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Oncological Emergencies

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Oncological Emergencies

  1. 1. Cancer Studies
  2. 2. Oncological Emergencies • Spinal cord compression • Bone marrow suppression/neutropenic sepsis • Superior vena cava obstruction • Raised intracranial pressure/Brain METS • Stridor • Acute blood loss • Obstruction • Biochemical crisis: hypercalcaemia • Pulmonary embolism
  3. 3. Spinal cord compression • Bone involvement from cancer LBTKP – Commonly: lung, breast, lung, myeloma, lymphoma – Less common: thyroid, kidney, bladder, bowel, melanoma • Can be initial presentation of malignancy: prostate, breast, myeloma • Crush fracture or tumour extension common • Occasional intramedullary METS • 66% cases: thoracic cord • Symptoms: – Back pain: within a nerve root, worse on coughing/straining – Saddle anaesthesia – Urinary retention/dribbling/incontinence – late – Constipation/dribbling/incontinence of faeces – late – Loss of power and sensation distal to area of obstruction – Limb weakness/unsteadiness when walking – Brisk reflexes early, absent reflexes late
  4. 4. Spinal Cord Compression • Signs: – Reduced tone in legs – Reduced reflexes late. Brisk early. – Decreased power and sensation – Reduced anal tone – Upgoing plantars (late) • Investigations – MRI whole spine – Bone scan (radioisotope) – If no Hx of malignancy, investigate for malignancy – CT chest/abd/pelvis • Management – Bed rest and catheter – DEXAMETHASONE 8MG BD IV/PO – Analgesia – Surgery or radiotherapy to METS (20Gy in 5fractions over 5days) • Indications for surgery: survival likely >3m, single site compression, no systemic disease, previous radiotherapy to spine, unknown 1o requiring Dx, bone fragment compressing cord, no response to steroids, no cancer
  5. 5. Cauda Equina Syndrome • Tumours below L1/L2 level • Symptoms: – Bilateral sciatic pain – Bladder dysfunction (retention/incontinence) – Impotence – Saddle anaesthesia – Loss of anal sphincter tone – MUST DO PR EXAM!!! – Weakness and wasting of gluteal muscles • Diagnosis by MRI spine • Rx: dexamethasone 8mg IV BD, RT, Sx
  6. 6. Pulmonary Embolism • Cancer patients are more prone to PE as they can be in a HYPERCOAGULABLE state. This can be due to cancer related blood constituent changes or pressure on vessel walls causing stasis/altered blood flow • Active cancer is on the WELLS score criteria for DVT • Symptoms: – SOB – Pleuritic chest pain – Dry cough – May have calf pain/swelling • Signs – Raised JVP – Tachycardia and tachypnoea, S1Q3T3 – “gallop rhythm” – high output states – Peripheral/central cyanosis – Vesicular breath sounds in most areas
  7. 7. Pulmonary Embolism • Investigations – ABG: decreased PaO2, decreased PaCO2 (due to reduced ventilation), can cause respiratory alkalosis – ECG: right heart strain S1Q3T3. rule out MI – D-dimer: raised (non-specific) – CTPA/VQA scan: identify non-perfused part of lung – CXR: wedge infarct • Treatment: – Oxygen therapy – Enoxaparin 1.5mg/kg/day – Consider starting warfarin for 6m – Analgesia: NSAIDs – ENOXAPARIN works best for cancer patients
  8. 8. Neutropenic Sepsis • Chemotherapy can cause bone marrow suppression, leading to pancytopenia. The reduction in WCC (neutropenia) leaves the patient at risk of developing infections. This can quickly lead to sepsis and septic shock • Cannot judge sepsis by temperature!!! • Symptoms and Signs: – Drowsy, decreased level of consciousness, confusion – Cold peripheries – Tachycardia – Hypotension – May be signs of infection e.g. cough in chest infection • Investigations: – Cultures: blood, urine, throat, current lines (hickmans, catheter) – Venous access, IV fluids: colloids – Catheter to monitor urinary output – Oxygen – IV Abx in accordance with hospital guidelines – Granulocyte Colony Stimulating Factor (CGSF) if haemodynamically unstable/slow response – Give GCSF prophylactically with next dose of chemo
  9. 9. Chemo Induced Thrombocytopenia • Bone marrow suppression leads to thrombocytopenia, leucopenia and anaemia • Signs & Symptoms – Increased tendency to bleed, difficult to stop – Petechiae – Large haemorrhage  hypovolaemic shock • Investigations – FBC – Coag screen – D-dimer: raised may indicate DIC • Management – Give platelets until above 10, 20 if septic – May need packed red cells if haemorrhage – If DIC: fresh frozen plasma required • DIC occurs when the coagulation and fibrinolysis systems are dysregulated. This can commonly occur in lung, pancreas, stomach and prostate cancer, as well as APL. Many small clots form and are subsequently broken down. This process leads to the consumption of clotting factors and platelets leading to increased risk of bleeding.
  10. 10. Bone Marrow Suppression • Major dose limiting factor in chemotherapy • RBC survive 120days, platelets 8days, neutrophils 1-2days so early problems are neutropenia and thrombocytopenia • Neutropenia particularly if line/catheter in/previous infection/open wound… • Management of neutropenic pt: – Blood cultures (peripheral and central if line in) – Sputum culture – Urine analysis and culture – CXR – Physical exam, swabs • Treatment: – Wide spectrum Abx e.g. IV tazocin • Low Hb: consider packed cells, investigate cause, rule out DIC
  11. 11. Lines • Hickman: – under clavicle – Tunnel catheter – Into subclavian vein, down to superior vena cava • PICC: – Peripherally inserted central catheter
  12. 12. Hypercalcaemia • Common malignancy related causes: – Parathyroid hormone related protein – Local osteolysis due to bony metastasis – Tumour producing Vitamin D metabolites • Commonly seen with BREAST, LUNG (nonsmallcell), multiple myeloma and prostate • Affects 20-40% pts with advanced cancer • Signs and Symptoms: – Bones: bone pain, pathological fractures – Stones: polyuria, polydipsia, kidney stones – Moans: confusion, depression, decreased level of consciousness/coma – Groans: constipation, pancreatitis, epigastric pain • Investigations: – U&E: Na and K raised due to dehydration, calcium RAISED >2.6 – Cause unknown: CTCAP, CXR, – ECG: decreased QT interval • Management – 4-6l saline over 24hrs – IV bisphosphonates e.g. zolendrenic acid – Catheter to monitor urine output
  13. 13. Corrected Calcium • Corrected calcium is calculated from the measured calcium. Calcium is bound to albumin so the amount of measured calcium depends on the level of albumin. Corrected calcium estimates the calcium level if the albumin was within the normal range. • Corrected calcium = measured calcium + (40-Alb) x 0.02 • E.g. Ca 3.46, Albumin 28 – Corrected calcium = 3.46 + (40-28) x 0.02 = 3.46 + 0.24 = 3.7 mmol/l.
  14. 14. Differential Diagnosis thirst, polyuria, constipation • Diabetes mellitus • Diabetes insipidus • Hypercalcaemia • Hypernatraemia • Psychogenic polydipsia
  15. 15. Brain Metastases/Raised ICP • Raised ICP: space-occupying lesion, hydrocephalus, benign intra-cranial HTN • Brain M increasing in prevalence since people are surviving longer with cancer • 20-40% pts with advanced disease: • Particularly LUNG, BREAST, MELANOMA • Symptoms: – Headaches- worse in the morning and on stooping – N&V – worse in morning – Confusion, altered behaviour – Focal neurological signs – Seizures • Investigations – CT brain • Management – DEXAMETHASONE 8MG BD IV/PO: shrink mass/inflammation to reduce risk of coning – whole brain radiotherapy if 2+ METS – Anti-epileptics for seizures: carbamazepine – ***can’t drive ever again OSCE!!!!!!!!!!! – Surgery: solitary met with controlled systemic disease, unknown diagnosis need sample, rapid deterioration, hydrocephalus (shunting)
  16. 16. SVC obstruction • Obstruction of the SVC occurs commonly with lung tumours and lymphomas which can press on SVC (right sided tumours) • Signs & Symptoms – Raised JVP – Puffy face and arms – Dilated veins on chest wall – Plethoric face – Headache (worse on stooping), visual disturbance (papilloedema) • Investigations – CXR: widened mediastinum/lung tumour – SVC venogram – CT with contrast • Management – Oxygen – Dexamethasone 8mg BD – Stent/radiotherapy/chemotherapy as appropriate • External compression: breast cancer, lung cancers, lymphoma, thymoma 90% • Internal thrombosis: central line, pacing wire 10% • DDx: heart failure, tamponade, external jugular vein compression
  17. 17. Stridor • Benign or malignant causes: – Non-malignant: foreign body, tracheal stenosis, vocal palsy – Malignant: primary respiratory tract tumours, bronchial (carina) tumours/ thyroid, mediastinal lymphadenopathy or MET • Signs and Symptoms – Goitre – Weight loss – Clubbing • Investigations – CXR: widening of mediastinum, 1o lung cancer – Bronchoscopy: biopsy/cytology – CT scan – Mediastinoscopy • Treatment: – Dexamethasone 8mg IV BD – Tumour debulking: radio/surgery
  18. 18. Obstruction • Intestinal – Pelvic cancers: ovarian 6-42%, cervical 5%, colonic 10-30% – May be complete, subacute or functional – Signs & symptoms: N&V, colicky pain, constipation, disyension, dehydration, projectile vomiting – Inv: erect and supine abdominal x-ray, barium studies, MRI – Treatment: IV fluid, NG tube, surgery/radiotherapy • Urinary Tract – Causes: bladder, prostate, cervis, pelvic cancers – Symptoms: asymptomayic, pain – Inv: abdominal US, cystoscopy
  • PinakinTandel

    Nov. 20, 2018
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    Jan. 18, 2018
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    Dec. 15, 2017
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    Dec. 14, 2017

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