This document summarizes several oncologic emergencies including:
1) Superior vena cava syndrome caused by obstruction of the superior vena cava which can be caused by lung cancer and treated with stents or chemotherapy and radiation.
2) Malignant spinal cord compression which occurs in 5-10% of cancer patients and presents with back pain and neurological deficits treated with dexamethasone and radiation.
3) Pericardial effusions and tamponade found in 5-10% of cancer patients which can be drained with pericardiocentesis and increased intracranial pressure from brain metastases treated with steroids and surgery or radiation.
This document discusses various oncologic emergencies organized by system. It covers cardiovascular emergencies like pericardial tamponade and superior vena cava syndrome. Neurological emergencies discussed include increased intracranial pressure and spinal cord compression. Other sections cover gastrointestinal, hematologic, infectious, metabolic and other emergencies cancer patients may experience. It provides details on mechanisms, symptoms, diagnosis and treatment of several example conditions like hypercalcemia, tumor lysis syndrome and mucositis. The document concludes by mentioning some new targeted cancer drugs and related complications.
1) Oncologic emergencies can involve several body systems and include conditions like pericardial tamponade, superior vena cava syndrome, increased intracranial pressure, spinal cord compression, tumor lysis syndrome, sepsis, and symptomatic complications from the cancer or its treatment.
2) The case documents presented examples of patients presenting with pericardial tamponade, superior vena cava syndrome, increased intracranial pressure from brain metastases, and spinal cord compression from a plasmacytoma.
3) For each emergency, the document discussed diagnostic tests, treatment approaches like steroids, surgery, radiation, chemotherapy, and emphasized the importance of rapid diagnosis and management
This document discusses various oncologic emergencies that can arise as complications of malignancy. It covers emergencies such as upper airway obstruction, malignant pericardial tamponade, superior vena cava syndrome, acute spinal cord compression, hypercalcemia, hyperviscosity syndrome, and others. For each emergency, it describes the typical causative tumors, symptoms, diagnosis, and treatment approaches. The goal is to highlight life-threatening complications of cancer and how emergency physicians can recognize and initially manage these conditions.
Reviews some of the emergencies in Oncology. For nursing students. Covers common oncologic emergencies including brain metastasis, spinal cord compression, SVC syndrome / SVC obstruction, Pain, Hypercalcemia, Hyperleukocytosis and Febrile Neutropenia.
Oncologic emergencies are vital for many healthcare practitioners to note even if they do not take care of cancer patients alone. This slide deck covers malignant spinal cord compression, hypercalcemia of malignancy, and tumor lysis syndrome.
1. The patient presented with hypercalcemia due to metastatic lung cancer. Symptoms included confusion, dehydration, and signs of renal impairment.
2. Initial management involved IV rehydration with normal saline to improve kidney function and increase calcium excretion. Bisphosphonate therapy was given to reduce calcium levels.
3. Further imaging found a mass in the right hilum and new liver metastasis, consistent with progression of the original lung cancer.
This document summarizes several oncological emergencies including superior vena cava syndrome, spinal cord compression, and hypercalcemia. It provides details on the causes, signs and symptoms, diagnostic evaluation, and treatment options for each condition. Superior vena cava syndrome is most often caused by lung cancer and presents with symptoms of facial and arm swelling. Diagnosis involves imaging tests like CT or MRI. Treatment may include stenting, radiation, or surgery. Spinal cord compression commonly results from breast, lung, or prostate cancers and causes pain, weakness, and sensory changes. MRI is the best imaging test and treatment involves steroids, radiation, or surgery.
This document discusses various oncologic emergencies organized by system. It covers cardiovascular emergencies like pericardial tamponade and superior vena cava syndrome. Neurological emergencies discussed include increased intracranial pressure and spinal cord compression. Other sections cover gastrointestinal, hematologic, infectious, metabolic and other emergencies cancer patients may experience. It provides details on mechanisms, symptoms, diagnosis and treatment of several example conditions like hypercalcemia, tumor lysis syndrome and mucositis. The document concludes by mentioning some new targeted cancer drugs and related complications.
1) Oncologic emergencies can involve several body systems and include conditions like pericardial tamponade, superior vena cava syndrome, increased intracranial pressure, spinal cord compression, tumor lysis syndrome, sepsis, and symptomatic complications from the cancer or its treatment.
2) The case documents presented examples of patients presenting with pericardial tamponade, superior vena cava syndrome, increased intracranial pressure from brain metastases, and spinal cord compression from a plasmacytoma.
3) For each emergency, the document discussed diagnostic tests, treatment approaches like steroids, surgery, radiation, chemotherapy, and emphasized the importance of rapid diagnosis and management
This document discusses various oncologic emergencies that can arise as complications of malignancy. It covers emergencies such as upper airway obstruction, malignant pericardial tamponade, superior vena cava syndrome, acute spinal cord compression, hypercalcemia, hyperviscosity syndrome, and others. For each emergency, it describes the typical causative tumors, symptoms, diagnosis, and treatment approaches. The goal is to highlight life-threatening complications of cancer and how emergency physicians can recognize and initially manage these conditions.
Reviews some of the emergencies in Oncology. For nursing students. Covers common oncologic emergencies including brain metastasis, spinal cord compression, SVC syndrome / SVC obstruction, Pain, Hypercalcemia, Hyperleukocytosis and Febrile Neutropenia.
Oncologic emergencies are vital for many healthcare practitioners to note even if they do not take care of cancer patients alone. This slide deck covers malignant spinal cord compression, hypercalcemia of malignancy, and tumor lysis syndrome.
1. The patient presented with hypercalcemia due to metastatic lung cancer. Symptoms included confusion, dehydration, and signs of renal impairment.
2. Initial management involved IV rehydration with normal saline to improve kidney function and increase calcium excretion. Bisphosphonate therapy was given to reduce calcium levels.
3. Further imaging found a mass in the right hilum and new liver metastasis, consistent with progression of the original lung cancer.
This document summarizes several oncological emergencies including superior vena cava syndrome, spinal cord compression, and hypercalcemia. It provides details on the causes, signs and symptoms, diagnostic evaluation, and treatment options for each condition. Superior vena cava syndrome is most often caused by lung cancer and presents with symptoms of facial and arm swelling. Diagnosis involves imaging tests like CT or MRI. Treatment may include stenting, radiation, or surgery. Spinal cord compression commonly results from breast, lung, or prostate cancers and causes pain, weakness, and sensory changes. MRI is the best imaging test and treatment involves steroids, radiation, or surgery.
The document discusses various oncologic emergencies including metabolic emergencies like tumor lysis syndrome, haematologic emergencies like hyperleukocytosis and coagulopathy, infections like febrile neutropenia and typhlitis, and neurological emergencies like spinal cord compression and increased intracranial pressure. It provides details on the pathophysiology, clinical features, investigations and management of these conditions.
This document discusses several oncological emergencies including spinal cord compression, bone marrow suppression/neutropenic sepsis, superior vena cava obstruction, raised intracranial pressure/brain metastases, stridor, acute blood loss, obstruction, biochemical crisis of hypercalcemia, and pulmonary embolism. It provides details on symptoms, signs, investigations, and management for each emergency. Spinal cord compression is discussed in depth including symptoms of back pain, sensory and motor deficits, and management with steroids, radiation, or surgery.
The document discusses several oncological emergencies including tumor lysis syndrome, leucoestasis, hypercalcemia, superior vena cava syndrome, spinal cord compression, and hyperviscosity syndrome. It provides details on the pathogenesis, risk factors, signs and symptoms, diagnostic evaluation and treatment recommendations for each condition. The treatment sections emphasize hydration, uric acid lowering agents, corticosteroids, radiation therapy, surgery, chemotherapy and other supportive measures depending on the specific emergency.
This document discusses tumor lysis syndrome (TLS), a metabolic oncologic emergency caused by the breakdown of malignant cells following chemotherapy or radiation therapy. TLS results in the release of potassium, phosphorus, uric acid and other intracellular components into the bloodstream, potentially causing hyperkalemia, hyperphosphatemia, hyperuricemia and other electrolyte imbalances. The document outlines risk factors for TLS, signs and symptoms of specific electrolyte abnormalities, treatment approaches, and importance of monitoring patients at risk.
Interactive talk on common hematological and oncological emergencies - which if not noticed early can lead to irreversible complications and death .
Intended to be used for educational purposes for the fertile minds in medicine .
Management of oncology emergencies, Mohh'd sharshirMoh'd sharshir
This document summarizes the management of oncologic emergencies, focusing on tumor lysis syndrome (TLS). TLS is caused by massive lysis of tumor cells, releasing potassium, phosphate and uric acid. It is classified based on laboratory and clinical criteria. Risk is highest in Burkitt lymphoma, ALL and other high-grade lymphomas. Prevention focuses on IV hydration and hypouricemic agents like rasburicase or allopurinol. Electrolyte abnormalities are managed based on their severity. High-risk patients receive aggressive prevention while intermediate-risk patients generally receive allopurinol prevention.
Oncological Emergencies are the group of conditions that occur as a direct or indirect results of cancer or its treatment that are potentially life-threatening.
after definition it consist of classification and descriptive explanation of each disease and in the end NURSES ROLE
Oncological emergencies are well explained. It is classified properly and important ones are explained clearly.
For video explanation follow me on YouTube
Nurse DE
https://youtu.be/GUQzSF7_UPc
Oncologic Emergencies and Symptom Managementflasco_org
1) Oncologic emergencies include conditions like hypercalcemia, tumor lysis syndrome, SIADH, hyperviscosity states, and increased intracranial pressure that require immediate medical intervention.
2) Tumor lysis syndrome occurs when cancer cells die off rapidly, releasing electrolytes and metabolites that can overwhelm the kidneys, potentially causing renal failure, arrhythmias or seizures. It is treated by managing individual electrolyte abnormalities and renal failure.
3) Increased intracranial pressure in cancer patients can be caused by vasogenic edema, hemorrhage, or obstruction of cerebrospinal fluid flow. Symptoms include headache, vomiting and altered mental status. Treatment involves steroids
Neonatal sepsis is a clinical syndrome of infection in infants under 1 month of age, which can include systemic infections like septicemia, meningitis, and pneumonia. It is a major cause of neonatal mortality in Sri Lanka. Early onset sepsis within 3 days of life is usually caused by maternal infections, while late onset sepsis after 3 days is often hospital-acquired. Signs are non-specific but may include fever, lethargy, poor feeding, and respiratory distress. Blood cultures and a full sepsis screen are important for diagnosis. Early administration of antibiotics is crucial. Complications can include organ damage, shock, and long term disabilities like cerebral palsy. Prevention strategies include identifying at-risk infants and
Coronary artery disease occurs when plaque builds up in the coronary arteries, narrowing the arteries and reducing blood flow to the heart. This document outlines the definition, risk factors, pathophysiology, signs and symptoms, diagnosis, and treatment of coronary artery disease. The modifiable risk factors include hyperlipidemia, smoking, hypertension, diabetes, obesity, and physical inactivity. The pathophysiology involves injury to endothelial cells, inflammation, lipid accumulation in artery walls, and formation of thrombus. Diagnosis involves history, physical exam, ECG, and lab tests. Treatment focuses on lifestyle changes, medications like statins, and procedures like angioplasty, stents, or bypass surgery.
This document discusses various hematologic emergencies and urgencies including leukostasis, hyperviscosity syndrome, thrombotic thrombocytopenic purpura, acute hemolytic transfusion reaction, cord compression, febrile neutropenia, bleeding diathesis, acute promyelocytic leukemia, and acute disseminated intravascular coagulation. It provides details on symptoms, diagnostic criteria, and treatment approaches for each condition. The goal is to identify life-threatening hematologic emergencies, determine their causes, and initiate appropriate urgent medical management.
This document discusses acute kidney injury (AKI). It defines AKI and outlines its causes including prerenal, renal, and postrenal. Risk factors, investigations, and management of AKI are reviewed. Three case studies of patients presenting with AKI are presented and questions are provided to test clinical decision making. Key steps in the acute management and workup of severe AKI cases are emphasized.
The document discusses symptom management of side effects from chemotherapy, immunotherapy, and targeted therapy, including mucositis, hair loss, infusion reactions, myelosuppression, peripheral neuropathy, and effects on sex and reproduction. It also covers common toxicities associated with immune checkpoint inhibitors such as pneumonitis, colitis, nephritis, hepatitis, hypothyroidism, and hyperthyroidism. Treatment options are provided for managing many of these side effects.
This document provides information on the adrenal gland, including its embryology, anatomy, physiology, and various disorders. It discusses topics such as adrenal cortex and medulla disorders, adrenal tumors, adrenal insufficiency, and adrenal surgery. Specific conditions covered include Cushing's syndrome, pheochromocytoma, congenital adrenal hyperplasia, hyperaldosteronism, adrenocortical carcinoma, and adrenal incidentaloma. Diagnostic tests and treatment options are provided for each condition. Adrenal surgery techniques such as open and laparoscopic approaches are also summarized.
1. The patient, a 20-year-old woman, was admitted with fever, left leg swelling and pain, and easy fatigability. Testing showed bilateral acute leukemia with involvement of both lymphoblastic and myeloblastic cells.
2. Deep vein thrombosis is a known complication in acute leukemia, likely due to hypercoagulability, hyperleukocytosis, and effects of treatment. Management involves anticoagulation but this poses challenges in thrombocytopenic patients.
3. The patient's prognosis is poor given her diagnosis of biphenotypic acute leukemia, which is resistant to treatment and has a high risk of relapse.
1. Oncological emergencies refer to urgent clinical situations in cancer patients caused by cancer or its treatment.
2. Some examples discussed are hypercalcemia, tumor lysis syndrome, lactic acidosis, hypoglycemia, syndrome of inappropriate antidiuretic hormone secretion, superior vena cava syndrome, spinal cord compression, severe cystitis, bladder hemorrhage, disseminated intravascular coagulation, and cardiac tamponade.
3. The document provides details on symptoms, signs, and treatment approaches for each of these conditions.
This document discusses adrenal incidentalomas, which are adrenal masses greater than 1cm discovered incidentally on imaging. It covers the epidemiology, risks of progression, imaging techniques, and assessment of hormonal functionality. For hormonally inactive incidentalomas, the risks of malignancy and developing hormonal hypersecretion are low. Dedicated adrenal imaging can help characterize lesions and determine need for follow up. Biochemical testing assesses for hormonal hypersecretion from conditions like pheochromocytoma, Cushing's syndrome, and primary hyperaldosteronism. Subclinical Cushing's syndrome is defined and testing approaches are outlined. Surgical resection may be considered for larger lesions or biochemically active
Atypical pulmonary metastasis: the radiologic findingsThorsang Chayovan
Pulmonary metastasis is common, with the lungs acting as a filter for cancer cells from the lymphatic system. While multiple, round nodules in random distribution are typical, atypical presentations can include poorly-defined lesions, cavitation, calcification, hemorrhage, pneumothorax, airspace opacities, tumor emboli, endobronchial growths, solitary masses, or vessels within tumors. Certain primary cancers like sarcomas are also linked to specific radiologic appearances of pulmonary metastases. Awareness of atypical presentations helps avoid misdiagnosis versus primary lung disease.
The document discusses airway emergencies in patients with malignancies. It covers causes of airway obstruction including primary tumors or metastases in the head, neck, lungs or mediastinum. Evaluation involves CT scans and bronchoscopy while treatment depends on whether the obstruction is proximal or distal. For proximal obstruction, tracheostomy or endotracheal intubation may be used. Distal obstruction may be treated with bronchoscopy, stents or radiotherapy. Definitive therapies aim to relieve the airway obstruction through procedures like laser resection or brachytherapy to allow further oncologic treatment.
The document discusses various oncologic emergencies including metabolic emergencies like tumor lysis syndrome, haematologic emergencies like hyperleukocytosis and coagulopathy, infections like febrile neutropenia and typhlitis, and neurological emergencies like spinal cord compression and increased intracranial pressure. It provides details on the pathophysiology, clinical features, investigations and management of these conditions.
This document discusses several oncological emergencies including spinal cord compression, bone marrow suppression/neutropenic sepsis, superior vena cava obstruction, raised intracranial pressure/brain metastases, stridor, acute blood loss, obstruction, biochemical crisis of hypercalcemia, and pulmonary embolism. It provides details on symptoms, signs, investigations, and management for each emergency. Spinal cord compression is discussed in depth including symptoms of back pain, sensory and motor deficits, and management with steroids, radiation, or surgery.
The document discusses several oncological emergencies including tumor lysis syndrome, leucoestasis, hypercalcemia, superior vena cava syndrome, spinal cord compression, and hyperviscosity syndrome. It provides details on the pathogenesis, risk factors, signs and symptoms, diagnostic evaluation and treatment recommendations for each condition. The treatment sections emphasize hydration, uric acid lowering agents, corticosteroids, radiation therapy, surgery, chemotherapy and other supportive measures depending on the specific emergency.
This document discusses tumor lysis syndrome (TLS), a metabolic oncologic emergency caused by the breakdown of malignant cells following chemotherapy or radiation therapy. TLS results in the release of potassium, phosphorus, uric acid and other intracellular components into the bloodstream, potentially causing hyperkalemia, hyperphosphatemia, hyperuricemia and other electrolyte imbalances. The document outlines risk factors for TLS, signs and symptoms of specific electrolyte abnormalities, treatment approaches, and importance of monitoring patients at risk.
Interactive talk on common hematological and oncological emergencies - which if not noticed early can lead to irreversible complications and death .
Intended to be used for educational purposes for the fertile minds in medicine .
Management of oncology emergencies, Mohh'd sharshirMoh'd sharshir
This document summarizes the management of oncologic emergencies, focusing on tumor lysis syndrome (TLS). TLS is caused by massive lysis of tumor cells, releasing potassium, phosphate and uric acid. It is classified based on laboratory and clinical criteria. Risk is highest in Burkitt lymphoma, ALL and other high-grade lymphomas. Prevention focuses on IV hydration and hypouricemic agents like rasburicase or allopurinol. Electrolyte abnormalities are managed based on their severity. High-risk patients receive aggressive prevention while intermediate-risk patients generally receive allopurinol prevention.
Oncological Emergencies are the group of conditions that occur as a direct or indirect results of cancer or its treatment that are potentially life-threatening.
after definition it consist of classification and descriptive explanation of each disease and in the end NURSES ROLE
Oncological emergencies are well explained. It is classified properly and important ones are explained clearly.
For video explanation follow me on YouTube
Nurse DE
https://youtu.be/GUQzSF7_UPc
Oncologic Emergencies and Symptom Managementflasco_org
1) Oncologic emergencies include conditions like hypercalcemia, tumor lysis syndrome, SIADH, hyperviscosity states, and increased intracranial pressure that require immediate medical intervention.
2) Tumor lysis syndrome occurs when cancer cells die off rapidly, releasing electrolytes and metabolites that can overwhelm the kidneys, potentially causing renal failure, arrhythmias or seizures. It is treated by managing individual electrolyte abnormalities and renal failure.
3) Increased intracranial pressure in cancer patients can be caused by vasogenic edema, hemorrhage, or obstruction of cerebrospinal fluid flow. Symptoms include headache, vomiting and altered mental status. Treatment involves steroids
Neonatal sepsis is a clinical syndrome of infection in infants under 1 month of age, which can include systemic infections like septicemia, meningitis, and pneumonia. It is a major cause of neonatal mortality in Sri Lanka. Early onset sepsis within 3 days of life is usually caused by maternal infections, while late onset sepsis after 3 days is often hospital-acquired. Signs are non-specific but may include fever, lethargy, poor feeding, and respiratory distress. Blood cultures and a full sepsis screen are important for diagnosis. Early administration of antibiotics is crucial. Complications can include organ damage, shock, and long term disabilities like cerebral palsy. Prevention strategies include identifying at-risk infants and
Coronary artery disease occurs when plaque builds up in the coronary arteries, narrowing the arteries and reducing blood flow to the heart. This document outlines the definition, risk factors, pathophysiology, signs and symptoms, diagnosis, and treatment of coronary artery disease. The modifiable risk factors include hyperlipidemia, smoking, hypertension, diabetes, obesity, and physical inactivity. The pathophysiology involves injury to endothelial cells, inflammation, lipid accumulation in artery walls, and formation of thrombus. Diagnosis involves history, physical exam, ECG, and lab tests. Treatment focuses on lifestyle changes, medications like statins, and procedures like angioplasty, stents, or bypass surgery.
This document discusses various hematologic emergencies and urgencies including leukostasis, hyperviscosity syndrome, thrombotic thrombocytopenic purpura, acute hemolytic transfusion reaction, cord compression, febrile neutropenia, bleeding diathesis, acute promyelocytic leukemia, and acute disseminated intravascular coagulation. It provides details on symptoms, diagnostic criteria, and treatment approaches for each condition. The goal is to identify life-threatening hematologic emergencies, determine their causes, and initiate appropriate urgent medical management.
This document discusses acute kidney injury (AKI). It defines AKI and outlines its causes including prerenal, renal, and postrenal. Risk factors, investigations, and management of AKI are reviewed. Three case studies of patients presenting with AKI are presented and questions are provided to test clinical decision making. Key steps in the acute management and workup of severe AKI cases are emphasized.
The document discusses symptom management of side effects from chemotherapy, immunotherapy, and targeted therapy, including mucositis, hair loss, infusion reactions, myelosuppression, peripheral neuropathy, and effects on sex and reproduction. It also covers common toxicities associated with immune checkpoint inhibitors such as pneumonitis, colitis, nephritis, hepatitis, hypothyroidism, and hyperthyroidism. Treatment options are provided for managing many of these side effects.
This document provides information on the adrenal gland, including its embryology, anatomy, physiology, and various disorders. It discusses topics such as adrenal cortex and medulla disorders, adrenal tumors, adrenal insufficiency, and adrenal surgery. Specific conditions covered include Cushing's syndrome, pheochromocytoma, congenital adrenal hyperplasia, hyperaldosteronism, adrenocortical carcinoma, and adrenal incidentaloma. Diagnostic tests and treatment options are provided for each condition. Adrenal surgery techniques such as open and laparoscopic approaches are also summarized.
1. The patient, a 20-year-old woman, was admitted with fever, left leg swelling and pain, and easy fatigability. Testing showed bilateral acute leukemia with involvement of both lymphoblastic and myeloblastic cells.
2. Deep vein thrombosis is a known complication in acute leukemia, likely due to hypercoagulability, hyperleukocytosis, and effects of treatment. Management involves anticoagulation but this poses challenges in thrombocytopenic patients.
3. The patient's prognosis is poor given her diagnosis of biphenotypic acute leukemia, which is resistant to treatment and has a high risk of relapse.
1. Oncological emergencies refer to urgent clinical situations in cancer patients caused by cancer or its treatment.
2. Some examples discussed are hypercalcemia, tumor lysis syndrome, lactic acidosis, hypoglycemia, syndrome of inappropriate antidiuretic hormone secretion, superior vena cava syndrome, spinal cord compression, severe cystitis, bladder hemorrhage, disseminated intravascular coagulation, and cardiac tamponade.
3. The document provides details on symptoms, signs, and treatment approaches for each of these conditions.
This document discusses adrenal incidentalomas, which are adrenal masses greater than 1cm discovered incidentally on imaging. It covers the epidemiology, risks of progression, imaging techniques, and assessment of hormonal functionality. For hormonally inactive incidentalomas, the risks of malignancy and developing hormonal hypersecretion are low. Dedicated adrenal imaging can help characterize lesions and determine need for follow up. Biochemical testing assesses for hormonal hypersecretion from conditions like pheochromocytoma, Cushing's syndrome, and primary hyperaldosteronism. Subclinical Cushing's syndrome is defined and testing approaches are outlined. Surgical resection may be considered for larger lesions or biochemically active
Atypical pulmonary metastasis: the radiologic findingsThorsang Chayovan
Pulmonary metastasis is common, with the lungs acting as a filter for cancer cells from the lymphatic system. While multiple, round nodules in random distribution are typical, atypical presentations can include poorly-defined lesions, cavitation, calcification, hemorrhage, pneumothorax, airspace opacities, tumor emboli, endobronchial growths, solitary masses, or vessels within tumors. Certain primary cancers like sarcomas are also linked to specific radiologic appearances of pulmonary metastases. Awareness of atypical presentations helps avoid misdiagnosis versus primary lung disease.
The document discusses airway emergencies in patients with malignancies. It covers causes of airway obstruction including primary tumors or metastases in the head, neck, lungs or mediastinum. Evaluation involves CT scans and bronchoscopy while treatment depends on whether the obstruction is proximal or distal. For proximal obstruction, tracheostomy or endotracheal intubation may be used. Distal obstruction may be treated with bronchoscopy, stents or radiotherapy. Definitive therapies aim to relieve the airway obstruction through procedures like laser resection or brachytherapy to allow further oncologic treatment.
This document compares silicone airway stents that are partially covered versus fully covered self-expanding metal stents (SEMS) across several categories: setting and equipment needs, mechanical properties, manipulation requirements, suitability for special situations, and risks of complications. Silicone stents are easier to deploy blindly and customize on site but are more prone to mucostasis, while SEMS are more difficult to manipulate but reduce risks of granuloma, fracture or tumor ingrowth. Neither stent is clearly superior in all situations.
This document discusses various causes and treatments for dyspnea, or shortness of breath, in patients with advanced lung cancer. It outlines that dyspnea is usually multifactorial in these patients and many underlying causes are irreversible. It then describes treating any reversible conditions like pneumonia, malignant pleural effusions, central airway obstructions, or superior vena cava syndrome. Both non-pharmacological interventions like breathing exercises and cooling techniques as well as various pharmacological treatments including opioids, benzodiazepines, oxygen, heliox, and diuretics are mentioned as options to provide palliative relief for dyspnea in lung cancer patients.
The document describes two case studies - Jason and Annie - and their starting points. Jason is the CEO of a company providing analytics to health insurers, but has struggled explaining his value proposition to prospective clients. Annie founded a company with a new industrial cleaner but needs help with strategy, pitching, and partnerships to scale. Both are open to help, but Jason does not think he needs assistance explaining his concept, while Annie is concerned about rates.
This is a lecture by Jim Holliman, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This document discusses airway stents, which are tube-shaped devices inserted bronchoscopically into airways to treat various large airway diseases. It describes indications for airway stenting including malignant and benign airway obstructions. The main types of stents are silicone, metal, and hybrid stents. The document reviews the techniques for inserting and monitoring airway stents as well as potential complications.
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, An...Bassel Ericsoussi, MD
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment
The document discusses the etiology, types, staging, and characteristics of bronchial carcinoma. The main causes are tobacco smoking, asbestos exposure, irradiation, and toxic metals. The four main types are squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and alveolar cell carcinoma. Staging involves assessing the tumor size (T stage), lymph node involvement (N stage), and presence of distant metastasis (M stage). Later sections provide more details on lymph node classification, calcification, FDG uptake, operability in certain cases like Pancoast tumors.
This document discusses the management of vascular oncology emergencies and hemorrhage through interventional radiology procedures. It provides an overview of the causes of hemorrhage in cancer patients, the goals and principles of embolization procedures to stop bleeding, and the identification of bleeding sites. Specific clinical scenarios involving gastrointestinal, genitourinary, and pulmonary hemorrhage are examined. The document reviews various embolic agents and techniques used to treat hemorrhage, as well as post-embolization care and monitoring. Technological improvements that can help interventional radiologists effectively manage oncology emergencies are also highlighted.
Radiation emergencies and preparedness in radiotherapyDeepjyoti saha
In a Radiotherapy Department where cancer patients are being treated with high energy photons,gamma rays,electrons; all the radiation workers should be alert regarding radiation accidents & how to face the situation.
Upper Airway Obstruction Dr Juhina Clinical Serise EM OMSB
This document summarizes upper airway obstruction in children. It discusses the anatomy of the pediatric airway and causes of stridor. Common causes of acute upper airway obstruction like croup, epiglottitis, and retropharyngeal abscess are described. Evaluation, management, and treatment of these conditions are outlined, including securing the airway if needed and administering antibiotics. Diagnostic tools like lateral neck x-rays are discussed.
The document provides an overview of oncologic emergencies including spinal cord compression, brain metastases, superior vena cava obstruction, febrile neutropenia, and hypercalcemia. For spinal cord compression, it discusses signs/symptoms, workup with MRI, treatment with corticosteroids and radiotherapy, and prognosis. It notes surgery plus radiotherapy is better than radiotherapy alone based on the Patchell 2005 study. For brain metastases, it outlines presentation, workup with imaging, treatment with steroids, radiotherapy, and stereotactic radiosurgery based on studies showing better outcomes than whole brain radiotherapy alone.
The document discusses airway obstruction and management. It defines the airway and why maintaining a clear airway is important. Three key reasons maintaining an airway is important are: sensitive organs like the brain and heart can die within minutes without oxygen; the trauma patient's airway should be addressed first; and the crucial first few minutes after injury. The document outlines various airway rescue methods including manual maneuvers like head tilt and chin lift, instrumentation like oropharyngeal airways and endotracheal tubes, and surgical options like cricothyroidotomy if other methods fail.
This document discusses key aspects of qualitative case study research. It outlines that case studies allow for an in-depth exploration of a phenomenon within its real-life context. The document discusses different approaches to case studies by researchers like Yin, Stake and Creswell. It also addresses important considerations for case study research like purposefully defining the case, collecting multiple sources of data, ensuring validity and ethics, and producing engaging written reports for academic audiences.
- Pupil involvement in 3rd nerve palsy suggests a compressive lesion like an aneurysm and MRI/MRA or MRI/CTA is needed.
- Acute Horner's syndrome requires ruling out internal carotid artery dissection with MRI/MRA of the head and neck.
- For ophthalmoplegia or vision loss in those over 60, giant cell arteritis must always be ruled out as the cause.
- An acute severe headache with ophthalmoplexy involving multiple cranial nerves could indicate pituitary apoplexy.
- Proptosis and eye redness in diabetic or immunocompromised patients may be due to a life-threatening fungal infection like muc
The document provides an example case study on the topic of coffee production and deforestation in the Amazon rainforest. It outlines the problem of thousands of acres of rainforest being burned to grow coffee trees. It then summarizes key points from several websites that were researched on this topic, finding that vast amounts of primary forest have been cleared for coffee cultivation, leading to rampant deforestation and impacts to wildlife habitats and migration routes. Potential solutions discussed include crop rotation, replanting forests, and promoting conservation and shade-grown coffee methods to help reduce environmental impacts.
Spinal Tumors: approach and managementAmit Agrawal
The spinal cord consists of
Central canal surrounded by an H-shaped gray matter region containing neurons
Outer myelinated nerve tracts, termed white matter, surround the central gray matter
Central canal is lined with ependymal cells
Astrocytes support gray matter neurons and white matter axons
Superior Vena Cava Syndrome. Etiology and managementRomanusMapunda1
Superior vena cava (SVC) syndrome is a collection of clinical signs and symptoms resulting from either partial or complete obstruction of blood flow through the SVC.
This obstruction is most commonly a result of thrombus formation or tumor infiltration of the vessel wall.
This document discusses various causes of non-compressive myelopathy, including infectious, inflammatory, vascular, metabolic, degenerative, and physical agent causes. It covers specific conditions such as transverse myelitis, multiple sclerosis, spinal infarction, vascular malformations, vitamin B12 deficiency, and radiation myelopathy. Treatment approaches are mentioned for some conditions.
Peripheral arterial disease affects around 12% of the adult population in the US. It most commonly presents as intermittent claudication. This document discusses the diagnosis and management of various vascular conditions. It covers topics like aneurysms, arterial occlusions, and venous diseases. Evaluation involves history, exam, imaging studies like duplex ultrasound and angiography. Treatment depends on the specific condition but may include lifestyle changes, medications, endovascular procedures, or surgery.
This document discusses the diagnostic criteria for rheumatic fever. It lists the major criteria as polyarthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham's chorea. The minor criteria include fever, arthralgia, elevated inflammatory markers, leukocytosis, and ECG abnormalities. A diagnosis of rheumatic fever requires supporting evidence of a preceding streptococcal infection and presence of either two major criteria or one major criterion with two minor criteria or three minor criteria.
1) Neutropenic sepsis or fever is a life-threatening complication of chemotherapy that requires urgent assessment and antibiotic therapy reflecting local sensitivities.
2) Spinal cord compression is an oncological emergency that requires immediate diagnosis and treatment with steroids and radiotherapy to limit neurological damage.
3) Cardiac tamponade presents with breathlessness and collapse, and requires urgent echocardiogram-guided drainage of pericardial fluid.
After this presentation, the reader should be able to describe features of papilledema with main causes and investigations needed in the work up and differentiate it from pseudopapilledema.
Diagnosis, management, workup in a case of Takayasu's arteritis. Definition, synonyms, history, epidimiology, pathophysiology, etiology of Takayasu's arteritis.
Superior vena cava obstruction results from conditions obstructing blood flow through the SVC, usually intrathoracic malignancies in 60-85% of cases. Non-small cell lung cancer is the most common cause. Symptoms include dyspnea, swelling of the face/neck/arms, and jugular venous distension. Treatment depends on the underlying condition and may include stenting, radiation, chemotherapy, or anticoagulation to relieve obstruction.
This document discusses venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers the pathophysiology of VTE involving Virchow's triad of venous stasis, endothelial injury, and hypercoagulability. Evaluation and diagnostic methods are described, including clinical assessment, d-dimer testing, ultrasound, CT, lung scanning, and angiography. Management includes anticoagulation with unfractionated heparin, low molecular weight heparin, fondaparinux, vitamin K antagonists, and direct thrombin inhibitors. Outcomes of both DVT and PE such as post-thrombotic syndrome and mortality are addressed
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB, MNAMS,FELLLOWSHIP ...chitrapandey
This document summarizes avascular necrosis of the femoral head, including:
1. It provides an overview of the typical clinical presentation, including gradual onset of hip pain that worsens with activity and is relieved by rest. Range of motion may be limited.
2. It discusses the blood supply of the femoral head and how avascular necrosis occurs when this blood supply is disrupted.
3. It reviews various classification systems for staging avascular necrosis, including the widely used Ficat & Arlet classification system which has 4 stages ranging from preclinical to osteoarthritis.
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatr...chitrapandey
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This document provides an overview of the diagnostic approach to evaluating patients presenting with suspected spinal cord compression due to metastatic disease. It discusses that spinal cord compression is a medical emergency that requires prompt diagnosis and treatment. The summary highlights that a thorough history, physical exam with attention to neurological findings, MRI of the entire spine, and administration of steroids are critical in the evaluation and management of these patients.
This document discusses different types of cardiomyopathy, including dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), and restrictive cardiomyopathy. DCM is characterized by enlarged heart chambers and reduced systolic function. HCM involves thickened heart muscle and potential outflow tract obstruction. Restrictive cardiomyopathy restricts heart filling due to stiff heart muscles. The causes, clinical presentations, diagnostic evaluations, and management strategies are described for each type of cardiomyopathy.
A 60-year-old male presented to the emergency department with the worst headache of his life along with nausea and vomiting. Subarachnoid hemorrhage (SAH) occurs when blood enters the subarachnoid space surrounding the brain. The most common cause is a ruptured brain aneurysm. Initial management included a CT scan, which has high sensitivity in detecting SAH, control of blood pressure to reduce risk of rebleeding, administration of nimodipine to prevent vasospasm, and neurosurgical consultation. The patient was admitted to the ICU for monitoring and treatment of potential complications of SAH such as rebleeding, vasospasm, hydrocephalus, and seizures.
This document discusses avascular necrosis (AVN) of the bone, also known as osteonecrosis. It begins by explaining that AVN results from interrupted blood supply to the bone, which can lead to bone and cell death. The most common sites of AVN are the femoral head, scaphoid, and talus. Non-surgical treatments include limited weight bearing, while surgical options include core decompression, bone grafting, and osteotomies to preserve the joint. More advanced cases may require joint replacement like hip resurfacing or total hip arthroplasty. Risk factors include corticosteroid use, alcoholism, trauma, and various medical conditions.
Dr. Yashveer Singh presented on primary vertebral body tumors. He discussed the different types of benign primary tumors that can occur including osteochondroma, hemangioma, eosinophilic granuloma, aneurysmal bone cyst, osteoid osteoma, and osteoblastoma. The presentation covered the pathology, clinical features, radiologic evaluation, and management of each tumor type. Pain is usually the primary symptom, and treatment involves surgery, embolization, or other procedures depending on the specific tumor and symptoms.
Brain metastases are common brain tumors in adults. The most common primary sites are lung, breast, melanoma, and colon cancers. Symptoms depend on the location of metastases and include headache, weakness, cognitive changes, seizures, and sensory or speech problems. MRI with contrast is the preferred imaging method and can detect multiple lesions, circumscribed margins, and edema. Treatment depends on prognosis and may include surgery, whole brain radiation, stereotactic radiosurgery, chemotherapy, or supportive care. Outcomes are classified by the recursive partitioning analysis which considers performance status, extracranial disease burden, age, and primary diagnosis.
This document defines pericardial effusion and cardiac tamponade, discusses their pathophysiology, etiology, clinical presentation, investigations, and management. Pericardial effusion is an abnormal amount of fluid in the pericardial space, while cardiac tamponade is acute heart failure caused by compression of the heart from a large or rapidly developing effusion. Clinical manifestations depend on the rate of fluid accumulation and include chest pain, lightheadedness, and decreased pulse pressure. Investigations include echocardiography, electrocardiography, and pericardiocentesis. Management involves bed rest, medications, drainage procedures, and surgery in severe cases.
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3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
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5. Obstruction of the superior vena
cava (SVC):
Severe reduction in venous return from
the head, neck and upper extremieties
Lung cancer, lymphoma (NHL),
primary mediastinal germ-cell tumor
metastatic disease (testicular cancer,
breast cancer), intravascular devices,
aortic aneurysm, thyromegaly,
thrombosis, fibrosing mediastintis,
histoplasmosis, Behcet’s disease
http://www.aboutcancer.com/svco.htm
6. Superior vena cava syndrome
Neck and facial swelling, dyspnea, cough.
Other symptoms: hoarseness, tongue
swellin, headache, nasal congestion,
epistaxis, hemoptysis, dysphagia, pain,
dizziness, syncope, and lethargy.
Dilated neck veins, increased dilated
collateral veins in the chest wall; cyanosis
of the face, arms and chest; proptosis,
glossal and pharyngeal edema,
obtundation; cardiac arrest or respiratory
failure. Esophageal varices may also
occur.
Enlarged mediastinum in CXR
CT scan shows central mediastinal vein
blockage + increased collateral vein
circulation.
Endobronchial or esophageal US guided
biopsy may provide the diagnosis.Harrison’s 19th
7. CXR
Mass, widening of the
mediastinum, pleural effusion
Main risk
Tracheal obstuction
Grades %
0 – Asymptomatic 10 Imaging
1 – Mild 25 Edema / cyanosis
2 – Moderate 50 Cough, dysphagia, visual disturbances
3 – Severe 10 Brain or laryngeal swelling, syncope on exertion
4 – Life-threatening 5 Brain or laryngeal swelling (obtundation, stridor), syncope or hypotension
5 - Fatal <1 Death
Yu, JB, J Thoracic Oncol, 2008
8. Colaterales venosos del sindrome de vena cava superior
Edema subcutáneo de la obstrucción de la vena cava
Casi total oclusión de la vena cava superior por adenopatía mediastinal
Superior vena cava syndrome
SVC obstruction
Collateral circulation
Tumor
9. Superior vena cava syndrome Treatment
Establish tissue diagnosis if unknown:
Bronchoscopy, esophagoscopy, CT guided biopsy, thoracoscopy, etc.
General measures
Diuretics, low-salt diet, head elevation, oxygen.
Glucocorticosteroids (only in lymphoma)
Treat the underlying condition
(Chemo)-RT for NSCLC
RT for metastatic solid tumors
Chemotherapy for SCLC, lymphoma and GCT
Surgery for benign processes
Anticoagulation / Device removal if due to thrombosis or fibrinolytic
therapy
SVCS relapses in 10%
SVC stent
Recommended in relapsed SVCS
Severe SVCS
Stent complications: heart failure, pulmonary edema, hematoma, SVC perforation,
migration, fracture, pulmonary embolismHarrison’s 19th
10. SVCS
Grade 1-3 Grade 4
SVC stent
Tissue diagnosis (if applicable)
Treat the underlying condition
RT for other malignanciesChemo for SCLC, GCT, lymphomas Specific Rx for non-malignant
Chemosensitive Non-malignantNon-chemosensitive Thrombosis
Chemotherapy Anticoagulation/fibrinolytic(Chemo)-RT Surgery
11. Malignant spinal cord compression (MSCC)
Occurs in 5-10% of patients with cancer
MSCC is the presenting feature in 10% of malignancies
Lung cancer is the most common cause of MSCC
Causes
Lung, breast, prostate, multiple myeloma are the big ones. Lymphomas,
melanomas, genitourinary tumors and RCC, neoplastic leptomeningitis cause
MSCC too.
Non-oncologic differential diagnosis
Osteoporotic vertebral collapse, disk disease, pyogenic abscess, vertebral
tuberculosis, radiation myelopathy, benign tumors, epidural hematoma, and
spinal lipomatosis.
Sites
Thoracic spine: 70%, Lumbosacral spine: 20%, Cervical spine: 10%.
Mechanism
Vertebral body metastases, extension of paravertebral tumors, intramedulary
metastases (usually with CNS metastases and leptomeningeal disease).
Tissue ischemia and cytokine release (VEGF) may accelerate tissue damage.
Harrison’s, 19th Ed
12. Malignant spinal cord compression (MSCC)
Clinical presentation
Back pain and tenderness
It is exacerbated by movement, cough or sneezing.
Worsens in the supine position.
Lhermitte’s sign may herald MSCC
Radiculopathic pain may also be present
Loss of bladder or bowel control tend to occur late in the course of MSCC
Physical examination
Pain induced by leg raising, neck flexion, or vertebral percussion; numbness or
paresthesia; loss of pinprick or vibration of position. Weakness, spasticity and
abnormal muscle stretching. Extensor plantar reflex. Deep tendon reflexes may
be brisk. Decreased anal tonus, perineal sensibility, and a distended bladder.
Absence of the anal wink and bulbocavernous reflexes.
Cauda equina syndrome
Low back pain, diminished sensation in a saddle distribution; rectal, bladder
dysfunction, loss of bulbocavernous, patellar and Achilles relexes; lower
extremity weakness.
Causes: Primary tumors of the glia or nerve sheath
Harrison’s, 19th Ed
13. Pérdida de las todas las
modalidades sensoriales hasta el
nivel de la lesión
Fuerza y reflejos osteotendíneos
disminuidos hasta el nivel de la
lesión
Miembros flácidos
Vejiga dilatada – retención
urinaria, Esfínter anal
disfuncional - constipación
15. Back pain
Neurologic exam
Suspicious of myelopathy
HD Dexamethasone
MRI of spine
Pain crescendo pattern
Lhermitte’s sign
Pain aggravated with cough,
valsalva or recumbency
Abnormal spine x-ray
Normal
Spine x-ray
Symptomatic therapy
Epidural
metastases
Bone metastases, no
epidural metastasesNormal
Surgery + RT or RT RT
Harrison’s, 19th Ed
6 mg IV q6h
Whole spine, preferred
18. Loblaw A. J Clin Oncol 23:2028-2037
Esteroides en compresión
medular
Resultados Comentarios
Dexametasona 96 mg IV x1, 24
mg VO q6h x3 día…(1)
81% ambulatorios
@3m
Toxicidad severa:
11%
Nada(1)
61% ambulatorios
@3m
NS (n=57)
Dexametasona 100 mg IV(2)
Mejoría en la fuerza
25%
NS
Dexametasona 10 mg IV(2)
Mejoría en la fuerza
8%
NS (n=37)
Dexametasona 100 mg(3)
Efectos adversos
serios: 14.2%
Casos y controles
Dexametasona 10 mg, seguido 4
mg IV q6h…(3)
Efectos adversos
serios: 0%
Casos y controles
No esteroides en ambulatorios(4)
20/20 ambulatorios
@3m post RT
(1)
Sorensen et al, (2)
Vecht et al, (3)
Heimdal et al, (4)
Maranzano et al.
19. Esteroides en compresión medular
metastásica
• Parecen eficaces (junto con RT)
• Dosis demasiado altas, demasiado
tóxicas
• Dosis demasiado bajas, menos
eficaces
• En pacientes Ambulatorios, RT
suficiente
• Recomendación (Soft)
• Dexametasona 6 mg IV q6h hasta
que se defina el manejo definitivo
White BD et al. NICE Guidance. BMJ 2008; 337:a2538
20. Cirugía para compresión medular
oncológica
• Indicaciones
• Dislocación de fractura
patológica
• Falla de la radioterapia
• Síntomas neurológicos
rápidamente progresivos
• Expectativa de vida >3 meses
• Tumor radioresistente
(melanoma, RCC)
• No diagnóstico oncológico
previo
• Complementar con
radioterapia (dentro de los
primeros 14 días post-op).
• Considerar bisfosfonatos /
Denosumab
• Limitaciones
• Ineficaz si paraplejía o
cuadriplejía >24 horas
• No recomendada si
expectativa de vida <3 meses
• Mortalidad 0-13%
• Complicación severa
• Laminectomía: 0-10%
• Resección de cuerpo vertebral:
10-54%
Loblaw A. J Clin Oncol 23:2028-2037
White BD et al. NICE Guidance. BMJ 2008; 337:a2538
Harrison’s, 19th Ed
21. Loblaw A. J Clin Oncol 23:2028-2037
Estado a la presentación % ambulatorio
después de
radioterapia
IC 95%
Ambulatorio 92% 89% - 95%
Ambulatoria con asistencia 65% 56% - 74%
Paraparético 43% 38% - 48%
Parapléjico 14% 10% - 17%
22. Pericardial effusion/tamponade
Found in autopsy in 5-10% of cancer patients.
Causes
Lung cancer, breast cancer, leukemias and lymphomas
Non-tumoral differential diagnosis
Irradiation, drug-induced pericarditis, hypothyroidism, idiopathic pericarditis,
infection, autoimmun disease
Radiation pericarditis
Acute inflammatory, self-limiting, within month of irradiation. Chronic effussive pericarditis up to 20 years
post radiotherapy, with pericardial thickening.
Symptoms
Most patients are asymptomatic.
Dyspnea, cough, chest pain, orthopnea and weakness.
Signs
Pleural effusions, sinus tachycardia, jugular venous distention, hepatomegaly,
peripheral edema, and cyanosis.
Typical pericardial signs are less frequent in malignant pericardial disease (pulsus alterans, paradoxical
pulse, diminished heart sounds, and friction rub).
Echocardiography is the test of choice.
CT scan with irregular pericardial thickening and mediastinal lymph nodes
is highly suspicious of malignant pericardial effusion
Harrison’s, 19th Ed
23. Pericardial effusion/tamponade
Treatment options
Pericardiocentesis (with or withou sclerosing agents)
Percardial window
Complete pericardial stripping
Cardiac irradiation or
Chemotherapy
Acute cardiac tamponade (malignant pericardial effusion with hemodynamic
instability) requires IMMEDIATE drainage of fluid (ie, pericardiocentesis).
Recurrence after pericardiocentesis occurs in 20%
Sclerosing agents diminish the risk of recurrence.
Bedside pericardiotomy should be reserved to TV shows.
In about 10% of patients there is a paradoxical worsening of the hemodynamic
status post pericardial fluid drainage (“low cardiac output syndrome”).
Prognosis is dismal.
Pericardial effusion with malignant cells carries a poor prognosis with a 7
week median survival in cancer patients.
Harrison’s, 19th Ed
24. Intestinal obstruction
Treatment options
Palliative (non-surgical) care
Surgery (high mortality rate: 10-20%).
Laparoscopy (sometimes helps)
Stents: may palliate patients without major surgery.
Nasogastric decompression (mostly for advanced intra-abdominal malignancy).
“Venting” gastrostomy (palliates nausea and vomiting).
Medications: antiemetic agents, analgesics, antiespasmodic, steroides, octreotide
Harrison’s, 19th Ed
Intestinal obstruction
Single-site, good PS
Surgery/laparoscopy
Single-site, poor PS
Stent / medical
Multiple sites
Medical / palliative
My algorithm…
NG tube
CT abdomen
Surgical consultation
Electrolyte, fluid and drug evaluation
Surgery (Open) PalliationLaparoscopy GI stent
Aggressive nutrition Aggressive symptom control
25. Malignant biliary obstruction
Causes
Cancer arising in the pancreas, ampulla of Vater, bile duct, or liver or by metastatic
disease to the periductal lymph nodes or liver parenchyma (gastric, colon, breast or lung).
Non-oncologic causes
Found in 25%: narcotics, vinca alcaloids, adhesions.
Clinical findings
Jaundice, light colored stool, dark urine, priritus, and weight loss (due to malabsorption).
Pain and infections are UNCOMMON.
Imaging modalities
US, CT scan, ERCP, percutaneous transhepatic cholangiography, MRI
Treatment
Stent
Surgical bypass
RT (+/-) chemotherapy.
In the absence of pruritus, biliary obstruction may be a largely asymptomatic cause
of death.
Harrison’s, 19th Ed
26. Increased intracraneial pressure
25% of cancer patients die with CNS metastases.
Brain metastases may be the first evidence of cancer.
Causes
Lung, breast, melanoma.
Non-oncologic causes
Tretinoin pseutumor cerebri with increased intracranial pressure.
Clinical findings
Headache, nausea, vomiting, behavioral changes, seizures, and focal, progressive
neurologic changes. Hemorrhagic metastases may mimick a hemorrhagic stroke
(melanoma, GCT and RCC).
Papilledema, neck stiffness, herniation syndromes.
Imaging modalities
Cranial contrast-enhanced CT. If negative, Gadolinium-enhanced MRI.
Treatment
Dexamethasone.
Surgery
Whole brain radiotherapy
Gamma knife
Shunt placement (if hydrocephaly an issue).
Harrison’s, 19th Ed
27. Harrison’s, 19th Ed
Brain mets
Single-site, good PS, good
prognosis
Surgery* + Gamma knife
Few small mets
Gamma knife / WBRT
Widespread CNS mets or poor
prognosis
WBRT/Palliation
My algorithm…
Dexamethasone 6 mg IV q6h
Neurosurgical consultation
RT consultation
*Surgery preferred if cancer diagnosis not histologically proven
WBRT: Whole brain radiotherapy
Surgery PalliationStereotactic radiosurgery Whole-brain irradiation
28. Seizures
Approximately 10% of CNS metastases patients develop seizures.
Causes
Tumor, metabolic, radiation injury, cerebral infarctions, chemotherapy-related, infections.
Metastatic disease is the MOST frequent cause of seizures in cancer patients.
Primary brain tumors cause seizure MORE often than metastatic tumors.
Drug-related seizures are RARE but can occur (etoposide, busulfan, ifosfamide,
chlorambucil)
Site
Occipital, posterior-fossa and sellar tumors are less likely to seize.
Seizures are frequent in melanoma metastases, and LG brain tumors.
Reversible posterior leukoencephalopathy syndrome(RPLS)
Headache, altered consciousness, generalized seizures, visual disturbances,
hypertension, and posterior cerebral white matter vasogenic edema on CT/MRI.
RPLS is associated with: chemotherapy, antiangiogenic therapy, and transplantation.
Treatment
Phenytoin or Levetiracetam +/- valproic acid.
Prefer levetiracetam (500 mg q12h, up to 3000 mg/day) or topiramate for long-term
anticonvulsant therapy since they do not inducte cytochrome P450 as
phenytoin/valproate do.
Surgical or stereotactic radiosurgery may alleviate seizures in some patients.
Harrison’s, 19th Ed
29. Hemoptysis
Up to 20% of lung cancer patients have hemoptysis
Causes
Lung cancer, carcinoid tumors, breast cancer, colon cancer, kidney cancer and melanoma.
Massive hemoptysis: more than 200 mL/24h
All hemoptysis should be considered life-threatening.
Treatment
ICU is needed if respiratory distress.
Lateral decubitus with the bleeding site down + oxygen.
Consider ET-intubation if airway is/may-be compromised + emergency bronchoscopy.
CT angiography with bronchial artery embolization may be an option for the stable patient
Surgery may be effective as salvage therapy.
Pulmonary hemorrhage may occur after Apergillus spp. Infection in hematologic
malignancies with prolongued neutropenia.
Bevacizumab may cause life-threatning bleeding in cavitated, vascular abutting or
squamous-cell NSCLC patients.
Harrison’s, 19th Ed
30. Neutropenia Febril
• DEFINICIÓN
– Fiebre mayor de 38 grados centígrados durante 1
hora o más o fiebre mayor de 38.3 grados
centígrados en 1 ocasión.
– Recuento absoluto de granulocitos menor de
500/mm3 o recuento de leucocitos < 1000/mm3
cuando se espera que el recuento de granulocitos es
menor de 500/mm3.
31. Fisiopatología.
• Barreras mucosas.
• Defectos inmunes.
Día 1 Día 8 Día 15 Día 22
Inicio de ciclo de quimioterapia Inicio de ciclo de quimioterapia
ANC<500/mm3
Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the
infectious diseases society of america. Clin Infect Dis. 2011;52(4)
32. Riesgo de infección en pacientes con cáncer
Riesgo de infección / CATEGORÍA
DE RIESGO PARA NEUTROPENIA
FEBRIL
Ejemplos de enfermedad y terapia Profilaxis antimicrobiana
Baja / BAJA Quimioterapia estándar para la
mayoría de tumores sólidos.
Neutropenia esperada <7 días
Ninguna (excepto profilaxis viral en
pacientes con historia de episodio
por HSV)
Intermedia / Usualmente, ALTA Trasplante autólogo
Linfoma
Mieloma múltiple
Leucemia linfoide crónica
Terapia con análogos de purina
Neutropenia esperada de 7 a 10
días
Bacteriano: considerar
fluoroquinolonas.
Micótica: Considerar fluconazole
durante la neutropenia y con la
mucositis anticipada
Viral: Durante la neutropenia y al
menos 30 días después de
trasplanta autólogo
Alta / ALTA Trasplante alogénico
Inducción y consolidación de
leucemia aguda
Terapia con Alemtuzumab
GVHD tratada con altas dosis de
esteroides
Duración anticipada de la
neutropenia >10 días
Bacteriana: Considere
fluorquinolona.
Micótica: considere fluconazol,
amfotericina, voriconazol,
posaconazol
Viral: Durante la neutropenia y al
menos 30 días después de
trasplanta autólogo
NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
34. Score de Riesgo para Neutropenia Febril -
MASCC
Síntomas leves (o no) de enfermedad 5
Síntomas SEVEROS asociados a la enfermedad 3
No hipotensión 5
No EPOC 4
Tumor sólido / no infección micótica 4
No deshidratación 3
Inicio de la fiebre FUERA del hospital 3
Edad entre 16 y 60 años 2
Con un puntaje igual o mayor a 21 se considera que es de bajo riesgo
con un valor predictivo positivo de 91%,
especificidad de 68% y sensibilidad de 71%.
Klastersky J, Paesmans M, Rubenstein EJ et al. The Multinational Association for Supportive Care in Cancer Risk Index:
A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. J Clin Oncol
2000;18(16):3038-51.
35. Neutropenia febrilNeutropenia febril
Infección identificada Sin Factor de Riesgo Con factor de riesgo
InestableEstable
Imipenem +
Vancomicina
Cefepime*
Piperacilina/Tazobactam o
Ceftriaxona*
Rx apropiado
GNR: Gram Negativos resistentes / MRSA: Staphylococcus aureus resistentes a meticilina
* + Vancomicina si factor de riesgo para MRSA
Factores de riesgo
Para GNR: Hospitalización reciente; betalactámicos en los últimos 3 meses; historia de GNR
Para MRSA: Catéter; betalactámicos en los últimos 3 meses; historia de MRSA
Para Pseudomona: Intubación >72 horas; úlceras crónicas; pneumopatía crónicamente infectada
Mi enfoque
36. Neutropenia febril
… Adicionar
NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
Sitio o presentación Comentario Considerar (adición)
Senos paranasales CT / RM / ORL Vancomicina si edema periorbitario
Amfotericina si posible infección micótica
Dolor abdominal CT / Amilasa / AST / Bilirrubina Metronidazol (C. difficile)
Terapia para anaerobios
Dolor perirrectal Inspección / CT Cubrimiento para anaerobios
Cubrimiento para enterococo
Cuidado local
Diarrea C. Difficile Metronidazol oral o IV si se sospecha C. difficile
Catéter vascular Cultivo de cada puerto y del sitio
de inserción
Vancomicina inicial (o a las 48 horas si no hay mejoría con el
antibiótico empírico)
Considerar retirar el catheter
Infiltrados
pulmonares
Evaluación según riesgo Adicionar Azitromicina o Fluorquinolonas para cubrir bacterias
atípicas.
Vancomicina o Linezolid si sospecha de MRSA
Considerar terapia antimicótica si hay alto riesgo
Considerar TMP-SMX si Pneumocystis jiroveci posible
Síntomas urinarios Citoquímico de orina, urocultivo Según patógeno aislado
Sistema nervioso
central
LCR / CT o RM Antipseudomona que atraviese la BHE + vancomicina + ampicilina
Encefalitis: Altas dosis de aciclovir
37. Neutropenia febril
… Adicionar G-CSF
NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
Sólo en las siguientes situaciones clínicas
(categoría 2B):
Pneumonía
Infección micótica invasiva
Infección progresiva
38. Neutropenia febril
NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
Así haya una infección establecida, el
cubrimiento antibiótico de amplio espectro se
debe conservar en el paciente neutropénico
febril
39. Neutropenia febril
NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
Antibióticos
Evaluar respuesta 3-5 días
Mejoría de la curva térmica
Signos y síntomas de infección estables o mejorando
Paciente estable hemodinámicamente
No beneficio en el cambio de antibiótico por “fiebre”
dentro de los primeros 3-5 días
Continuar hasta
El esquema antibiótico inicial debe continuarse
mínimo hasta ANC >500/mcl
Otras variables deben ser tenidas en cuenta:
Velocidad de defervescencia
Sitio específico de infección (si lo hay)
Patógeno aislado
Enfermedad de base
40. NCCN® Practice Guidelines in Oncology – v.2.2009, www.nccn.org
Duración sugerida de la terapia antibiótica para infección documentada
Infección Duración sugerida (Días) Comentario
Piel / tejido blando 7-14
Bacteremia gram negativa 10-14
Bacteremia gram positiva 7-14
S. Aureus 14 Contados a partir del primer
cultivo negativo y
ecocardiografía negativa
Candida spp. 14 Contados a partir del primer
cultivo negativo
Sinusitis 10-21
Pneumonía bacteriana 10-21
Aspergillus spp. 90
HSV/VZV 7-10
Influenza 5
Considerar retirar el catéter de acceso venoso cuando hay infecciones en la corriente sanguínea de: Cancida, S.
aureus, Pseudomona aeruginosa, Corynebacterium jeikeium, Acinetobacter, Bacillus, micobacterias atípicas, levaduras,
hongos, enterococos resistentes a vancomicna y Stenotrophomonas maltophilla, flebitis séptica, infecciónes tuneladas
o infección del bolsillo del puerto
41. Tumor lysis syndrome (TLS)
Hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia caused by the
destruction of a large number of rapidly proliferating neoplastic cells.
Causes
Burkitt’s lymphoma, ALL, High-grade Lymphomas, chronic leukemias, and, rarely,
solid tumors. Fludarabine-treated CLL.
TLS has been described with the administration of glucocorticoids, letrozol, tamoxifen,
rituximab, or spontaneously.
TLS occurs during or shortly (1-5 days) after chemotherapy.
Harrison’s, 19th Ed
Rapid
cell
killing
High
serum
uric acid
Urinary
urate
obstruction
ARF
High
serum
P
Low
serum
Ca
NM/Cardiac
irritabilty/T
etany
High
serum
K
Ventricular
arrhythmias/s
udden death
Kidney calcium phosphate deposition
Lactic acidosis
Acidosis
Dehydration
Urinary uric acid crystals
Urinary uric acid higher than urinary creatinine
42. Sindrome de lisis tumoral
Coiffier B. J Clin Oncol 2008; 26:2767-2778
Cánceres asociados a SLT en adultos
Linfoma no Hodgkin 28%
Leucemia mieloide aguda 27%
Leucemia linfoide aguda 19%
Leucemia linfoide crónica 10%
Mieloma múltiple 3.9%
Enfermedad de Hodgkin 1.6%
Tumores sólidos 1%
43. Sindrome de lisis tumoral
Coiffier B. J Clin Oncol 2008; 26:2767-2778
Factores de riesgo para SLT
Tipo de tumor Linfoma de Burkitt
Linfoma linfoblástico
Linfoma difuso de células grandes
Leucemia linfoide aguda
Tumores sólidos (alta proliferación y respuesta
rápida a tratamiento)
Masa tumoral Enfermedad voluminosa (>10 cm)
Incremento LDH (> 2 x LSN)
Leucocitos > 25000/uL
Función renal Falla renal pre-existente
Oliguria
Ácido úrico basal >7.5 mg/dL
Terapia eficaz citorreductiva Variable
44. Sindrome de lisis tumoral
Coiffier B. J Clin Oncol 2008; 26:2767-2778
Estratificación de riesgo de SLT
Tipo de tumor Alto riesgo Riesgo Intermedio Bajo Riesgo
Linfoma No Hodgkin Burkitt, linfoblástico,
Leucemia linfoide
aguda
Linfoma difuso de
células grandes
Linfoma indolente
Leucemia linfoide
aguda
>100k/mm3 50-100k/mm3 <50k/mm3
Leucemia linfoide
aguda
>50k/mm3
Monoblástica
10-50k/mm3 <10k/mm3
Leucemia linfoide
crónica
10-100k/mm3
Fludarabina
Demás
46. Sindrome de lisis tumoral
Coiffier B. J Clin Oncol 2008; 26:2767-2778
Definición de laboartorio de SLT – Cairo-Bishop
Variable Valor Δ del basal
Ácido úrico > 8 mg/dL ↑ 25%
Potasio > 6 mg/L ↑ 25%
Fósforo > 1.45 mMol/L ↑ 25%
Calcio < 1.75 mMol/L ↓ 25%
NOTA: 2 o más cambios de laboratorio que dentro de 3 días antes o 7 días
después de quimioterapia citotóxica
47. Definición y gradación clínica del SLT – Criterios de Cairo-Bishop
Grado
Complicación 1 2 3 4 5
Creatinina <1.5 x LSN 1.5-3 x LSN 3-6 x LSN >6 x LSN Muerte
Arritmias No requiere
tratamiento
Tratamiento no
urgente
Sintomática o
requiere de
dispositivo
Con peligro
para la vida
Muerte
Convulsiones Ninguna Una
generalizada,
controlada con
anticonvulsivan
te; hasta varias
focales,
infrecuentes,
que no afecten
las actividades
diarias
Convulsiones
con alteración
de la
consciencia.
Convulsiones
pobremente
controladas.
Convulsiones
con pobre
respuesta al
tratamiento
Status
epilepticus,
convulsiones
de difícil
control -
prolongadas
Muerte
LSN: Límite superior de lo normal
Coiffier B. J Clin Oncol 2008; 26:2767-2778
48. Harrison’s, 19th Ed
TLS
If high serum uric acid (8) and
high creatinine (1.6)
IV hydration 3000 mL/m2/day
Urine pH above 7 with bicarbonate
Allopurinol 300 mg/m2/day
Monitor serum chemistry
Correct treatable renal conditions
Rasburicase 0.2 mg/kg/day
If high serum uric acid (8) and
high creatinine (1.6)
Delay chemo or chemo +
hemodialysis
If not high-serum uric acid (8) and not-
high creatinine (1.6), high urine pH (7)
Discontinue bicarbonate, start
chemotherapy
Begin hemodialysis if high serum potassium (6), serum uric acid (10), high
cratinine (10), high phosphate (10), sympotomatic hypocalcemia
Recombinant urate oxidase
May cause hypersensitivity: bronchospasm, hypoxemia, hypotension
Do not use in G6PD deficiency
Also discontinue bicarbonate if high Phosphate
49. Hipercalcemia asociada a malignidad
• Incidencia: 20 – 30%
• Más comunes
• Ca de mama
• Ca de pulmón.
• Mieloma múltiple.
• Mecanismos
- Metástasis líticas (20%).
- MM / Ca de mama.
- PTHrp (80%)
- No metastásicos / LNH / SCC.
- Calcitriol (1-25 diOHvitD)
- Linfoma Hodgkin.
Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005;352(4):373.
50. Hipercalcemia asociada a cáncer
Ca corregido(mg/dL) = Ca medido(mg/dL) + 0.8 (4 - Albúmina(gr/dL) )
Ca (mMol/L) = Ca sangre (mg/dL) * 0.25
Stewart AF. N Engl J Med 2005;352:373-9
Tipos de hipercalcemia asociada a cáncer
Tipo Frecuencia Metástasis
óseas
Agente
causal
Tipo de tumor
Hipercalcemia humoral
asociada a malignidad
80% Rara PTHrP Escamocelulares, renales,
ovario, endometrio, mama
Osteolítica 20% Universal Citokinas Mama, mieloma, linfoma
Vitamina D <1% Rara Vitamina D Linfoma
Hiperparatiroidismo
ectópico
<1% Variable PTH Variable
51. Diagnóstico.
Calcio sérico normal: 8.5 – 10.5 mg/dl.
Corregir con albúmina
Pseudohipercalcemia: deshidratación, mieloma múltiple
Calcio ionizado: Más específico.
EKG: Prolongación PR, QRS ancho, QT corto
Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005;352(4):373.
300 ms
52. Hipercalcemia asociada a
malignidad
• Calcio Corregido
– Leve: Calcio Corregido 3.1 – 3.2 mMol/L
• Anorexia, náuseas, pérdida de peso, debilidad, constipación
y alteraciones en el estado mental
– Moderada: Calcio Corregido 3.2-3.3 mMol/L
• Similar a la hipercalcemia leve con disfunción renal asociada
y depósito de calcio en los órganos y tejidos
– Severa: Calcio Corregido 3.3-3.4 mMol/L
• Náuseas y vómito severos, deshidratación, disfunción renal,
estado confusional severo con pérdida de la conciencia
– Potencialmente fatal: Calcio corregido > 3.4 mMol/L
• Coma, paro cardíaco
54. Major P, et al. J Clin Oncol 2001;19:558-567
Stewart AF. N Engl J Med 2005;352:373-9
Hipercalcemia asociada a cáncer
Medir calcio, albúmina, fósforo y creatinina
Establecer severidad
> 12 mg/dL (3 mMol/L)< 12 mg/dL + síntomas
SSN @ 100-150 mL/hora
Considerar furosemida
Corregir fosfato (si <3 mg/dL)
Ácido zoledrónico 4 mg IV – 15 min
Prednisolona: puede ser eficaz en linfoma y mieloma
Tratar la enfermedad de base
55. Human antibody infusion reactions
The initial infusion of Monoclonal Antibodies is associated with fever, chills, nausea,
asthenia and headache in up to half the patients.
Hypotension and bronchospasm occur in 1%, or less.
Severe AEs like ARDS, pulmonary infiltrates or cardiogenic shock are very rare.
Laboratory abnormalities
High LFTs, PT and thrombocytopenia.
Mechanism
Cytokine release syndrome (CRS) with activation of immune effector processes (cells,
complemente) mediated by TNFa, IFN gamma, IL6, IL10
Prevention
Acetaminofen, defenhydramine and cortisone.
Treatment
Stop the offending agent
Symptomatic treatment (steroid, anti H1 and antipyretic)
Reinitiate infusion at half the rate, when reaction subsides.
Hypersensitivity reactions to antineoplastic drugs
May occur with several antineoplastic agents, most notably, taxanes and platinum
compounds.
Prevention of infusional reaction is the cornerstone of pacltaxel-induced hypersensitivity
reaction. It is accomplished with antiH1, antiH2 and glucocorticosteroids administered
BEFORE paclitaxel infusion. Paclitaxel must be infused with a filter.
Desensitization should be considered in hypersensitivity type I with high IgE (ie,
Carboplatin).
Harrison’s, 19th Ed
56. Hemorrhagic cystitis
Caused by Cyclophosphamide or Ifosfamide (both are metabolized to acrolein, an irritant).
Late allogeneic BMT hemorrhagic cystitis may be related to polyoma virus BKV or adenovirus type-11.
Clinical symptoms
Gross hematuria, frequency, disuria, burning, urgency, incontinence, nocturia.
Prevention
High urine output with IV fluids
MESNA coadministration
Treatment
Urinary irrigation with formalin solution (0.37-0.74%) for 10 mins (N-Acetyl cysteine may
also be used).
Neutropenic enterocolitis (Typhlitis)
Inflammation and necrosis of the cecum and surrounding tissues that may complicate
therapy of acute leukemia (or any setting with prolongued neutropenia).
Clinical findings
RLQ abdominal pain, rebound tenderness, and a tense, distended abdomen in the setting
of fever and neutropenia.
Watery diarrhea with mucosal sloughing and bacteremia are common.
Images
CT scan shows instetinal-wall thickening (1+ cm), pneumatosis intestinalis.
Treatment
Wide-spectrum antibiotics (with C. difficile coverage), NG-tube, bowel rest. Avoid surgery
unless an abdominal catastrophe is diagnosed.
Harrison’s, 19th Ed
57. Further reading
• Oncologic emergencies: Harrison’s chapter 331 (pages 1787-1798).
• Infections in patients with cancer: Harrison’s chapter 104 (pages 490-
492)