S18C235 - Emergency Complications of Malignancy

Question 1

Malignant Airway Obstruction

Answer 1

• get a CT
• don’t do DL if you can help it b/c this can invoke bleeding or edema
• give O2, give heliox
• if upper airway may require cricothyroidotomy

Question 2

Bone mets/pathologic #

Answer 2

• pathologic #s usually affect axial skeleton
• present with POOP
• can use bone scan but bear in mind increased uptake dose not necessarily mean mets
• can treat with palliative radiotherapy

Question 3

Malignant Spinal Cord Compression

Answer 3

• mets in vertebral bodies from solid ogan tumors is most common cuase
• thoracic vertebrae is most common location
• mets enlarge, erode into spinal canal, compress cord
• back pain, worse when supine, muscle weakness, radicular pain, bbowel/bladder dysfxn
• MRI
• dexamethasone 10mg IV then 4mg PO/IV q6h
• radiotherapy emergency or surgery

Question 4

Malignant pericardial effusion with tamponade

Answer 4

• often occur with breast and lung but also melanoma, leukemia, lymphoma
• shock, tachy, HoTN, narrow pulse pressure
• ECG - decreased voltage
• electrical alterans
• pericardiocentesis or pericardial window for tx as well as chemo and RT

Question 5

Superior Vena Cava Syndrome

Answer 5

• elevated venous pressure in the upper boday from obstruction of venous blood flow through the SVC
• external compression of the SVC by an extrinsic malignant mass
• associated cancers: lung, lymphoma
• only an emergency if neurologic abnormalities are present due to increased ICP
• Sx: facial swelling, dyspnea, cough, arm swelling are typical
• other sx: hoarse voice, syncope, h/a, dizziness, confusion, Sz, aLOC
• dx: CT with contrast (CXR can also help)
• tx: raise head of bed, steroids, loop diuretic, RT, stent, chemo, bypass graft

Question 6

Hypercalcemia: etiology

Answer 6

• common in malignancy, esp BrCa, LuCa, multiple myeloma
• mechanisms:
  1. production of parathyroid hormone related protein (most common) - binds receptors, mobilizes calcium from bones and increases renal absorption of Calcium
  2. extensive local bone destruction - bone mets
  3. production of vit D analogues (lymphoma)

Question 7

Hypercalcemia: sx and tx

Answer 7

• lethargy, confusion, constipation, anorexia, nausea
• tx: IV NS at 250-500cc/h until euvolemic then 100-150cc/h (will reduce but not normalize the calcium)
• only use lasix if pts have CHF or renal insufficiency, do not use it routinely
• other tx of malignancy assoc hyperca.: calcitonin, glucocorticoids, bisphosphonates
• hemodialysis if profound Sx or renal failure

Question 8

SIADH: normovolemic hyponatremia

Answer 8

• ectopic secretion of ADH common fro bronchogenic cancer but also chemo, opioids, carbamazepine, SSRI
• hyponatremia, decreased serum osmolality, less than max dilute urine, euvolemic

Question 9

SIADH: hyponatremia sx

Answer 9

Sx: anorexia, nausea, malaise, h/a, confusion, obtundation, seizures, coma
Sz usually generalized tonic-clonic

Question 10

SIADH: tx

Answer 10

• water restriction
• if >125mEq/L do water restriciton of 500cc /d and close f/u
• 10 in first 24h

Question 11

Adrenal Insufficiency

Answer 11

• can by from direct invasion and destruction of adrenal tissue but more commonlyl from physiologic stress with chronic glucocorticoid therapy
• vasomotor collapse
• hypoglycemia, hyponatremia, hyperkalemia, eosinophilia, HoTN refractory to volume loading and pressors
• if on steroids give a dose of IV steroids with glucocorticoid and mineralocorticoid effect
• hydrocortisone 100-150mg IV
• methylprednisolonge 20-30mg IV
• dex 4mg IV

Question 12

Tumor Lysis Syndrome

Answer 12

• massive cytolysis and release of intracellular contents
• usually occur with tx of cancer
• rarely seen in solid tumors
• hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia (hypoca may cause tetany, Sx, arrhythmias)
• end organ damage: renal failure from uric acid precipitation in renal tubules, cardiac arrest
• prevention: alllopurinol, hydration

Question 13

Febrile neutropenia and infection

Answer 13

fever dfn: 38.3 (100.9) or 38 for >1h (100.4)

• lowest count usually occurs 5-10d after last dose and recover w/in 5d
• NO DRE
• thorough exam, cultures, chem panel,
• low risk for severe infxn if: appear well, no abdo pain, no physical signs of infxn, normal CXR – may be considered for out-pt care
• treat with empiric Abx
• add vanco if: severe mucositis, signs of catheter site infxn, recent use of fluoroquinolones, HotN, prevalence of MRSA
• outpatient: cipro and amox-clav
• monotherapy: cefepime, ceftazidime, imipenem, pip-taz

Question 14

Hyperviscosity syndrome

Answer 14

• causes: waldenstrom macroglobulinemia, IgA myeloma, polycythemia, leukemia, deydration
• Sx: vague, dyspnea, fever, fatigue, abdo pain, h/a, blurry vision, aLOC
• smear: rouleaux formation
• tx: IV fluids, plasmapheresis, leukapharesis, phlebtomry of 2 units

Question 15

Thromboembolism

Answer 15

VTE common in malignancy

-cancer pts not at increased risk for AC-related bleeding complications, including brain mets

Question 16

Chemo induced N/V

Answer 16

• tx : benzo, corticosteroids, ondansetron, maxeran
• dopamin receptor antagonist: maxeran
• serotonin antagonist: ondansetron
• histamine receptor antagonist: gravol

Question 17

Extravasation of Chemo agent

Answer 17

• pain, erythema, swelling w/in hours of infusion
• there are some antidotes for some chemo agents (vincristine, cisplatin, paclitaxel, doxorubicin)
• avoid pressure to area
• may adminitster antidote through the original line
• rest, elevation
• may need plastics consult for skin debridement