CPHON: Oncology and Hematology Emergencies

TLS (tumor lysis syndrome)

metabolic emergency: breakdown of large amount of tumor cells release intracellular metabolite creating electrolyte imbalances

• high risk: ALL, AML, burkitt lymphoma, neuroblastoma

• tx: IVF, allopurinol/raspuricase, restrict potassium, weights and I/Os, frequent labs, assess for chvosteks/trousseaus signs

hyperleukocytosis

metabolic emergency: WBC is >100, most common in ALL, increased blood viscosity can result in stasis

• sx: HA, blurred vission, seizures, coma, tachypnea, hypoxia, SOB, infiltrates in CXR, AKI, increase K/uric acid

• tx: hydration, alkalized, allopuriol/raspuricase, if unstable - leukapheresis

DI (diabetes insipidus)

metabolic emergency: inability to concentrate urine can cause life threatening electrolyte imbalances, not enough ADH, neurogenic- pituitary gland, nephrogenic- kidneys don’t respond

• sx: thirst, polyuria, dehydration, hypernatremia (>145), low specific gravity (dilute urine vs concentrated blood), hypotension

• tx:

  • neurogenic- fluids, DDAVP, vasopressin

  • nephrogenic- low sodium diet (reduces amount of urine by kidneys) and fluids

SIADH (syndrome of inappropriate antidiuretic hormone)

metabolic emergency: overproduction of ADH leading to water retention and low sodium levels, hypervolemia- life threatening electrolyte imbalances

• sx: decreased UO, hyponatremia, high specific gravity (concentrated urine, dilute blood), N/V, muscle cramps

• tx: treat underlying disease, correct sodium (goal >130), diuretics, fluid restriction

effusions

vascular emergencies:

pleural: build up of fluid in lungs/chest cavity

• tx: diuretics, chemotherapy if d/t malignancy

pericardial: build up of fluid around heart

• tx: pericardiocentesis, open heart surgery

cardiac tamponade

vascular emergency: build up of fluid around the heart putting pressure and preventing from pumping well

• tx: quick removal of fluid- pericardiocentesis

SVC syndrome (superior vena cava)

vascular emergency: occurs from compression or obstruction of the SVC commonly caused by mediastinal mass

• sx: cough, dyspnea, horse voice/stridor, tachypnea, orthopnea, chest pain, arrest, edema face/arm, cyanosis, petechiae of head, pleural effusion, JVD

• tx: oxygen, positioning, tx mass (radiation/steroids), tx thrombosis (LMWH, catheter removal)

priapism

vascular emergency: prolonged erection >4 hrs, often occurs in SCD males as young as 3 yrs, sickling obstructs vessels of penis, painful/can lead to impotence

• tx: aggressive hydration, pain management, urologist surgery, exchange transfusion

VOD (veno-occlusive disease or SOS)

vascular emergency: damage to hepatic sinusoidal cells causing occlusion, congestion, and necrosis (venous outflow obstruction)- lead to liver/organ failure and death ~1-3 weeks post transplant

• risks: chemo (alkylating agents, platins, thiopurines), radiation

• sx: high bili, weight gain, painful hepatomegaly, increased abd girth

• tx: supportive- avoid further injury, hypotension, defibrotide, anti thrombotic meds, diuretics

VOC (vaso-occlusive crisis)

vascular emergency: in SCD, restricts blood flow and leads to sudden onset of pain (back, chest, and extremities), can lead to hypoxemia and tissue injury/death

• triggers: cold, infection, dehydration, stress

• tx: pain control, hydroxyurea

ACS (acute chest syndrome)

vascular emergency: complication of SCD causing rapid deterioration of resp function, most commonly caused by infection leading to pulm infarction

• sx: fever, cough, increased WOB

• tx: pain control, fluids, antibiotics, oxygen, IS/early mobility

stroke

vascular emergency: complication of SCD, presents with focal neuro deficits (hemiplegia most common), or HA, altered LOC, vomiting, seizures

• tx: etiology based, oxygen, tpa sometimes, IVF, exchange transfusions

thrombosis

vascular emergency: inappropriate formation of clot caused by stasis, endothelial damage or hypercoagulability

• risk: autoimmune disease, dehydration, immobility, malignancy, contraceptives, obesity, surgery, trauma

  • DVT- pain, tenderness, swelling, erythema

  • PE- hypoxia, dyspnea, cough, tachycardia

• tx: anticoagulation (heparin drip or oral anticoagulation long term), filter

splenic sequestration

vascular emergency: RBC becomes trapped and sickled in spleen for SCD

• sx: pallor, weakness, splenomegaly, tachycardia, reduced hgb and plt, high retic

• tx: hydration, transfusion, splenectomy (on PCN prophy and vaccines)

bowel obstruction

GI emergency: section of bowel or intestine becomes partially/totally blocked so stool can not pass- if untreated, can lead to perforation, infection, and death

• sx: pain, N/V, feels “full”, constipation

• tx: decompression, surgery, balloon dilation

typhlitis

GI emergency: inflammation of cecum, suspect when neutropenic pt fevers

• sx: RLQ abd pain, bloody diarrhea, N/V

• tx: await recovery of granulocytes, antibiotics, supportive care

perirectal abcess

GI emergency: deep infection that tracks along the rectum, may have severe rectal pain with no obvious signs

• when neutropenia resolves, can be seen

• tx: anitbiotics, surgical incision/drainage

hemorrhagic cystitis

GU emergency: sudden onset of hematuria and bladder pain d/t to damage to epithelium

• sx: dysuria, frequency, hematuria

• tx: IV hydration, mesna, irrigation

neutropenic fever

infectious emergency: neutrophil count <1000, most often caused by cancer treatment

• antibiotics, cultures/infection workup, GCSF

sepsis

infectious emergency: body’s response to extreme, life threatening infection

• risks: neutropenia, mucous membrane breaks, invasive devices, malnutrition,

• sx: fever, tachycardia, poor perfusion

• tx: early recognition, rapid fluid bolus/pressors (for shock), antibiotics

septic shock

infectious emergency: profound circulatory, cellular, and metabolic abnormalities causing decreased tissue perfusion, cellular hypoxia, organ failure, and possibly death

• sepsis with hypotension despite fluid rescucitation

increased ICP (intracranial pressure)

neurologic emergency: results from obstruction of CSF flow causing HA, lethargy, N/V, irritability, increased head size, bulging fontanels

• tx: remove cause- surgery, drain, radiation

seizures

neurologic emergency: partial/generalized affected area in brain

• risks: CNS tumor, metastasis, tumor location, scar tissue, necrosis, CNS infection, hyponatremia

• can cause status epilepticus (>5min), aspiration, injury

• tx: surgical resection, shunts, steroids, anticonvulsants

PRES (posterior reversible encephalopathy syndrome)

neurologic emergency: brain edema due to neurotoxicity, can be from allo BMT, organ transplant, autoimmune disease, or high dose chemo

• sx: HA, vision change, paresis, nausea, AMS, also possible seizures/coma

spinal cord compression

neurologic emergency: mass invades the vertebrae leading to compression/collapse, can be seen in almost all tumors- most often sarcoma mets and neuroblastoma, germ cell, lymphoma, and CNS tumor mets

• sx: weakness/sensory deficits, gait abnormalities/paraplegia, incontinence, back pain (at night/laying flat)

• tx: act fast, immediate relief- steroids, laminectomy, chemo/radiation

cytokine release syndrome

onc emergency: systemic inflammatory response triggered by infections or drugs (usually immunotherapy), needs prompt tx to prevent cardiopulm collapse and death

• sx: fever, fatigue, muscle/joint pain, N/V/D, rash, tachycardia, hypotension

• tx: mild- nsaids/antipyretics, moderate- oxygen/IVF/ antihypotensives, and severe- immunosuppressive agents/steroids

DIC (disseminated intravascular coagulation)

hem emergency: consumption of platelet and plasma clotting factors, has decreased plts, increased PT and decreased fibrinogen which can result in tissue ischemia

• risks: malignancy, infection, trauma

• sx: plts<20, hypotension, petechiae, uncontrolled bleeding

• tx: find underlying cause, symptom management, replacement (FFP/blood/plts)

anaphylaxis

hypersensitivity emergency: immediate reaction to foreign substance, occurs in seconds to minutes can be life threatening (more rapid= more severe)

• risk: IV chemo, antibiotics, meds, contrast

extravasation

exposure emergency: leakage of vesicant into extravascular space that can cause tissue injury/necrosis, needs CVC admin

• tx: observe for swelling/redness, antidotes, heat/cold depending on drug, SLAPP

SLAPP

stop infusion

leave needle

aspirate

pull needle

provider notify