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Flashcards in Oncology Emergencies Deck (16):
1

What emergencies fall into each of the following categories?
- right now this minute
-today
-if not today, tomorrow

right now: neutropenic fever, tamponade, cord compression, CNS mets w/ sx

Today: coagulopathies, tumor lysis, leukostasis, hyperviscosity, severe thrombocytopenia, INR over 9

if not today, tomorrow: SVC syndrome, most hypercalcemia, most CNS mets w/o edema, INR 5-9

2

Spinal Cord Compression
-MC presentation
-other sx
-MC cancers causing this
-usually arise in which vertebrae?
-describe CA metastases to the spine

MC presentation is BACK PAIN!!! make sure to always get XRAY when seeing for 1st time.

Other sx:
-inflammation, paraesthesias, autonomic dysfunction follows motor/sensory
-radicular pain

MC cancers causing this: breast, prostate, lung, and MM. They like to go to the bone.

Mets usually arise in the thoracic vertebrae.

mets: travel here through venous plexus and invades the epidural space and thecal sac.

3

Spinal Cord Compression:
-best initial evaluation?
-Tx

Best initial evaluation is MRI of WHOLE SPINE! next best step is CT myelogram.

Tx:
-Decadron (dexamethasone)
-Neurosurgery
-Radiation therapy IF multiple levels

4

CNS metastases w/ Sx:
-signs and sx
-MC from what types of CA?
-dx
-tx

signs and sx:
-HA, seizures, altered mental status, focal deficits

MC from lung*, breast*, kidney, colorectal, and melanoma.

Dx:
-MRI of whole brain

Tx:
-decadron if edema
-dilantin if seizures
-surgery plus radiation therapy for isolated mets.

5

What is the MC type of brain tumor?

What is the MC intracranial tumor in adults?

Brain METASTATIC CA!!!!
*PANCE*

6

Vascular events- Hyperviscosity:
-sx
-MC cause
-serum viscosity level
-tx

sx: sombolence, HA, blurry vision, dizziness

MC cause: Waldenstroms
others: polycythemia vera, essential thrombocytosis, MM

Serum viscosity is usually greater than 5cP

Tx:
-hydrate patient
-apheresis for IgM plus chemotherapy
-phlebotomy for polycythemia vera
-Hydroxyurea (chemotherapy) and aspirin for essential thrombocytosis

7

Vascular Events- Leukostasis:
-MC associated with what type of CA?
-Sx
-What is this?
-tx

MC associated with AML w/ WBC greater than 100,000

sx: altered mental status, coma, hypoxia, renal insufficiency

WHat: blood is thick with tones of white cells that are behaving inappropriately.

Tx:
-hydration
-quinton access(central catheter) (renal) and chemotherapy (onc)
-LP for cytology to rule in/out CNS leukemia
-steroids

(Hydrate to dilute the blood since its very viscous. ; need rapid cytoreduction via chemotherapy. Will need prophylaxis for tumor lysis syndrome.)

8

Cardiac Tamponade:
-most commonly associated with which CA?
-sx
-EKG findings
-dx
-tx

MC associated with Lung and breast CA

Sx:
-pulses paradoxus
-big heart on CXR
-left/right sided failure
-Becks triad*
--hypotension
--distended neck veins
--muffled heart sounds (rub-velchro)

EKG findings:
-electrical alternans, low voltage, ST elevation

Dx: echo and cytology from pericardiocentesis

Tx:
- catheter drainage of fluid
-chemotherapy
-subxiphoid pericardial window or balloon pericardiotomy

9

Superior venacava syndrome:
-MC associated with what CA?
-sx
-

MC associated with lung (bronchogenic*)(Pancoast) CA, lymphoma, breast CA, mediastinal tumors

Sx: facial edema, symmetric or asymmetric upper extremity edema
-SOB
*edema is worse in the AM and gets better as the day progresses.

10

SVC Syndrome:
-Dx
-Tx

Dx:
-CXR
-pulse ox (not hypoxic)
-CT

Tx:
-chemo for CA
-radiation
-heparin or corticosteroids

11

Tumor Lysis syndrome:
-when does this occur?
-MC with which CA??
-sx
-Lab findings
-Tx

When: occurs in tumors with high body burden and high chemosensitivity, occurs d/t therapy


Associated with : high grade lymphomas(Burketts) or leukemias, small cell, germ cell less common

Sx: few clinical sx other than being ill with obvious lab abnormalities due to RENAL FAILURE.
-n/v/diarrhea
-anorexia
-blood in urine
-tetany
-cramps

Lab:
-hyperkalemia
-hyperphosphatemia
-hyperuricemia
-hypocalcemia

Tx:
-correct conditions that make effects worse: dehydration, renal obstruction, IV contrast
-D5 with 1/2 NS and insulin(drives K+ into cells)
-lasix, mannitol
-allopurinol (keeps uric acid production down)
-Kayexalate (lowers K)
-may use dialysis

12

Hypercalcemia:
-MC associated with what CA?
-Sx
-Tx

MC associated with breast, lung, MM, squamous CA (make PTH-rP)

Sx: fatigue, n/v, constipation, anorexia, apathy, decreased consciousness

Tx:
-replete volume
-furosemide
-IV pamidronate ( slows down the breakdown of bone)
-IV zoledronic

13

SIADH:
-MC CA associated
-sx at serum Na levels
--less than 120
--less than 110
-tx

MC associated with small cell

Serum Na:
-less than 120: anorexia, irritability, n/v, constipation, muscle weakness, myalgia
-less than 110: seizure, death, coma, abnormal relfexes, papilledema

tx:
-treat the underlying tumor
-limit fluid intake to 500-1000ml/day
-lasix
-parenteral Na replacement with severe neurological sx

14

Neutropenic Fever:
-sx
-duration of neutropenia determines organism,
--short term
--long term
-cause
-tx

Sx: initially subtle, then rapid development of hypotension, dyspnea, sepsis

Short term: gram -
Long term: fungal, viral, opportunistic

Cause: chemotherapy, usually 10-15 days after chemo is given

Tx:
-treat the source of the problem or you treat emperically.
-Cefipime, moxifloxacin, Pip/gent, aztreonam

15

Severe Thrombocytopenia
-cause
-sx
-tx

Cause: idiopathic. immune

Sx:
-asymptomatic
-mucosal bleeding, epistaxis, gingival bleeding, bullous hemorrhage
-cutaneous bleeding, petechiae, ecchymoses
-menorrhagia
-CNS bleeding

Tx:
-be sure its not TTP, DIC, HIT, Hellp
-check smear, LDH, PT/PTT, fibrinogen, CBC, any heparin use?
-if actively bleeding you transfuse (hgb less than 7)
-Prednisone if pt well
-IVIG if ill

16

Over anticoagulation:
-INR level
-management

INR 5-9

Management:
Pts on Warfarin:
- assess for bleeding, head trauma
- FFP and Vit K for significant bleeding
- give Vit K PO for INR greater than 9.

Pts on non-warfarin:
-assess for bleeding and head trauma
-identify specific agent causing increased INR and call pharmacy
-protamine sulfate for heparin or LMWH
-factor VII for significant bleeding especially with fondaparinux (Arixtra)