Oncological Emergencies

Question 1

4 common oncological emergencies

Answer 1

Sepsis (neutropenic)
Spinal cord compression
Hypercalcaemia
Superior Vena Cava Obstruction (SVCO)

Question 2

Expected presentation of a patient with sepsis

Answer 2

5-12 days following chemotherapy treatment 
High temperature
High HR
High RR 
Low BP
General malaise/fatigue 
Bloods - low WCC (neutrophils)

Question 3

Management for neutropenic sepsis

Answer 3

ABC approach
Investigate and treat sepsis aggressively

3in

• oxygen
• IV antibiotics (broad spectrum tazocin or meropenem)
• fluids

3 out

• blood cultures
• VBG/ABG (lactate)
• catheterise (urine output)

Question 4

Presentation of spinal cord compression

Answer 4

Known metastatic cancer
Worsening (thoracic) back pain
Difficulty walking
Bilateral leg weakness

Question 5

Red Flags for back pain

Answer 5

R -referred pain (multi segmental/band like)
E -escalating pain, poorly responsive
D -differnent character/site to previous symptoms
F -funny feelings/odd sensations
L -lying flat increases pain (also laughing/coughing)
A -agonising pain
G -gait disturbance/unsteadiness (first sign may be difficulty climbing stairs)
S -sleep disturbance (pain worse @ night)

Question 6

How common is spinal cord compression?

Answer 6

Present in 5% of all cancer patients

Question 7

For how many patients is metastatic spinal cord compression their first presentation?

Answer 7

20%

Question 8

How commonly is thoracic spine affected?

Answer 8

60%

Question 9

Management of spinal cord compression

Answer 9

High dose steroids - dexamethasone 16mg stat then 8mg BD
Flat bed rest
Investigate with MR whole spine within 24 hours - assess spinal stability- bed rest/mobilisation
CT chest abdomen and pelvis to help inform decision about surgery
Organise definitive treatment

Question 10

Presentation of SVCO

Answer 10

Dyspnoea
Neck and face swelling
Headache
Blurred vision

Question 11

Where is cancer causing SVC obstruction most commonly found?

Answer 11

Right upper lobe
Upper mediastinum

Primary lung tumour or lymph node

Question 12

How is SVCO confirmed?

Answer 12

Contrast CT

Question 13

Management of SVCO

Answer 13

ABC
High dose steroids (16mg Dex stat, 8mg BD)

Ongoing management depends on underlying diagnosis/prognosis
Stents sometimes used
Chemotherapy/radiotherapy

Question 14

Presentation of hypercalcaemia

Answer 14

Acute abdomen
Nausea
Dehydration
Confusion

Question 15

Causes of hypercalcaemia

Answer 15

Primary hyperparathyroidism
Cancer
Drugs
Granulomatous diseases 
Endocrine
Familial

Question 16

What is expected on bloods in hypercalcaemia?

Answer 16

High urea
High creatinine
High adjusted calcium
Low parathyroid hormone

Question 17

Management of hypercalcaemia

Answer 17

IV fluid rehydration - several litres over first 24 hours (monitor fluid balance and electrolytes)
IV bisphosphonate (zolendronic acid) -only after rehydration (unless calcium very high)

Denosumab can be used as an alternative

Question 18

Bloods requested in spinal cord compression?

Answer 18

FBC - bone marrow infiltration can lead to bone marrow suppression with anaemia and thrombocytopenia

Bone profile - hypercalcaemia can occur with bone mets

U&Es - esp. important if hypercalcaemia is found

LFTs - marker for other sites of mets