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Year 4 > Oncology Emergencies > Flashcards

Oncology Emergencies Flashcards

1
Q

Define neutropenic sepsis?

A

Fever of >38 or features of sepsis in a patient with a neutrophil count <0.5 x10 ^9/L

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2
Q

What are the severities of neutropenia?

A

General neutropenia = absolute neutrophil count <1.5

Severe neutropenia = ANC <0.5

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3
Q

What are some of the clinical features of neutropenic sepsis?

A
  • Temp >38 or <36
  • Acute confusion
  • HR >90
  • RR >20
  • BP <90 mmHg
  • Urine output <0.5ml/kg/hour
  • Other specific features of infection; cough, dysuria
  • non specific generally unwell
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4
Q

What investigations would you do for suspected neutropenic sepsis

A
  • ABG (lactate)
  • Bloods: FBC for neutrophils, LFT, U&E, CRP
  • Blood culture
  • Culture of any lines
  • Urine culture
  • Sputum MC+S
  • Stool MC+S
  • Wound swab
  • CXR
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5
Q

How do you manage neutropenic sepsis?

A
  • Blood Cultures
  • Lactate
  • High flow oxygen
  • IV fluids 0.9% saline over 15 mins
  • Antibiotics
  • Monitor urine output
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6
Q

What is the antibiotic of choice in managing neutropenic sepsis?

A

Empirical penicillin/ Tazobactam (Tazocin) 4.5g TDS for minimum of 5 days

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7
Q

What is the antibiotic of choice in managing neutropenic sepsis if patient is penicillin allergic?

A

Meropenem 1g TDS

Consult local micro

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8
Q

What is the MASCC risk index?

A

A scoring system for helping decide management of neutropenic sepsis patients
Score >21 = low risk, consider outpatient management with oral antibiotics
Score <21 = high risk, inpatient management and IV abx

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9
Q

What is tumour lysis syndrome?

A

A metabolic disruption arising from the breakdown of malignant cells
Can occur with any tumour but higher risk with haematological malignancies

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10
Q

What metabolic disturbances do you see in tumour lysis syndrome?

A

Hyperkalaemia
Hyperphosphateaemia
Hypocalcaemia
Hyperuricaemia

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11
Q

What are some of the consequence of metabolic disturbance in tumour lysis?

A
  • AKI
  • Arrhythmia
  • Sudden death
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12
Q

What are some of the risk factors associated with a high risk of tumour lysis syndrome?

A
  • High proliferation rate of tumour
  • Chemosensitivity
  • Large tumour burden
  • Pre-existing metabolic disturbance
  • Renal impairment
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13
Q

What are some of the signs and symptoms of tumour lysis syndrome?

A
  • lethargy
  • syncope
  • N&V
  • diarrhoea
  • Anorexia
  • Muscle cramps/ weakness
  • Pruritis
  • seizures
  • dysrhythmia
  • fluid overload
  • cardiac arrest
  • bronchospasm (wheeze)
  • Tetany and Paraesthesia
  • Haematuria
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14
Q

What investigations would you do for suspected tumour lysis syndrome?

A
  • U&E
  • Serum urate
  • ECG
  • Cardiac monitoring
  • LDH
  • lactate
  • urine microscopy
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15
Q

What is the name of the definition system for determining tumour lysis syndrome?

A

Cairo- Bishop Definition

Splits into clinical and lab diagnosis

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16
Q

What Lab values are needed to diagnose tumour lysis syndrome?

A

2 or more of within 7 days of treatment:

  • Uric acid >476 or 25% increase
  • K of >6 or 25% increase
  • Phosphate of >1.45 or 25% increase
  • Calcium of <1.75 or 25% decrease
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17
Q

What clinical diagnosis of the cairo- bishop score is needed to diagnose tumour lysis?

A

Presence of 1 of the following that cannot be attributed to a therapeutic agent:

  • Serum creatinine >1.5 x upper limit of normal
  • Cardiac arrhythmia / sudden death
  • Seizure
18
Q

What urate lowering agents are used in treatment of tumour lysis syndrome?

A

Allopurinol - Prevents conversion of hypoxanthine to uric acid (but does not act on pre-existing uric acid)

Rasburicase - recombinant urate oxidase, metabolises uric acid –> allatonin
Can be used as prophylaxis and treatment

19
Q

What is rasburicase contraindicated in?

A

G6PD deficiency

20
Q

Aside from urate lowering agents, how is tumour lysis treated?

A
  • Hyperphosphateaemia: hydrate, diet restriction, phosphate binders in severe cases
  • Hyperkalaemia: ECG monitor and calcium gluconate, insulin/ dextrose and nebuliser salbutamol
  • Hypocalcaemia: - only treat if symptomatic as may cause calcium deposits in kidneys- treated with calcium gluconate
21
Q

Which malignancies most commonly cause SVCO?

A
  • Lung , NSCLC most common

- Non Hodgkin’s lymphoma (due to mediastinal nodes)

22
Q

What 4 collateral systems develop in SVCO?

A
  • Azygous
  • Internal mammory
  • Long thoracic (femoral and vertebral)
23
Q

What are the clinical features of SVCO?

A
  • Pemberton’s sign +
  • Blurred vision
  • Headache
  • Oedema of upper limb
  • Engorged veins in neck and chest wall
  • Chest pain
  • Dyspnoea
  • Cough
  • Cyanosis
  • Confusion
  • Coma
24
Q

How is SVCO investigated?

A
  • CXR - 80% show abnormality and helps rule out other causes
  • Contrast enhanced CT makes definite diagnosis
  • Duplex USS used in patients with indwelling catheter
25
Q

What is the general management of SVCO?

A

Conservative: elevate bed, O2 sats optimised
Stenting
Radiotherapy
Chemotherapy

26
Q

What is the emergency management of SVCO? (rare)

A

Only if causing respiratory distress or cerebral oedema

  • consider steroids and diuretics
  • definitive management is end-vascular stunting, shunt or thrombolysis
27
Q

What is the significant in terms of outlook for patients SVCO?

A

Negative prognostic factor
Average 6 months life expectancy
Short term relief of symptoms is mainstay

28
Q

Define spinal cord compression

A

Radiological evidence of indentation of the thecae sac secondary to cancer

Thecae sac = component of dura mater

29
Q

Which cancers most commonly cause spinal cord compression?

A 
Lung
Breast
Kidney
Thyroid
Prostate
30
Q

Where do most spinal cord compressions occur?

A

60% thoracic
30% lumbar
10% cervical

31
Q

What are the clinical features of spinal cord compression?

A
  • Pain (95% cases) usually prices neurological symptoms by several werks
  • Weakness - 85% cases, typically symmetrical, progressive
  • Hyperreflexia if UMN involved
  • Paraesthesia
32
Q

How would you investigate/ diagnose malignant spinal cord compression?

A

MRI investigation of choice

33
Q

How do you manage malignant spinal cord compression?

A
  • Surgical Emergency
  • 16mg stat of dexamethasone + PPI (avoid after midday)
  • Monitor BMs (due to steroids)
  • Analgesia
  • VTE prophylaxis
  • Bed rest with log rolls
34
Q

What is the definitive management of malignant spinal cord compression?

A
  • External beam radiotherapy (adjuvant or stand alone) for 5 consecutive days
  • Stereotactic radiotherapy (high dose) in renal cell carcinoma or sarcoma
  • Decompression and reconstruction or vertebroplasty surgery)
35
Q

What level of serum calcium is classified is malignant hypercalcaemia?

A

> 2.6 mmol/L

36
Q

What are the different severities of malignant hypercalcaemia?

A 
Mild = 2.6-3.0 mmol/L
Moderate = 3.0-3.5 mmol/L
Severe = >3.6 mmol/L
37
Q

What are the 3 main mechanisms that cause malignant hypercalcaemia?

A 
Osteolytic metastasis (20% cases) most common in breast
PTH related PTHrP secretion (80% cases)
Increased 1,25 dihydroxyvitamin D production (leads to increased calcium absorption from GI enterocytes)
38
Q

What are the clinical features of hypercalcaemia?

A 
Stones: kidney and gallbladder
Thrones: polyuria 
Bones: pain 
Groans: constipation and muscle weakness
Psychiatric overtone: depression and confusion
39
Q

What investigations do you do for suspected malignant hypercalcaemia?

A

Serum adjusted calcium

Confirm malignancy if diagnosis not already known: examination, CT, myeloma screen

40
Q

How do you manage malignant hypercalcaemia

A

If mild: oral fluids
If moderate or severe:
- Admit
- IV hydration 3L of 0.9% NaCL over 24 hours
- Bisphosphonates (Pamidronate or Zoledronic acid) takes 2-4 days to start lowering calcium

41
Q

What important consideration must you give when prescribing bisphosphonates for hypercalcaemia

A

Can be nephrotoxic
Need to hydrate well first with 3L of fluids
Give bisphosphonate in 4th bag

Year 4 (5 decks)

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