Oncology - Oncologic And Hematologic Emergencies

Front 1

types of emergencies: urgency approach

Back 1

Right now this minute:

• neutropenic fever
  
• tamponade
  
• cord compression
  
• CNS mets with sx
  

today

• coagulopathies
  
• tumor lysis
  
• leukostasis
  
• hyperviscosity
  
• severe thrombocytopenia
  
• INR over 9
  

If not today, tomorrow

• SVC syndrome
  
• most hypercalcemia
  
• most CNS mets without edema
  
• INR 5-9
  

Front 2

what's the difference between pericardial effusion and cardiac tamponade

Back 2

effusion becomes tamponade once pressure on heart affects diastolic filling

Front 3

what number constitutes severe thrombocytopenia

Back 3

<50

Front 4

sx of SVC syndrome

Back 4

tortuous veins on chest, neck, face

swollen face when they wake up

treat with filter

Front 5

why is hypercalcemia classified as today but not right now urgency?

Back 5

Why is hypercalcemiaimportant but not right now

Weakness or tetany,parasthesias, numbmess, N/V

Have to treatelectrolyte abnormalities slowly or it can irritate the heartMore K+ but Ca2+ aswell

Front 6

how do you treat hypercalcemia

Back 6

slowly so the heart isn't irritated

same with K+

Front 7

high number of people with these cancers present with lower back pain

Back 7

prostate

breast

lung

these cancers go to the bone

Front 8

most frequent presenting symptom of cancer

Back 8

pain

Front 9

neurological: cord compression

Back 9

• in most, presents as back pain
  
• inflammation and paresthesias
  
• autonomic dysfunction FOLLOWS motor/sensory
  
• usually occurs in diseases with vertebral body mets, not hematogenous dural mets
  
• rapid deterioration (days) predicts worse outcome than longer (weeks)
  

Front 10

neurological: cord compression imaging/labs/treatment

Back 10

MRI/CT +/- pyelogram of the WHOLE spine

decadron

neurosurgery in most circumstances

XRT

radiation therapy IF multiple levels

Front 11

progression of pain with cancer

Back 11

Pain precedes othercancer symptoms by about 7 weeks

Then the painbecomes more redicular: becomes nerve pain

Usually symmetricbefore weakness presents

Will complain ofnumbness in extremeties

Then loss of boweland bladder

Then ataxia wherethey can't walk

Front 12

a very common met area in the back

Back 12

sacroiliac joint

Front 13

some sx of brain mets

Back 13

• Altered mentalstatus
  
• Vision changes
  
• Cranial nerveproblems
  
• Seizures
  
• Headaches
  
• Personality changes
  
• Confusion
  
• Smelling strangethings
  
• Numbness/parasthesiasin the face
  
• Focal neurologicsigns is what the neurologist will look for
  

Front 14

what is the most common brain tumor

Back 14

metastatic

60% of lung ca = brain mets

20% of breast ca = brain mets

Front 15

primary cancers that tend to met to brain

Back 15

adults:

• lung
  
• breast
  
• kidney
  
• melanoma
  

kids:

• sarcoma
  
• neuroblastoma
  
• germ cell tumors
  

Front 16

where do brain mets tend to go in the brain?

Back 16

• Cerebral hemisphere80%
  
• Cerebellar: 15%
  
• Brain stem 5%
  
• Smallcell carcinoma of the lung goes to all parts of the brain
  

Front 17

intervention for neurological brain mets

Back 17

• decahedron if edema
  
• dilantin only if seizure is witnessed or suspected
  
• good imaging of whole brain: MRI
  
• neurosurgery if no Dx, or clearly isolated met
  

Get steroids onboard

Control for seizures

Get MRI done asap

Turn over tooncology and neuro

Front 18

what is centipose

Back 18

comparing viscosity of something to water

cP

Front 19

if your blood is too viscous what problems can it cause

Back 19

PE

Stroke

Front 20

what is polycythemia vera

Back 20

too many RBC

Front 21

what is erythrocytosis

Back 21

too many RBC

Front 22

why does multiple myeloma cause hyper viscous blood

Back 22

too many messed up plasma cells

Front 23

what is waldenstroms macroglobinemia

Back 23

Waldenström's macroglobulinemia is a type ofcancer affecting B cells, a type of white blood cell. The main attributingantibody is immunoglobulin M. WM is an "indolent lymphoma". It is atype of lymphoproliferative disease, which shares clinical characteristics withthe indolent non-Hodgkin lymphomas.

Front 24

normal serum viscosity

PV Hgb

ET platelet count

Back 24

normal serum viscosity usually >5cP

polycythemia vera, Hgb >19 or 20

essential thrombocytosis, platelets well over 10^6

Front 25

if you see neurological symptoms of hyper viscosity, go this:

Back 25

• HYDRATE
  
• apheresis for IgM (waldenstrom's), plus chemo
  
• phlebotomy for polycythemia vera, replace units with NS, goal Hgb ~15
  
• Hydroxyurea and aspirin for essential thrombocytosis
  

Front 26

what causes too many white blood cells

Back 26

ALL in kids

AML in adults

lots of huge blast cells in the system which cause neurological and pulmonary infarcts

this is what kills these patients

20-40% mortality if not treated

Front 27

leukostasis is most common in what cancer

Back 27

AML with WBC >100,000

CLL, CML uncommon even with WBC >300,000

• altered mental status, coma common, but other organs also involved
  
• hypoxia, renal insufficiency
  
• may worsen during induction chemo for AML
  

Front 28

three things that will give a false positive on a mono spot test

Back 28

lymphoma

ALL

AML

Front 29

treatment of leukostasis

Back 29

• HYDRATE
  
• quint on access (renal) and chemo (onc)
  
• a LP for cytology to rule in/out CNS leukemia
  
• steroids
  

AML and ALL two mostcommon

CLL, CML less common

Once you get more ofthese blast cells, you get more hypoxic, direct endothelial damage, reducedblood flow, cells release massive cytokines, inflammation, inflammatory cellscome,

Very delicatebalancing act

Need rapidcytoreduction via chemo

Will need profylaxisfor tumor lysis syndrome

These are thehighest risk for running into all kinds of electrolyte abnormalities: uricacid, hyperphosphatemia, etc

Front 30

what is Beck's triad?

Back 30

1. distant, muffled heart sounds
   
2. distended neck veins
   
3. low arterial blood pressure
   

Front 31

what will you see on EKG with cardiac tamponade

Back 31

electrical alternans where qrs gets bigger and smaller

low voltage on EKG

ST elevation in all leads

Front 32

what might you hear with cardiac tamponade

Back 32

rub

Front 33

if it's tamponade, what do you do?

Back 33

drain it

Front 34

what if it's just a pericardial effusion at 200mL not into Beck's triad

Back 34

treat with NSAIDs

Front 35

causes of cardiac tamponade

Back 35

1. idiopathic (probably viral, though)
   
2. autoimmune
   
3. malignancy sends the fluid out of the bases of the lungs
   

malignancy effusions are common but not commonly symptomatic

most common primaries are lung and breast cancers to do this

Front 36

presentation of cardiac tamponade

Back 36

left or right sided failure, pulses paradoxus (drop in bp of 10mmHg on inspiration), big heart on CXR (water bottle heart)

Front 37

cardiac tamponade intervention

Back 37

• echo and cytology from pericardiocentesis
  
• catheter drainage of the pericardial space
  
• medical management
  
• oncology input re: chemo
  
• CT surgery input re: subxiphoid pericardial window or balloon pericardiotomy, especially for recurrent effusions in pts with good performance status
  

Front 38

who do you commonly get SVC with cancer

Back 38

thymomas and mediastinal lympadenopathy commonly compress the SVC

the most common is bronchogenic carcinoma

Front 39

symptoms of SVC

Back 39

SOB

arm/face swelling

Front 40

is SVC an emergency

Back 40

a relative emergency, even with CNS symptoms

Front 41

intervention of svc syndrome

Back 41

pulse ox

cxr

chest ct to outline mass that will need tx

oncology (chemo for small cell, lymphoma, germ cell)

radiation for all others

heparin or steroids

IR? stenting?

Front 42

chemo for these three cancers involved with SVC

Back 42

small cell lung cancer

lymphoma

germ cell

Front 43

metabolic: tumor lysis syndrome

Back 43

occurs in tumors with high body burden and high chemosensitivity

usually high grade lymphomas or leukemias

small cell, germ cell less common

usually due to therapy, so you know the dx already

may occur at onset of therapy, or after a day or two, up to 5 days

few clinical sx other than being ill with obvious lab abnormalities due to renal failure

Front 44

why lab abnormalities in tumor lysis syndrome

Back 44

renal failure

Front 45

tumor lysis syndrome notes

Back 45

• Tumor lysissyndrome: with AML/ALL and you get cytogenic reduction and you kill all thecells, the tumor cells release :Potassium,phosphates, nucleic acids that will eventually become uric acids that turnsinto gout they are uricemic
  
• Into systemiccirculation
  
• Goes to the kidneysand causes a lot of injury
  
• Most often afteryou've initiated cytotoxic tx with high grade leukemias, lymphomas (especiallyBurkett's lymphoma)
  
• Any highproliferative rate large tumor burden tumors very sensitive to chemo
  
• Cells die morerapidly, concern about tumor lysis
  
• Most pts have issuesrelated to their renal failure
  

Front 46

labs with tumor lysis syndrome

Back 46

hyperuricemia

hyperkalemia

hyperphosphatemia

HYPOcalcemia

due to rapid turnover of tumor cells (with or without anti-tumor therapy)

Front 47

pre-treatment for tumor lysis syndrome

Back 47

fix conditions that will make effects worse, such as dehydration, renal obstruction, IV contrast

get baseline labs: K, Ca, Phos, Uric acid, LDH, Cr

alkaline diuresis: D51/2 NS with 2 or 3 amps bicarb at 200+ cc/hr

keep urine pH >7

keep urine output high: lasix, mannitol

how to keep uric acid production down: allopurinol 600mg load, then 300mg/day

Front 48

keep urine output high with these meds for tumor lysis

Back 48

lasix

mannitol

Front 49

keep urine pH at ____ for tumor lysis syndrome

Back 49

>7

Front 50

how to keep uric acid PRODUCTION down in tumor lysis syndrome

Back 50

allopurinol 600mg load, then 300/day

Front 51

what kind of sx will a pt with tumor lysis syndrome have

Back 51

hypocalcemia:

n/v diarrhea, anorexia, lethargy, blood in urine from kidney damage, seizures

hyperkalemia:

heart irritation, can't have heart go into tetany

K+/Ca2+ very irritating to myocardium, check 2-3x/day there will be changes that fast!!!

Front 52

how often do you check K+/Ca2+ with tumor lysis syndrome?

Back 52

2-3x/day

Front 53

start on slide 38

Back 53

38