: >/= 38 degrees on single occasion, <36 degrees in an unwell pt, apyrexial but unwell with signs/symptoms of sepsis
33
What things do you need to consider in neutropenic sepsis?
- Consider gram positive cover if central line in situ
- Check penicillin allergy
- Consider renal function
- Avoid gentamicin if platinum chemo due to renal risk
34
What are the most common causes of hypercalcaemia in cancer patients?
- Bone metastases especially breast, prostate and myeloma
- Paraneoplastic syndrome - may be associated with PTrH in absence of bone metastases, seen especially in squamous carcinomas e.g. lung, head and neck, cervix
35
What are the most common causes of hypercalcaemia in non-cancer patients?
- Primary hyperparathyroidism
- Drugs e.g. thiazide diuretics, lithium, vitamin D excess
- Endocrine causes e.g. thyrotoxicosis
- Chronic granulomatous disease e.g. sarcoid/TB
- Familial hypocalciuric hypercalcaemia
- Prolonged immobilisation
36
What would be seen on an ECG in hypercalcaemia?
- Short QT
| - Ventricular arrhythmia possible in extreme hypercalcaemia
37
What are the complications of tumour lysis syndrome?
- Uric acid crystals/Ca/PO4 in renal tubules > impaired renal function, AKI, even death
- Increased phosphate leads to decreased Ca > tetany, seizures, arrhythmia
- Increased potassium > life-threatening arrhythmia
38
What is the best way to prevent tumour lysis syndrome?
- Identify patients at risk - high tumour volume, highly chemo/radiosensitive tumours, renal dysfunction
- Aggressive hydration with strict fluid balance
- Monitor electrolytes closely
- Rasburicase (works quicker, recombinant urate oxidase) for high risk patients
- Allopurinol (xanthine oxidase inhibitor) for intermediate risk patients
39
What cancers need specific therapy in SVCO?
- Lymphoma/germ cell tumours - chemotherapy is an alternative to stent insertion
- Radiotherapy occasionally recommended if occlusion is not amenable to stent placement.
40
What investigations need to be done in suspected raised ICP?
- Obs
- MMSE, GCS
- Full neuro exam + resp/cardio/abdo
- Fundoscopy
- Bloods - FBC, CRP, U+Es, LFTs, glucose, calcium, Mg (?deranged electrolytes)
- CXR
- Non-contrast CT
41
What is the management of raised ICP in a cancer patient?
- Dexamethasone 8mg BD + PPI
- Analgesia
- Anti-emetic
- Elevate head of bed
- Advise not to drive
- Seek advice from oncology and neurosurgical teams
