Flashcards in Oncology Emergencies, GI Emergencies, Cirrhosis Complications Deck (130):
What tumors can cause SVC syndrome?
- Small cell lung ca
- Squamous cell lung ca
- Anaplastic mediastinal ca
Besides tumors, what else can cause SVC syndrome?
- Thrombosis from indwelling catheter
- SVC compression/occlusion
Sx's of SVC syndrome (7)
- Hoarseness, stridor
- Nasal congestion, epistaxis
- Orthopnea, syncope
Signs of SVC syndrome (3)
- Neck/arm vein distention
- Facial swelling/edema
- Mentation changes
Signs of SVC syndrome that are considered emergencies (4)
- Facial plethora
- Supraventricular palpable mass
- Horner's syndrome (miosis, ptosis, anhidrosis)
What's the best diagnostic imaging for SVC syndrome? Alternatives?
CT scan w/ contrast
Alt: MRI, contrast venography, Tc99m radionuclide venography
Tx of SVC syndrome
- Elevate head of bed
- IV steroids, IV diuretics
- Emergent mediastinal radiation
What tumors can cause acute spinal cord compression? (7)
- Lymphomas, multiple myeloma, sarcomas
Sx's of acute spinal cord compression
- Localized back pain +/- tenderness
- Distal sensory deficits
- Gait disturbance
- Urinary incontinence
What is the diagnostic imaging of choice for diagnosing acute spinal cord compression?
MRI - best for CNS
Tx of acute spinal cord compression
- Spine immobilization
- Foley catheter (incontinence)
- IV steroids, diuretics, mannitol
- Emergency decompressive laminectomy or radiation
What tumors can cause hypercalcemia of malignancy?
- Metastatic breast, lung, prostate
- Multiple myeloma
- Head/neck SCC
Sx's of hypercalcemia of malignancy
"Moans, groans, bones, psychiatric undertones"
- Back pain
- Neuro sx's
At what point is hypercalcemia of malignancy dangerous?
Corrected Ca2+ >12
Remember to correct for albumin!
What labs would indicate hypercalcemia of malignancy?
- Calcium, duh (>12 corrected is dangerous)
- Low serum Cl-
What would you see on EKG for pt with hypercalcemia of malignancy? (3)
- Short QT
- Low voltage
- Prolonged PR
Tx for hypercalcemia of malignancy
- IVF -> IV Lasix when euvolemic
- SQ/IM calcitonin
- Dialysis if renal/heart failure
- Treat malignancy, duh
- Stop taking Ca2+, Vit D, NSAIDs
What bisphosphonates might you consider for hypercalcemia of malignancy?
- Zolendronic acid (DON'T use in renal failure)
What should pt with hypercalcemia definitely avoid?
PO phosphate - binds to Ca2+ & blocks up renal tubules
Equation for ANC
10 x WBC in 1000s x (%PMN + %bands) = ANC
fyi - PMN = Polys
Criteria for febrile neutropenia
- Single PO temp >101.3 OR sustained >100.4 for 1hr
- ANC <1000 (Severe is ANC <500)
When is a common time to see febrile neutropenia?
During Nadir after chemo (cell lines transiently hit rock bottom) - usually 5-10 days after last dose, lasts 5 days
Si/Sx of febrile neutropenia
Kinda sick to super sick - range from asx fever to severe sepsis
Work-up for febrile neutropenia
- Blood culture x2 (peripheral vein + catheter)
- Urine, sputum cx
- Stool, CSF cx if indicated
- CT if respiratory complaints (CXR nl)
Door to abx window for febrile neutropenia
<1 hr (ASAP)
Which abx is best for febrile neutropenia?
Tx for afebrile neutropenia
- IV abx (vanco, cefepime) for 5-7 days (PO if ANC >1000)
- Confirm neg. cx before discharge
Tx for febrile neutropenia
- IV abx for 5-7 days (PO if ANC >1000)
- Antifungal on day 4
- Consult ID
What can you give to pt with more serious case of neutropenia?
Neupogen or Neulasta, commonly given 48hr s/p chemo - speeds resolution, reduces hospital stay by 1 day BUT doesn't change mortality
What are you most concerned about for pt with neutropenia?
Bacteremia (medical emergency)
Risk factors for infection in pt with neutropenia
- Duration of neutropenia
- ANC <1000
- Central lines
- Hepatic/renal insufficiency
When is tumor lysis syndrome likely to occur?
6-72 hrs after intiation of chemo/radiation
Risk factors for tumor lysis syndrome
- Large tumor burden
- High growth fraction
- High preRx serum LDH or uric acid
- Pre-existing renal insufficiency
Si/Sx's of tumor lysis syndrome
- Decreased urinary output
- Muscle weakness
- Arrythmias, palpitations
- Acute renal failure
What electrolytes abnormalities do you expect with tumor lysis syndrome?
Tx for tumor lysis syndrome
- Stop the chemo/radiation!
- Aggressive IVF, diuresis, +/- bicarb to alkalinize urine to pH7 (may worsen hypocalcemic tetany) → goal of 150mL/hr urine output
- Rasburicase (uric acid → allantoin)
- Hemodialysis last resort
Tx for hyperkalemia in tumor lysis syndrome
- Kayexelate (bind to K+, excrete in stool)
When is emergency hemodialysis indicated in tumor lysis syndrome?
Uric acid >10
Unable to tolerate diuresis
How/why can thrombocytopenia occur w/ malignancy? (6)
- Bone marrow tumor infiltration
What med. should pts with thrombocytopenia in malignancy avoid?
Spontaneous bleeds occur if platelets are ______
Platelet transfusion is indicated in thrombocytopenia of malignancy if...
- Plt <10k
- CNS bleed (even if plt >10k)
Most common causative tumors leading to DIC
- Acute leukemia
- Pancreas ca
- Prostate ca
Lab values for acute malignancy-related DIC
Tx for acute malignancy-related DIC
- Platelets, clotting factors
- May need tumor debulking
Lab values for chronic malignancy-related DIC
Labs may be normal
Tx for chronic malignancy-related DIC
Treat intravascular thrombosis w/ heparin
Common causative tumors of malignant pericardial tamponade
- Acute leukemia
Non-tumor causes of malignant pericardial tamponade
Si/Sx's of malignant pericardial tamponade (5)
- Muffled heart sounds
- Pulsus paradoxicus
- Low voltage QRS +/- pulsus alternans
Imaging dx of malignant pericardial tamponade
Tx of malignant pericardial tamponade
- Pericardial window under local anesthesia
- Intrapericrdial chemo or sclerosis
What structure separates UGIB from LGIB?
Ligament of Treitz (duodenojejunal junction)
Which is more common, UGIB or LGIB?
Suspect UGIB in pt with BUN:Cr _____ without renal insufficiency
Possible causes of UGIB (8-ish)
- PEPTIC ULCER
- Esophagitis, gastritis, duodenitis
- Gastroduodenal erosions
- Mallory Weiss tear
- Variceal bleed
- Angiodysplasia, telengiectasia
- Vascular ectasia
Besides previous bleed, what are other risk factors for UGIB (6)
- ETOH (liver dz)
- Steroids (peptic ulcer, esophagitis)
- Liver dz
- Anticoagulants, NSAIDs
- Severe vomiting
- Aortic surgery (aortoenteric fistula)
What's the Rockall scoring system used for?
Predictor of mortality in UGIB pts
Risk factors for UGIB mortality according to Rockall scoring system
- Age >60
- Indications of shock (SBP≥100, HR>100)
First, intubate (if indicated) and hemodynamically stabilize UGIB pt. Then...
Endoscopy - identify source & tx
- Mechanical clip +/- epi
- Thermal coagulation + epi
- Fibrin or thrombin + epi
You tried endoscopy for actively bleeding UGIB pt, but couldn't find the source. What now?
Angiography + transcatheter arterial embolization
HCT goal for elderly UGIB
When would you transfuse plts in UGIB pt?
Plt <50k & active bleeding
After you stabilize pt & tx UGIB, what do you want to do for the long run?
Prevent re-bleeding: High-dose IV PPI bolus + continuous infusion → PO x8wks
What special test do you want to perform for UGIB?
H. pylori test - if pos. tx w/ PPI + 2 abx (clarithromycin, amoxicillin, Flagyl) x7d
What's important to note in preventing variceal bleeding?
Keep portal pressure <12 mmHg
Tx for variceal bleeding
Resuscitation + endoscopy → banding +/- sclerotx → repeat in 5-7 days if refractory → vasoconstrictor (octreotide & somatostatin) +/- tamponade → TIPSS → liver transplant
Important notes about tamponade via esophageal balloon for variceal bleeding
- Don't inflate for >24 hrs
- Temp. fix, will re-bleed after deflation
Indications for TIPSS
- Refractory variceal bleeding
- Refractory ascites
- Budd Chiari (clot in hepatic v.)
Bridge to liver transplant
Like any other type of surgery, TIPSS has risk of failure, occlusion, thromboembolism, hemorrhage, infection. Name 5 other complications.
- Hepatic encephalopathy
- Liver failure
What can help with prevention of variceal bleeding?
- Beta-blockers (e.g. propranolol, nadolol)
- Long-acting nitrates
- Soft foods
- ?Prophylactic banding in cirrhosis
Possible causes of LGIB (7)
- Colitis (IBD, infectious, ischemic)
- Dieulafoy's lesion
(7) Risk factors for severe LGIB, i.e. cont. bleeding within 24 hrs, HCT decline, recurrence
- HR >100
- SBP <115
- Nontender abd exam
- Bleeding during first 4 hrs of evaluation
- ASA use
- >2 comorbid conditions
Tx for LGIB
None - most resolve spontaneously → elective colonoscopy after bleeding stops
That LGIB just won't stop on its own, and the pt is hemodynamically UNstable. What are your options?
- Angiography + embolization (diagnostic & therapeutic)
- Tagged RBC scan → localizes bleeding but NOT therapeutic; may need to follow w/ angiography
Complications of angiography for LGIB?
- Bowel infarction
- Renal failure
That LGIB just won't stop on its own, but the pt is hemodynamically stable. What are your options?
- Urgent colonoscopy w/in 6-12 hrs
- CT angiogram (bedside), NOT therapeutic
Why is urgent colonoscopy not urgent enough for active LGIB in unstable pt?
Needs rapid purge prep w/ 5-6L Golytely over 3 hrs until clear stools
How many grams of acetaminophen is toxic?
What is acetaminophen used for?
Analgesic & antipyretic
How does acetaminophen cause toxicity?
Depletes glutathione from liver → accumulate NAPQI → hepatic necrosis
When does peak plasma levels occur in APAP toxicity?
Within 4 hrs
How much APAP does it take to damage the liver?
- Adults → >150mg/kg in acute dose OR 7.5g in 24 hrs
- Children → >200mg/kg
Complications of APAP toxicity
- Renal failure
- Metabolic acidosis
- Hypophosphatemia, hypo/hyperglycemia
- Cerebral edema
Phases of APAP toxicity & time periods
Phase 1 = 30 min-4 hr
Phase 2 = 24-48 hr
Phase 3 = 3-5 days
Phase 4 = 4 days - 2 wks
What happens in phase 1 of APAP toxicity?
30 min - 4 hrs → N/V, anorexia, pallor, diaphoresis
What happens in phase 2 of APAP toxicity?
24-48hrs → RUQ pain, elevated LFTs, prolonged PT, deteriorating renal fx
What happens in phase 3 of APAP toxicity?
3-5 days → renal failure, hepatic necrosis, hepatic encephalopathy, death d/t hepatic failure
What happens in phase 4 of APAP toxicity?
4 days - 2 wks → complete resolution or death
Management of APAP toxicity since dialysis not useful
- Ipecac or gastric lavage within 1-2hrs
- Activated charcoal within 4 hrs
PTT of ____ has high mortality
Plot APAP level at 4 hrs post-ingestion (incorrect if earlier) → 150mg/dL at 4 hrs is toxic
You plotted the Rumack-Matthews nomogram. The APAP level is above the "risk line". Now what?
PO/IV/NGT N-acetylcysteine (glutathione sub) - complete full course (q4hrs, x17 doses) , DON'T STOP even if levels drop → if emesis within 1 hr of dose, repeat dose (give Reglan)
What labs might be important for APAP toxicity (besides APAP levels)?
- Tox screen for other substances (co-OD)
- AST/ALT q24 hrs (rise at 24-36 hrs)
Signs of ascites (6)
- Flank dullness +/- shifting dullness
- Palmar erythema
- Caput medusa
- Engorged jugular veins
Any new case of ascites requires...
- CBC, CMP, LFTs, urea
- Abdominal U/S
- Diagnostic paracentesis + Ascitic fluid analysis (total protein, albumin, cell count , +/- cx)
SAAG = serum albumin - ascites albumin
High SAAG (____) indicates portal HTN or nonperitoneal cause of ascites
>1.1g/dL (or 11g/L)
How can you prevent tumor lysis syndrome?
Allopurinol pre/post chemo
How do you diagnose Grade I ascites? Tx?
Only detectable via U/S → salt restriction
Presentation of Grade II ascites
Moderate symmetrical abdomen enlargement w/ shifting dullness
Tx of Grade II ascites
Salt restriction + diuretics
- Add furosemide (Lasix) if not losing 2kg/wk or hyperkalemia
- Fluid restriction only if there's dilutional hyponatremia (Na+ <125)
Dosing for spironolactone for Grade II ascites
100mg/day → +100mg/day q7 days to max 400mg/day if needed
Dosing for furosemide for Grade II ascites
40mg/day → +40mg/day to max 160
Max recommended weight loss for diuresing Grade II ascites
0.5kg/day in pts w/out edema OR 1kg/day with edema
In what situations would you D/C diuretics for ascites tx?
- Severe hyponatremia (<120)
- Renal failure
- Incapacitating muscle crams
- Stop spironolactone if K+>6
- Stop Lasix if K+<3
Presentation of Grade III ascites
Marked abdominal enlargement with transmitted thrill (tense ascites)
Tx of Grade III ascites
Large volume paracentesis + albumin infusion +/- diuretics
How much is drained in large volume paracentesis for Grade III ascites?
5L at a time - give 6-8g albumin/L removed
You're doing like >3 paracenteses/month on this ascites pt... There must be some other option?
TIPSS ...unless the pt has hepatic encephalopathy
Complications of ascites (5)
- Umbilical hernia
- Hydrothorax (pleural effusion)
- Hepatorenal syndrome
- Hepatic encephalopathy
Ascitic neutrophil count for SBP
Most common pathogens for SBP
E. coli or streptococcus
Ascitic neutrophil count >250 but negative cx
Ascitic neutrophil count <250 but positive cx
When would you treat SBP?
Whenever ascitic neutrophil count >250, regardless of sx's OR prophylaxis in cirrhosis pts with GIB
Tx for SBP
Ceftriaxone IV x5 days
Turns out your SBP pt is allergic to ceftriaxone.
Augmentin or fluoroquinolone (except for pt already on SBP ppx)
Dx hepatorenal syndrome
Pt with advanced liver dz with proteinuria <0.5g/day w/out microhematuria and no other identifiable cause of renal failure
Rapid, progressive impairment (>100% incr. in Cr in <2wks)
Stable, less progressive renal impairment
Prevention of HRS
Dx/tx infections of cirrhosis pts - infections has highest risk of HRS
Tx of HRS
- Monitor in ICU - urine output, fluid balance, ideal CVP
- Blood/ascitic cx w/ ppx abx if neg.
- Hemodialysis if hyperK+, hypervolemic, metabolic acidosis
- D/C diuretics
- Liver transplant
Signs of hepatic encephalopathy
- Personality changes
- Intellectual impairment
- Depressed level of consciousness
Why does hepatic encephalopathy occur?
Ammonia produced by GIT not detoxified d/t liver failure → cerebral edema, ICP, possible herniation
Possible causes/risk factors for hepatic encephalopathy (7)
- Renal failure
- Medications (e.g. benzos, antipsychotics)
Diagnostics/labs for hepatic encephalopathy
- Head CT to rule out bleeds/lesions
- EEG to rule out seizure
- Ammonia, to confirm dx
Tx for hepatic encephalopathy
- Lactulose → titrate to achieve 2-4 soft stools/day without diarrhea
- Lactulose failed = abx neomycin, rifaximin (alt. Flagyl, PO vanco)
- Fermentable fibers
How does lactulose work?
Pass through small bowel unchanged, ferments into lactic acid → ammonia acidified to ammonium (poorly absorbed), non-ammonia/urease-producing GIT, laxative