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Flashcards in Emergencies Deck (63):
1

Neurological Emergencies

Cord Compression
CNS metastases
Vascular events: Hyperviscosity/ leukostasis

2

Cardiopulmonary Emergencies

Cardiac tamponade
SVC syndrome

3

Metabolic Emergencies

Tumor lysis
Hypercalcemia
SIADH

4

Hematological Emergencies

Neutropenic fever
Severe thrombocytopenia
Overanticoagulation

5

Emergencies That Need to be Approached Immediately

Neutropenic fever
Tamponade
Cord compression
CNS metastases with symptoms

6

Emergencies That Need to be Approached Today

Coagulopathies
Tumor lysis
Leukostasis
Hyperviscosity
Severe thrombocytopenia (

7

Emergencies That Need to be Approached Today or Tomorrow

SVC Syndrome
Most hypercalcemia
Most CNS mets without edema
INR 5-9

8

Neurological: Cord Compression

Inflammation
Paresthesia
Autonomic dysfunction
Usually with vertebral mets
Rapid deterioration = worse outcome

9

How does cord compression occur?

Thecal sac becomes compressed
Spread through venous plexus & blood stream

10

Examination of Cord Compression

MRI/CT of whole spine
Decadron
Neurosurgery
XRT: radiation if multiple levels

11

How do steroids help with cord compression?

Decreased risk of paralysis due to reduction in inflammation

12

What is the most common brain tumor?

Brain mets

13

CNS Metastases with Symptoms

Headaches
Altered mental status
Vision changes
Ataxia
CN problems
Seizures
Personality changes
Confusion
Sensory changes

14

Which cancers like to go to the brain?

Lung
Breast
Colorectal
Melanoma
Kidney
Germ cell
Neuroblastoma
Sarcoma
Prostate

15

Presentation of Brain Metastases

Headache
Seizures
Altered mental status
Focal deficits

16

What improves survival of isolated brain mets?

Surgery + radiation

17

Necessary Steps to Treat Brain Metastases with Symptoms

Decadron: edema, focal symptoms
Dilantin: seizures
MRI imaging
Neurosurgery

18

Symptoms of Leukostasis

Altered mental status
Coma
Other organs involved: brain, respiratory
Hypoxia
Renal insufficiency

19

Leukostasis Mostly In

AML: WBC > 100,00

20

Relatively Nonspecific Symptoms Hyperviscosity

Somnolence
Headache
Blurry vision
Dizziness

21

What condition is hyperviscosity most common with?

Waldenstrom's

22

Less Common Conditions with Hyperviscosity

Multiple myeloma
Polycythemia vera
Essential thrombocytosis

23

Polycythemia Vera Hemoglobin Levels

>19 or 20

24

Essential Thrombocytosis Platelet Level

>10^6

25

Necessary Steps to Treat Hyperviscosity

Hydrated
Apheresis for IgM + chemotherapy
Phlebotomy for polycythemia vera
Hydroxyurea & aspirin for essential thrombocytosis

26

Necessary Steps to Treat Leukostasis

Hydrated
Quentin access (renal)
Chemotherapy
LP for cytology rule in/out CNS leukemia
Steroids

27

Most Common Primaries with Cardiac Tamponade

Lung
Breast

28

What does an EKG show with cardiac tamponade

Electrical alternans
Low voltage
ST elevation in all leads

29

Presentation of Cardiac Tamponade

Left or right sided failure
Pulsus paradoxus
Big heart on CXR

30

3 Main Reasons for Tamponade

Malignancy
Idiopathic
Autoimmune

31

Beck's Triad

Low arterial blood pressure
Distended neck veins
Distant, muffled heart sound

32

Necessary Steps to Treat Cardiac Tamponade

Echo & cytology from pericardiocentesis
Catheter drainage of pericardial space
Medical management
Chemotherapy
Subxiphoid pericardial window or balloon percardiotomy

33

Define Pulsus Paradoxis

Drop of 10 mmHg in arterial blood pressure on inspiration

34

Cancers with SVC Syndrome

Lung cancer
Bronchogenic carcinomas
Lymphoma
Breast cancer
Mediastinal tumors

35

Presentation of SVC Syndrome

Facial edema
Symmetric or asymmetric upper extremity edema common
SOB but not hypoxic

36

Necessary Steps to Treat SVC Syndrome

Pulse Ox/CSR
Chest CT to outline mass
Chemo for small cell, lymphoma, germ cell
Radiation for almost all else
Heparin or corticosteroids
IR: stenting

37

Tumor Lysis Syndrome

Occurs in tumors with high body burden & high chemrsensitivity
Usually due to therapy
Few clinical symptoms other than being ill with obvious lab abnormalities due to renal failure

38

Cancers Associated with Tumor Lysis Syndrome

High-grade lymphomas
High-grade leukemias
Small cell
Germ cell

39

Tumor Lysis Syndrome Lab Abnormalities

Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia

40

Necessary Steps for Pre-Treatment of Tumor Lysis Syndrome

Fix conditions that will make effects worse: dehydration, renal obstruction, IV contrast
Baseline labs: K, Ca, Phos, Uric acid, LDH, Cr
Alkaline diuresis: D5 1/2 with 2-3 amps NaHCO3/1 at 200+ cc/hr
Allopurinol 600 mg, then 300/day to keep uric acid production down
Rasburicase

41

Necessary Steps During Treatment for Tumor Lysis Syndrome

High K+, low Ca++
Keep alkaline urine output high
Check BID electrolytes, phos, UA, Ca, LDH, Cr
Keep phosphate 6, K

42

Cancers Associated with Hypercalcemia

Breast
Lung
Multiple myeloma
SCC make PTH-rP

43

Presentation of Hypercalcemia

Gradual in onset
Fatigue
N/V
Constipation
Anorexia
Apathy
Decreased consciousness

44

Pathologic Role of PTH-rP

Does everything PTH does but without negative feedback system

45

Necessary Steps to Treat to Hypercalcemia

Volume replete patient
Furosemide
IV Pamidronate (Aredia) or IV Zoledronic (Zometa)
Adjunct: dialysis, calcitonin (Miacalcin), steroids

46

Symptoms of SIADH with Serum Sodium

Anorexia
Irritability
N/V
Constipation
Muscle weakness
Myalgia

47

Symptoms of SIADH with Serum Sodium

Seizure
Coma/Death
Abnormal reflexes
Papilledema

48

SIADH Most Common in What Cancer

Small cell lung cancer

49

Lab Results of SIADH

Decreased BUN & serum osmolarity
Increased urine osmolarity & sodium levels

50

Necessary Steps to Treat SIADH

Treat tumor
Limit fluid intake to 500-1000 mL/day
Furosemide
Parenteral sodium replacement with severe neurological symptoms
Monitor electrolytes: Magnesium, K+, Ca++

51

Presentation of Neutropenic Fever

Initially subtle
Rapid development of hypotension, dyspnea, sepsis

52

Short-term Neutropenia Predicts What Type of Organisms

Gram-negative >> gram-positive

53

Long-term Neutropenia Predicts What Type of Organisms

Fungal
Viral
Opportunistic

54

Necessary Steps to Treat Neutropenic Fever

Evaluate patient for a source: blood, CXR, sputum, urine, skin, LP
Suspected source: treat it
Not a suspected source: treat empirically

55

Empiric Antibiotics to Treat Gut Flora

Cefipime
Moxifloxacin
Pip/Gent
Aztreonam
Add coverage for lack of response

56

Symptoms of Severe Thrombocytopenia

Asymptomatic
Epistaxis
Gingival bleeding
Bullous hemorrhages
Petechiae
Eccymosis
Menorrhagia
CNS bleeding least common

57

Platelet Defect Bleeding

Site: skin, mucous membranes
Minor cut bleeding: yes
Petechiae: present
Ecchymoses: small, superficial
Hemarthrosis: rare
Bleeding after surgery: immediate, mild

58

Clotting Factor Defect Bleeding

Site: deep in soft tissue
Minor cut bleeding: not usually
Petechiae: absent
Ecchymoses: large, palpable
Hemarthrosis: common
Bleeding with surgery: delayed, severe

59

Necessary Steps to Treat Thrombocytopenia

Be sure it's not TTP, DIC, HIT, HELLP
Assess for active bleeding
Transfuse if patient is actively bleeding
Prednisone 1mg/kg/day if patient well
IVIG x 2 days if patient ill
Kids: remit
Adults: relapse & require splenectomy

60

What does HELLP stand for?

Hemolysis
Elevated Liver enzymes
Low Platelet count

61

Overanticoagulation

Agents being used more & more
INR's up to 5
INR's >9

62

Necessary Steps to Treat Overanticoagulation for Patients on Warfarin

Assess whether there is significant bleeding
Assess for head trauma
Assess whether the patient should be anti coagulated again in the future
Give FFP & Vitamin K for significant bleeding
Give PO Vitamin K for INR >9 without bleeding
Avoid SQ Vitamin K

63

Necessary Steps to Treat Overanticoagulation for Patients on Non-Warfarin Agents

Assess for bleeding & head trauma
Identify the specific agent & call pharmacy/hematology
For significant bleeding, consider protamine sulfate for heparin or LMWF
Significant bleeding, consider recombinant activate Factor VII