Oncologic Emergencies It’s Not A Tumor! Increasing incidence of cancer Oncologic Emergencies Improved survival Patients with malignancies may present to Diane M. Birnbaumer, M.D., FACEP EDs and general medical offices Professor of Medicine Oncologic emergencies University of California, Los Angeles Those resulting from the disease itself Senior Clinical Educator Department of Emergency Medicine Those resulting from cancer therapy Harbor-UCLA Medical Center Oncologic Emergencies: Oncologic Emergencies: General Categories General Categories Cardiovascular Emergencies Metabolic Emergencies Malignant pericardial effusion Hypercalcemia Superior vena cava syndrome Tumor Lysis Syndrome Hematologic Emergencies Neurologic Emergencies Hyperviscosity due to dysproteinemia Malignant spinal cord compression Hyperleukocytosis and leukostasis Brain metastases and increased ICP Infectious Complications Neutropenic fever 1
Oncologic Emergencies Case Presentation 48 year old female with lymphoma CASE receiving chemotherapy presents complaining of nausea, vomiting and PRESENTATIONS extreme fatigue. No other complaints. PMH: None except lymphoma SH: Nonsmoker, nondrinker Meds: Ondansetron, ativan Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation VS: T=100.6 HR 100 RR 18 110/60 Patient states her temperature at home was 100.5 Normal habitus; looks fatigued, nontoxic Last chemo was one week ago Has left arm PICC line; looks good Total body exam normal except enlarged liver and spleen, palpable cervical and What do you order now? axillary nodes Blood cultures, urine culture, CBC, chem- 10, UA, CXR ordered Do you need to know anything else? 2
Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation Chem-10, CXR, UA all normal Chem-10, CXR, UA all normal CBC 10.9 CBC 10.9 2.0 390 2.0 390 32.9 32.9 Differential: 5% PMNs, 90% lymphs, 5% Differential: 5% PMNs, 90% lymphs, 5% monos monos What is the ANC? Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation Chem-10, CXR, UA all normal What do you now? CBC 10.9 2.0 390 32.9 Differential: 5% PMNs, 90% lymphs, 5% monos What is the ANC? 2000 x 5% = 100 3
Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever Most commonly seen after chemotherapy Fever Also seen in myelogenous cancers Single oral temperature > 38.3C (101.3F) Risk of infection depends on… Sustained temperature > 38C (100.4F) for > 1 hour Depth of neutropenia Duration of neutropenia Neutropenia Comorbid conditions (e.g. mucositis) Absolute neutrophil count < 1,000 Nadir usually 5-10 days after last chemo Severe neutropenia dose Absolute neutrophil count < 500 Recovers 5 days after nadir (usually) Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever Organisms Presentation Multiple organisms implicated Fever usually only symptom Enteric gram negatives May range from fever only to severe sepsis Gram positives Neutropenia leads to atypical presentation Frequently no organism recovered with common infections E.g. pneumonia patients may have no infiltrate; UTI patients may have no pyruia 4
Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever Presentation Evaluation Careful physical examination crucial Blood cultures Particular attention to skin, oral cavity, sites of Peripheral vein AND any indwelling catheters indwelling catheters, perianal area Urine cultures Rectal examination discouraged Sputum cultures Stool, CSF cultures if indicated Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever Evaluation Treatment CXR may be normal All febrile neutropenic patients should receive antibiotics ASAP Consider CT for higher resolution Afebrile neutropenic patients with high suspicion of infection also should get rx Broad spectrum to start; narrow later Use local “antibiogram” and published guidelines to determine best choices 5
Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Case Presentation Treatment Patient was pan-cultured Most patients should be admitted IV vancomycin, cefepime started in the Highly selected patients MAY be treated as ED outpatients Patient admitted Very close follow-up necessary All cultures negative Must have ready access to health care Assess personal / social situation Cell count rebounded in 3 days Discharged with oncology follow-up Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation 37 year old woman treated for breast VS normal cancer 5 years ago with negative Exam normal except paravertebral TTP surveillance on follow up presents to lower thoracic and lumbar spine PMD’s office with mid - and low back pain Mild TTP midline same areas after pulling her children in a wagon. Pain improved with ibuprofen. No other Patient reassured, sent home with prn complaints. ibuprofen PMH: Otherwise normal 6
Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation Returns two days later with worsening 3 days later patient is brought to ED pain because of inability to get out of a chair and urinary and fecal incontinence. Back No neurologic complaints pain significantly worse. Exam unchanged except perhaps a bit VS WNL more TTP midline Exam reveals no rectal tone, decreased sensation T10 level down, 2/5 strength What would you do now? bilateral lower extremities Sent home again with same instructions Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation What tests do you order now? Do you give her any treatment? 7
Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Spinal Cord Compression Relatively common Usually results from extension from spinal bony metastases 2.5 to 6% of cancer patients Most common: Breast, lung, prostate Less commonly extends through foramina Lymphomas, sarcomas Confers poor prognosis overall Will not see bony destruction Urgent need to make diagnosis and treat Most common in thoracic spine Neuro status at presentation and rapidity of onset predict functional outcome Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Spinal Cord Compression Presentation Presentation 90% have back pain Symptoms 80% have preceding diagnosis of malignancy Radicular pain Motor weakness May have several simultaneous lesions Gait disturbance Bowel or bladder dysfunction BACK PAIN + MALIGNANCY = SCC!! Imperative to try to diagnose before neurologic dysfunction occurs 8
Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Spinal Cord Compression Evaluation Treatment MRI is imaging study of choice Start as soon as possible; need tissue diagnosis Consider imaging entire spine (+/- C spine) Glucocorticoids CT myelography second choice Dexamethasone 10-16 mg IV, then 4 mg every 6 Plain films / nuclear medicine poor choices hours Limited sensitivity and specificity Radiation Plain films may show bony lesions Mainstay of therapy (?) Negative plain films do NOT rule out SCC Surgery may also be indicated (or preferable) Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation Patient treated with corticosteroids in the 80 year old male with colon cancer ED presents with shortness of breath. Has been coming on gradually over past 2-3 Neurosurgery consulted – felt medical weeks. Now unable to sleep flat and therapy more appropriate unable to walk across the room. Emergent radiation treatment started PMH: HTN, DJD Patient had minimal neurologic recovery SH: 20 pk/yr smoking; quit 20 yr ago 9
Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation VS: HR 120, reg 100/90 26 Afeb Neck veins distended Heart sounds normal Moderate pedal edema Lungs clear Rest of exam normal What do you think is wrong? What do you do now? Oncologic Emergencies Oncologic Emergencies Case Presentation Case Presentation The nurse brings you this rhythm strip What is this? What do you do now? What do you do now? 10
Oncologic Emergencies Oncologic Emergencies Case Presentation Malignant Pericardial Effusion Echo Common in advanced cancer Frequently asymptomatic Poor prognosis Most patients die within one year Oncologic Emergencies Oncologic Emergencies Malignant Pericardial Effusion Malignant Pericardial Effusion Presentation EKG Symptoms depend on rapidity of onset Low voltages May see dyspnea, cough, chest pain, Electrical alternans dysphasia, hiccups, hoarseness May find tachycardia, distant heart sounds, JVD, UE and LE edema, pulsus paradoxus Tamponade = hypotension/shock with tachycardia, JVD 11
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