Oncological Emergencies Flashcards
What are the 4 most common oncological emergencies?
- neutropenic sepsis
- hypercalcaemia
- metastatic spinal cord compression
- superior vena cava obstruction (SCVO)
What is the definition of neutropenic sepsis?
patients having cancer treatment whose neutrophil count is less than 1 x 10^9 per litre and has either:
- a temperature higher than 38 degrees
- other signs and symptoms consistent with clinically significant sepsis
What is the difference between septicaemia and sepsis?
Septicaemia:
this is the presence of a pathogen in the bloodstream, which can lead to sepsis
Sepsis:
systemic inflammatory response syndrome (SIRS) triggered by a primary localised infection
SIRS - clinical signs that occur in response to systemic inflammation
What needs to be present for SIRS or sepsis to be diagnosed?
2 or more of:
1. temperature < 36o or > 38o
2. tachycardia where HR > 90bpm
3. respiratory rate > 20 per min OR PaCO2 < 4.3kPa
4. white cell count > 12 x 10^9or < 4 x 10^9
it is sepsis when there are 2 or more of these signs but they RESULT FROM INFECTION
What is meant by severe sepsis?
sepsis with signs of organ hypo-perfusion
- hypoxaemia
- oliguria
- lactic acidosis
- acute alteration in mental state
What is meant by septic shock?
severe sepsis with hypotension
OR the requirement for vasoactive drugs despite adequate fluid resuscitation
hypotension is systolic BP < 90 or a decrease > 40 from baseline
Why does neutropenic sepsis occur in cancer patients?
- chemotherapy is given to target cancer cells, but it will also target healthy cells
- damage to the bone marrow from chemotherapy results in a drop in neutrophil count
Which patients are at a greater risk of neutropenic sepsis?
it is common with intense chemotherapy regimes:
1. haematological malignancies
2. breast cancer
3. germ cell tumours
How does someone with neutropenic sepsis typically present?
Why is it important to identify this quickly?
- patients will decompensate quickly
- typically, a young patient receiving chemo will present with a temperature but other parameters are normal
- they do not have the neutrophil count to mount the infection so rapidly decompensate
important to identify early as it has a 5% mortality rate
When does neutropenic sepsis typically occur?
it typically occurs between 7 and 14 days post-chemotherapy
it is VITAL to ask patients when they had chemotherapy
What is the typical presentation of someone with neutropenic sepsis?
- they present with being non-specifically unwell
- they may be tachycardic or hypotensive
- they may have a temperature
- they may have localising signs of infection
a temperature can depend on whether they have had paracetamol
Why is it important to perform a head-to-toe examination of anyone presenting with non-specific signs of illness?
to look for localising signs of infection that could be affecting one part of the body
What are common signs of a CNS infection?
- headache
- visual disturbances
- neck stiffness
What are common signs of a respiratory tract infection?
- cough
- shortness of breath
- chest discomfort
Why is it important to inspect the oral cavity in chemotherapy patients?
- some chemotherapy regimes can result in mucositis (sore mouth)
- if the mouth becomes ulcerated, this is a potential route for infection
What question is particularly important to ask chemotherapy patients when it comes to a potential source of infection?
do they have a central venous catheter in place?
the area of the line must be assessed for signs of redness and discharge
this could be a PICC line in-situ, Hickman line, central line or portacath
What symptoms may suggest a GI tract infection?
- abdominal pain
- diarrhoea
Which patients are more likely to have stents in place and what symptoms might infection produce here?
Biliary stents (liver malignancy):
infection may produce RUQ pain or rigors
Ureteric stents:
infection may produce flank pain, dysuria, haematuria + frequency
What are the 4 most important areas to cover in a neutropenic sepsis history?
- chemotherapy drugs and TIMING + any access / lines
- previous episodes
- presence of localising symptoms
- any allergies
What is involved in the physical examination for suspected neutropenic sepsis?
- temperature + circulatory status (ABC)
- NEWS score
- full systematic examination (cardiovascular, respiratory + abdominal)
- focus on potential sites of infection (lines / catheters / perianal area)
- review previous + recent microbiology for resistant organisms
What is meant by the A-E approach for a potential septic patient?
A - airway
B - breathing
C - circulation
D - disability
E - exposure
if one or more red flag is present during any stage, the patient should be treated for sepsis
What red flags may be identified during the breathing stage of assessment?
- RR >/= 25 breaths per minute
- O2 required to keep SpO2 > 92%
What red flags may be identified during the circulation stage of assessment?
- tachycardia > 130 bpm
- systolic BP < 90 or a drop of 40 from normal
- lactate >/= 2 mmol/l
What red flags may be identified during the disability stage of assessment?
- acute confusional state
- responds only to voice or pain or unresponsive
V, P and U in the AVPU scale
What red flags may be identified during the exposure assessment?
- non-blanching rash
- mottled, ashen or cyanotic apperance
- urine output < 0.5 ml/kg/hour
What should be done if any red flag symptoms are present?
- B - blood cultures
- U - measure urine output
- F - IV fluids
- A - broad spectrum antibiotics
- L - measure lactate
- O - high-flow oxygen
SEPSIS 6 performed within 1 hour (BUFALO)
What is an alternative way of remembering the sepsis 6?
- take blood cultures, give IV antibiotics
- take urine output, give IV fluids
- take lactate, give high-flow oxygen
the take 3 / give 3 method
What blood samples are useful in a patient with signs of neutropenic sepsis?
- FBC - to look at the neutrophil count and for signs of anaemia
- inflammatory markers - CRP and lactate
- LFTs to assess liver function
- assessment of hepatic function to determine if patient is dehydrated
What blood cultures are taken?
- x2 paired blood cultures are taken (aerobes & anaerobes)
- if a line is present then 1 is taken from this and 1 from the periphery
- if the patient does not have a line, then 2 peripheral samples are used
What additional investigations may be performed depending on presentation?
- swabs are taken from any area that shows a discharge
- sputum culture
- urine analysis and culture
- stool analysis and culture (if diarrhoea)
- CXR if respiratory signs / symptoms
What parameters does the MASCC score consider?
- infection burden
- co-morbidities
- age > 60
- blood pressure
- presence of COPD
- tumour type - haematological / solid
- fluid status
- in-patient / out-patient
the lower the score, the lower the risk of a poor outcome
What is G-CSF?
they are haematopoitic growth factors that promote stem cell proliferation and shorten the duration of neutropenia
G-CSF agents are Filgrastim or Lenograstim
this does NOT mean that the patient will not be neutropenic
it shortens the duration of the neutropenia, meaning it is less likely to contract an infection during this time
Describe normal calcium homestasis when there is a high blood calcium level
- the thyroid gland releases calcitonin when blood calcium is too high
- calcitonin promotes the osteoblasts to deposit calcium within the bone
- calcitonin reduces absorption of calcium in the kidneys
- this results in a decline in blood calcium levels
Describe calcium homeostasis when blood calcium is too low
- the parathyroid gland releases PTH
- PTH promotes osteoclasts to release calcium from the bones
- PTH stimulates the kidneys to absorb calcium from the urine
- the kidneys convert 25-hydroxy Vitamin D to dihydroxy Vitamin D - this stimulates the bowels to absorb calcium
What is transforming growth factor alpha and how does it work?
- it is a polypeptide stimulator of cell growth and replication that is produced by many cancer cells
- it is a powerful stimulator of bone resorption
How do PTH-related peptides work?
- it is a tumour-associated protein that mimics PTH
- it stimulates bone resorption and increases plasma calcium
What are the general symptoms of hypercalcaemia?
- dehydration
- muscle weakness
- fatigue
- bone pain
What are the CNS symptoms of hypercalcaemia?
- confusion
- seizures
- proximal neuropathy
- hyporeflexia
- coma
What are the GI tract symptoms of hypercalcaemia?
- weight loss
- N & V
- abdominal pain
- constipation
- ileus
- dyspepsia
- pancreatitis
What is the most common ECG finding in hypercalcaemia?
bradycardia with a short QT interval
wide T waves + prolonged PR interval can also be seen
What is shown in this image?
metastatic spinal cord compression (MSCC) at T10
the vertebra is affected by the tumour and the CSF (white layer surrounding SC) is not evident at this level
What are the key features of an UMN lesion?
- no muscle wasting (except for disuse atrophy)
- “clasp-knife spasticity” / hypertonia
- clonus present
- hyperreflexia
- positive Babinski sign
What is the treatment pathway for suspected MSCC?
- 16mg dexamethosone with PPI cover
- urgent MRI of whole spine within 24 hours
dexamethasone is a steroid that can aid with removing some oedema and decompressing the spinal cord prior to intervention
What is meant by superior vena cava obstruction (SVO)?
obstruction to the superior vena cava blood flow by external compression, thrombosis or direct invasion of the SVC
this restricts blood return to the heart from the head, neck and UL
What are the characteristic symptoms of SVCO?
- swelling of the face / neck / arms
- distended veins across the neck + chest
- breathlessness
- headache (worse on coughing)
- cyanosis
- visual disturbances
What is the first-line investigation for suspected SVCO?
CXR
this gives the ability to identify mediastinal widening and may show the primary cause of SVCO
CXR is normal in 16% patients with SVCO
mediastinal widening = width > 8cm on PA view
After CT results, what are the potential treatment options for SVCO?
- vascular stent if cause is external compression + patient decompensated
- radiotherapy / chemotherapy - if cancer would respond quickly to these
- anticoagulation with LMWH if thrombus is confirmed
