Oncology Emergencies, GI Emergencies, Cirrhosis Complications Flashcards Preview

Therapeutics II > Oncology Emergencies, GI Emergencies, Cirrhosis Complications > Flashcards

Flashcards in Oncology Emergencies, GI Emergencies, Cirrhosis Complications Deck (130):
1

What tumors can cause SVC syndrome?

- Small cell lung ca
- Squamous cell lung ca
- Lymphoma
- Anaplastic mediastinal ca

2

Besides tumors, what else can cause SVC syndrome?

- Thrombosis from indwelling catheter
- SVC compression/occlusion

3

Sx's of SVC syndrome (7)

- Dyspnea
- Hoarseness, stridor
- Nasal congestion, epistaxis
- Orthopnea, syncope

4

Signs of SVC syndrome (3)

- Neck/arm vein distention
- Facial swelling/edema
- Mentation changes

5

Signs of SVC syndrome that are considered emergencies (4)

- Facial plethora
- Supraventricular palpable mass
- Horner's syndrome (miosis, ptosis, anhidrosis)
- Papilledema

6

What's the best diagnostic imaging for SVC syndrome? Alternatives?

CT scan w/ contrast

Alt: MRI, contrast venography, Tc99m radionuclide venography

7

Tx of SVC syndrome

- Elevate head of bed
- IV steroids, IV diuretics
- Emergent mediastinal radiation

8

What tumors can cause acute spinal cord compression? (7)

- Breast
- Lung
- Prostate
- Renal
- Lymphomas, multiple myeloma, sarcomas

9

Sx's of acute spinal cord compression

- Localized back pain +/- tenderness
- Paraparesis/paraplegia
- Distal sensory deficits
- Gait disturbance
- Urinary incontinence

10

What is the diagnostic imaging of choice for diagnosing acute spinal cord compression?

MRI - best for CNS

11

Tx of acute spinal cord compression

- Spine immobilization
- Foley catheter (incontinence)
- IV steroids, diuretics, mannitol
- Emergency decompressive laminectomy or radiation

12

What tumors can cause hypercalcemia of malignancy?

- Metastatic breast, lung, prostate
- Multiple myeloma
- NHL
- Head/neck SCC

13

Sx's of hypercalcemia of malignancy

"Moans, groans, bones, psychiatric undertones"

- Constipation
- Polydipsia
- Back pain
- Neuro sx's

14

At what point is hypercalcemia of malignancy dangerous?

Corrected Ca2+ >12

Remember to correct for albumin!

15

What labs would indicate hypercalcemia of malignancy?

- Calcium, duh (>12 corrected is dangerous)
- Low serum Cl-

16

What would you see on EKG for pt with hypercalcemia of malignancy? (3)

- Short QT
- Low voltage
- Prolonged PR

17

Tx for hypercalcemia of malignancy

- IVF -> IV Lasix when euvolemic
- Bisphosphonates
- SQ/IM calcitonin
- Steroids
- Dialysis if renal/heart failure
- Treat malignancy, duh

- Stop taking Ca2+, Vit D, NSAIDs

18

What bisphosphonates might you consider for hypercalcemia of malignancy?

- Pamindronate
- Zolendronic acid (DON'T use in renal failure)
- Denosumab

19

What should pt with hypercalcemia definitely avoid?

PO phosphate - binds to Ca2+ & blocks up renal tubules

20

Equation for ANC

10 x WBC in 1000s x (%PMN + %bands) = ANC

fyi - PMN = Polys

21

Criteria for febrile neutropenia

- Single PO temp >101.3 OR sustained >100.4 for 1hr
- ANC <1000 (Severe is ANC <500)

22

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

23

Si/Sx of febrile neutropenia

Kinda sick to super sick - range from asx fever to severe sepsis

24

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)

25

Door to abx window for febrile neutropenia

<1 hr (ASAP)

26

Which abx is best for febrile neutropenia?

Vancomycin
Cefepime

27

Tx for afebrile neutropenia

- IV abx (vanco, cefepime) for 5-7 days (PO if ANC >1000)
- Confirm neg. cx before discharge

28

Tx for febrile neutropenia

- IV abx for 5-7 days (PO if ANC >1000)
- Antifungal on day 4
- Consult ID

29

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

30

What are you most concerned about for pt with neutropenia?

Bacteremia (medical emergency)

31

Risk factors for infection in pt with neutropenia

- Duration of neutropenia
- ANC <1000
- Comorbidities
- Central lines
- Hepatic/renal insufficiency

32

When is tumor lysis syndrome likely to occur?

6-72 hrs after intiation of chemo/radiation

33

Risk factors for tumor lysis syndrome

- Large tumor burden
- High growth fraction
- High preRx serum LDH or uric acid
- Pre-existing renal insufficiency

34

Si/Sx's of tumor lysis syndrome

- Decreased urinary output
- Muscle weakness
- Arrythmias, palpitations
- Confusion
- Acute renal failure

35

What electrolytes abnormalities do you expect with tumor lysis syndrome?

- Hyperuricemia
- Hyperkalemia
- Hyperphosphatemia
- Hypocalcemia

36

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

37

Tx for hyperkalemia in tumor lysis syndrome

- CaCl
- Bicarb
- Glucose/insulin
- Kayexelate (bind to K+, excrete in stool)
- Dialysis

38

When is emergency hemodialysis indicated in tumor lysis syndrome?

K+ >6
Uric acid >10
Cr >10
Unable to tolerate diuresis

39

How/why can thrombocytopenia occur w/ malignancy? (6)

- Chemo/radiation
- Bone marrow tumor infiltration
- Hypersplenism
- DIC
- Infection-induced
- ITP

40

What med. should pts with thrombocytopenia in malignancy avoid?

NSAIDS

41

Spontaneous bleeds occur if platelets are ______

<10k

42

Platelet transfusion is indicated in thrombocytopenia of malignancy if...

- Plt <10k
- CNS bleed (even if plt >10k)

43

Most common causative tumors leading to DIC

- Acute leukemia
- Pancreas ca
- Prostate ca

44

Lab values for acute malignancy-related DIC

↓plt
↓fibrinogen
↑PT/PTT/FDP

45

Tx for acute malignancy-related DIC

- Platelets, clotting factors
- May need tumor debulking

46

Lab values for chronic malignancy-related DIC

Labs may be normal

47

Tx for chronic malignancy-related DIC

Treat intravascular thrombosis w/ heparin

48

Common causative tumors of malignant pericardial tamponade

- Melanoma
- HL
- Acute leukemia
- Lung
- Breast
- Ovarian

49

Non-tumor causes of malignant pericardial tamponade

Radiation pericarditis

50

Si/Sx's of malignant pericardial tamponade (5)

- Hypotension
- JVD
- Muffled heart sounds
- Pulsus paradoxicus
- Low voltage QRS +/- pulsus alternans

51

Imaging dx of malignant pericardial tamponade

Echo

52

Tx of malignant pericardial tamponade

- Pericardiocentesis
- Pericardial window under local anesthesia
- Pericardiectomy
- Radiation
- Intrapericrdial chemo or sclerosis

53

What structure separates UGIB from LGIB?

Ligament of Treitz (duodenojejunal junction)

54

Which is more common, UGIB or LGIB?

UGIB

55

Suspect UGIB in pt with BUN:Cr _____ without renal insufficiency

BUN:Cr >20:1

56

Possible causes of UGIB (8-ish)

- PEPTIC ULCER
- Esophagitis, gastritis, duodenitis
- Gastroduodenal erosions
- Mallory Weiss tear
- Variceal bleed
- Tumor
- Angiodysplasia, telengiectasia
- Vascular ectasia

57

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)

58

What's the Rockall scoring system used for?

Predictor of mortality in UGIB pts

59

Risk factors for UGIB mortality according to Rockall scoring system

- Age >60
- Indications of shock (SBP≥100, HR>100)
- Comorbidities

60

First, intubate (if indicated) and hemodynamically stabilize UGIB pt. Then...

Endoscopy - identify source & tx

- Mechanical clip +/- epi
- Thermal coagulation + epi
- Fibrin or thrombin + epi

61

You tried endoscopy for actively bleeding UGIB pt, but couldn't find the source. What now?

Angiography + transcatheter arterial embolization

62

HCT goal for elderly UGIB

>30%

63

When would you transfuse plts in UGIB pt?

Plt <50k & active bleeding

64

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

65

What special test do you want to perform for UGIB?

H. pylori test - if pos. tx w/ PPI + 2 abx (clarithromycin, amoxicillin, Flagyl) x7d

66

What's important to note in preventing variceal bleeding?

Keep portal pressure <12 mmHg

67

Tx for variceal bleeding

Resuscitation + endoscopy → banding +/- sclerotx → repeat in 5-7 days if refractory → vasoconstrictor (octreotide & somatostatin) +/- tamponade → TIPSS → liver transplant

68

Important notes about tamponade via esophageal balloon for variceal bleeding

- Don't inflate for >24 hrs
- Temp. fix, will re-bleed after deflation

69

Indications for TIPSS

- Refractory variceal bleeding
- Refractory ascites
- Budd Chiari (clot in hepatic v.)

Bridge to liver transplant

70

Like any other type of surgery, TIPSS has risk of failure, occlusion, thromboembolism, hemorrhage, infection. Name 5 other complications.

- Hepatic encephalopathy
- Hemobilia
- Cholangitis
- HF
- Liver failure

71

What can help with prevention of variceal bleeding?

- Beta-blockers (e.g. propranolol, nadolol)
- Long-acting nitrates
- Soft foods
- ?Prophylactic banding in cirrhosis

72

Possible causes of LGIB (7)

- DIVERTICULOSIS
- Angioectasias
- Hemorrhoids
- Colitis (IBD, infectious, ischemic)
- Neoplasm
- Post-polyectomy
- Dieulafoy's lesion

73

(7) Risk factors for severe LGIB, i.e. cont. bleeding within 24 hrs, HCT decline, recurrence

- HR >100
- SBP <115
- Syncope
- Nontender abd exam
- Bleeding during first 4 hrs of evaluation
- ASA use
- >2 comorbid conditions

74

Tx for LGIB

None - most resolve spontaneously → elective colonoscopy after bleeding stops

75

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

76

Complications of angiography for LGIB?

- Bowel infarction
- Renal failure
- Hematomas/thromboses
- Dissection

77

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

78

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

79

How many grams of acetaminophen is toxic?

15g

80

What is acetaminophen used for?

Analgesic & antipyretic

81

How does acetaminophen cause toxicity?

Depletes glutathione from liver → accumulate NAPQI → hepatic necrosis

82

When does peak plasma levels occur in APAP toxicity?

Within 4 hrs

83

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

84

Complications of APAP toxicity

- Jaundice
- Renal failure
- Hyperlactatemia
- Metabolic acidosis
- Hypophosphatemia, hypo/hyperglycemia
- Arrhythmias
- Pancreatitis
- GIB
- Cerebral edema

85

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

86

What happens in phase 1 of APAP toxicity?

30 min - 4 hrs → N/V, anorexia, pallor, diaphoresis

87

What happens in phase 2 of APAP toxicity?

24-48hrs → RUQ pain, elevated LFTs, prolonged PT, deteriorating renal fx

88

What happens in phase 3 of APAP toxicity?

3-5 days → renal failure, hepatic necrosis, hepatic encephalopathy, death d/t hepatic failure

89

What happens in phase 4 of APAP toxicity?

4 days - 2 wks → complete resolution or death

90

Management of APAP toxicity since dialysis not useful

- Ipecac or gastric lavage within 1-2hrs
- Activated charcoal within 4 hrs
- Laxative

91

PTT of ____ has high mortality

>180

92

Rumack-Matthews nomogram

Plot APAP level at 4 hrs post-ingestion (incorrect if earlier) → 150mg/dL at 4 hrs is toxic

93

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)

94

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)

95

Signs of ascites (6)

- Flank dullness +/- shifting dullness
- Palmar erythema
- Jaundice
- Splenomegaly
- Caput medusa
- Engorged jugular veins

96

Any new case of ascites requires...

- CBC, CMP, LFTs, urea
- Abdominal U/S
- Diagnostic paracentesis + Ascitic fluid analysis (total protein, albumin, cell count , +/- cx)

97

Calculate SAAG

SAAG = serum albumin - ascites albumin

98

High SAAG (____) indicates portal HTN or nonperitoneal cause of ascites

>1.1g/dL (or 11g/L)

99

How can you prevent tumor lysis syndrome?

Allopurinol pre/post chemo

100

How do you diagnose Grade I ascites? Tx?

Only detectable via U/S → salt restriction

101

Presentation of Grade II ascites

Moderate symmetrical abdomen enlargement w/ shifting dullness

102

Tx of Grade II ascites

Salt restriction + diuretics
- Spironolactone
- Add furosemide (Lasix) if not losing 2kg/wk or hyperkalemia
- Fluid restriction only if there's dilutional hyponatremia (Na+ <125)

103

Dosing for spironolactone for Grade II ascites

100mg/day → +100mg/day q7 days to max 400mg/day if needed

104

Dosing for furosemide for Grade II ascites

40mg/day → +40mg/day to max 160

105

Max recommended weight loss for diuresing Grade II ascites

0.5kg/day in pts w/out edema OR 1kg/day with edema

106

In what situations would you D/C diuretics for ascites tx?

- Severe hyponatremia (<120)
- Renal failure
- Encephalopathy
- Incapacitating muscle crams
- Stop spironolactone if K+>6
- Stop Lasix if K+<3

107

Presentation of Grade III ascites

Marked abdominal enlargement with transmitted thrill (tense ascites)

108

Tx of Grade III ascites

Large volume paracentesis + albumin infusion +/- diuretics

109

How much is drained in large volume paracentesis for Grade III ascites?

5L at a time - give 6-8g albumin/L removed

110

You're doing like >3 paracenteses/month on this ascites pt... There must be some other option?

TIPSS ...unless the pt has hepatic encephalopathy

111

Complications of ascites (5)

- Umbilical hernia
- Hydrothorax (pleural effusion)
- SBP
- Hepatorenal syndrome
- Hepatic encephalopathy

112

Ascitic neutrophil count for SBP

>250/mm^3

113

Most common pathogens for SBP

E. coli or streptococcus

114

"Culture-negative SBP"

Ascitic neutrophil count >250 but negative cx

115

"Bacterascites"

Ascitic neutrophil count <250 but positive cx

116

When would you treat SBP?

Whenever ascitic neutrophil count >250, regardless of sx's OR prophylaxis in cirrhosis pts with GIB

117

Tx for SBP

Ceftriaxone IV x5 days

118

Turns out your SBP pt is allergic to ceftriaxone.

Augmentin or fluoroquinolone (except for pt already on SBP ppx)

119

Dx hepatorenal syndrome

Pt with advanced liver dz with proteinuria <0.5g/day w/out microhematuria and no other identifiable cause of renal failure

120

HRS1

Rapid, progressive impairment (>100% incr. in Cr in <2wks)

121

HRS2

Stable, less progressive renal impairment

122

Prevention of HRS

Dx/tx infections of cirrhosis pts - infections has highest risk of HRS

123

Tx of HRS

- Monitor in ICU - urine output, fluid balance, ideal CVP
- Blood/ascitic cx w/ ppx abx if neg.
- Vasopressin
- Hemodialysis if hyperK+, hypervolemic, metabolic acidosis
- D/C diuretics
- Liver transplant

124

Signs of hepatic encephalopathy

- Personality changes
- Intellectual impairment
- Depressed level of consciousness

125

Why does hepatic encephalopathy occur?

Ammonia produced by GIT not detoxified d/t liver failure → cerebral edema, ICP, possible herniation

126

Possible causes/risk factors for hepatic encephalopathy (7)

- Constipation
- Infections
- GIB
- Shunts
- Renal failure
- Medications (e.g. benzos, antipsychotics)
- Diuretics

127

Diagnostics/labs for hepatic encephalopathy

- Head CT to rule out bleeds/lesions
- EEG to rule out seizure
- Ammonia, to confirm dx

128

Tx for hepatic encephalopathy

- Lactulose → titrate to achieve 2-4 soft stools/day without diarrhea
- Lactulose failed = abx neomycin, rifaximin (alt. Flagyl, PO vanco)
- Probiotics
- Fermentable fibers

129

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

130

Caution with lactulose

Overdose can cause hypovolemia, worsening encephalopathy d/t total body acidosis