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#11 Oncology emergencies
Terms in this set (66)
Advanced lung cancer, breast cancer, leukemia or lymphoma can be associated with
pericardial disease and tamponade
Chemotherapeutic drugs and radiation may cause
What is the most specific sign of tamponade?
You evaluate a patient with dyspnea, nonspecific chest discomfort, dysphagia and hoarseness. He also appears to elevated jugular venous pressure. You suspect pericardial disease and order a CXR an EKG. What will you find confirming your diagnosis?
CXR- enlarged cardiac silhouette
EKG- low voltage QRS, non-specific ST-T changes and electric alternans
Echocardiography is most helpful in making a diagnosis of tamponade because
you can determine early diastolic collapse of R atrium or ventricle from external pressure
Treatment of pericardial disease and/or tamponade can include:
- pericardiocentesis (temporary)
- pericardial window formation
- insertion of bleomycin or tetra-/doxy-cycline in intrapericardial space to sclerose and prevent recurrence
Elevated venous pressures in the upper extremities, head and neck causing increased intracranial pressure, edema and venous distention is
superior vena cava syndrome
What is the MOST COMMON cause of superior vena cava syndrome?
extrinsic compression by mediastinal mass, usually bronchogenic carcinoma
especially small cell cancer
of the lung or non-Hodgkin lymphoma
What are some other causes of superior vena cava syndrome?
medistinal germcell tumors
Superior vena cava syndrome should be treated as an emergency which patients?
-adults with mental status changes
- increased intercranial pressure
- cardiovascular collapse
- evidence of upper airway obstruction
How do you diagnose superior vena cava syndrome?
suspect in any patient with sensation of fullness in the face
facial swelling distended neck veins or
venouscollateral in the neck or chest
What is the MOST helpful way of diagnosing superior vena cava syndrome?
though you would start with a CXR looking for widened superior mediastinum, right side mass
Superior vena cava syndrome is not a true emergency in most cases. true or false?
Non-emergent treatment of SVC includes
chemo or radiation to shrink the tumor
maybe a stent
anticoagulate to prevent SVC thrombosis
What hematologic emergency is seen with multiple myeloma and Waldenstrom macroglobulinemia?
Hyper viscosity due to monocolonal proteins
Common complains of Hyper viscosity due to monocolonal proteins?
problems with small vessels "plugged" in head: loss of vision and hearing, HA, vertigo, dizzy, tinnitus, diplopia, and ataxia
PX of Hyper viscosity due to monocolonal proteins?
papilledema, retinal hemorrhage, dilated retinal veins, mucosal hemorrhage
Treatment for Hyper viscosity due to monocolonal proteins?
plasmaphoresis & treat underlying malignancy
Define Disseminated intravascular coagulation (DIC):
activation of the clotting process by tissue factor, impaired fibrinolysis and deficiency in the coagulation cascade
Chronic DIC is
with malignancy. True or False?
DIC due to malignancy will always have an abnormal clotting test. True or False?
False. clotting test may be normal or near normal
What is a common finding of acute DIC?
low platelet count
How do you treat DIC?
-eliminate the underlying cause
- replace platelets and clotting factors
What's a normal platelet count?
Bleeding time is increased when the platelet count falls below
What platelet count causes spontaneous bleeding?
Hematologic emergency with more bleeding & bruising?
Bleeding with thrombocytopenia how is thrombocytopenia caused?
bone marrow infiltration or toxicity 2nd to chemo or radation therapy
Although rare, what presents with TTP or HUS?
How is a diagnosis of thrombotic microangiopathy made?
peripheral smear exam showing
anemia with schistocytes
What is the most effective therapy for thrombotic microangiopathy?
none available, mortality is high
Neutropenia is presumed with:
a single temp >38.3 *C (101 F)
The risk of neutropenia is
increased frequency and severity of infections
What other factors could increase infections?
deficient phagocytic function secondary to cytotoxic therapy and breakdown of skin and mucosal barriers (chemo)
Neutropenic complications are prevented by
aggressive treatment of abrasions or mucositis
no fresh flowers!! :(
use of low-microbial diets
*colony-stimulating factors -> G-CSF and GM-CSF
A neutropenic patient with pneumonia may have a normal CXR. Why?
not enough WBCs (neutrophils) to initiate a response
What are the MOST COMMON infectious bacteria that attack neutropenic (a.k.a; immunocompromised) patients?
Gram-positive Staphs and Streps
gram-negatives are less common (E.coli, P aeruginosa, Klebiella)
What other infections are neutropenic patients susceptible too?
fungal infections: Candida, Aspergillus, Zygomycetes
Your neutropenic patient has an unidentified bacterial infection, what do you prescribe?
broad spectrum antibiotic
-treat with antibiotic through catheter but if it's fungal, take that cath out
In the patient history, a splenectomy is documented. What type of infections is this patient at a high risk for?
encapsulated bacteria, including S. pneumoniae, H. influ,
, Capnocytophage canimorsus and
Group A strep
Is a metabolic emergency possible with malignancy present?
Yes, hypercalcemia occurs in 1/3 of patients with malignancy
What about malignancy causes hypercalcemia?
tumors secrete hormones that releases Ca2+
What type of cancers can cause hypercalcemia?
non-small cell lung cancer
, breast cancer, head and neck cancer, myeloma and t cell lymphoma are most common
Hypercalcemia can present with abdominal pain due to
The single most urgent treatment of hypercalcemia is:
infusion of normal saline
What type of diuretic would you NOT use after correcting the volume in a hypercalcemic patient?
HTZ - it causes the retention of calcium
Should a person with hypercalcemia be mobilized or immobilized?
mobilized! get them moving
What happens when tumor cells are killed rapidly?
hyperphosphatemia (w/ 2ndary hypocalcemia)
Tumor lysis syndrome occurs most commonly when treating which cancers?
lymphoma and leukemia (but may occur with other solid tumors)
Patients at risk of tumor lysis syndrome should be
hospitalized and well hydrated with ongoing diuresis and electrolyte checks
Allopurinol or Rasburicase will lower
uric acid levels
Name the most common cancers to metastasize to the brain
What percentage of patients with systemic cancer will have a brain met?
Symptoms of brain metastasis include
increased intracranial pressure associated with nonspecific symptoms; headache that is
, nausea, vomiting (more frequent in the morning)
What test is more sensitive for imaging possible brain cancer?
MRI with contrast
What can be used to reduce intracranial pressure and swelling?
MOst common tumors that cause epidural spinal cord compression:
renal caricnoma and
70% of epidural spinal cord compressions occur:
at the thoracic level
Most common symptom of epidural spinal cord compression is
PAIN in back
, either local or radicular
Diagnostic tool of choice for the entire spine is
When should treatment of spinal compression be initiated?
immediately (dexamethasone 16 mg IV)
What is the mainstay of treatment at the level of the tumor?
(primary tumor really needs to be treated)
Leptomeningeal metastases occurs mainly with
melanoma and lymphoma
Signs and symptoms of leptomeningeal metastases:
referable to brain, cranial nerves or spine:
changes in mental status, ataxia etc.
Does systemic chemotherapy cross into CSF?
no, may have to treat via lumbar puncture
What 3 medications can be given IV or via lumbar puncture to treat leptomeningeal metastases?
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