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Oncological Emergencies

Febrile Neutropenic patients

These pts can get ill v quickly in hours.

Diagnosis

Assume neutropenic sepsis if:
  1. Have received chemo in last 4m, or
  2. Acute haematological malignancy eg AML, ALL or
  3. Neutrophil count ≤0.5×10^9 /l (normally 1.8 - 7) or
  4. Temp > 38 or
  5. Any of above and signs of clinical deterioration, such as: shock (BP<90), HR>100, raised RR, respiratory distress, hypoxia or
  6. Multiple organ failure

Treatment

  1. Tazocin (IV) + Gentamicin for a minimum of 5d and 24h afebrile
  2. Consult microbiologist
  3. Deterioration: change to imipenem

Spinal Cord Compression

Causes

Extradural mets typically

Clinical

Back pain with root distribution, weakness, sensory loss, bowel and bladder dysfunction

Investigation

Urgent MRI of whole spine

Treatment

Dexamethasone. Discuss with neurosurgeon or clinical oncologist immediately.

SVC obstruction with airway compromise

Causes

Lung Ca mainly. Rarer: mediastinal enlargement (eg. GCT), ↑LNs, thymus malignancy, thrombotic disorders (eg Behcets), thrombus around IV central line, hamartoma.

Signs/Symptoms

Dyspnoea, orthopnoea, swollen face and arms, cough, plethora/cyanosis, headache, engorged Veins
Pemberton's test
: lifting the arms over the head for >1m gives facial plethora/cyanosis, raised JVP, inspiratory stridor

Investigation

Sputum cytology, CXR, CT, venography

Treatment

Tissue diagnosis soon if undiagnosed. Dexamethasone. Consider balloon venography and SVC stenting. Radiotherapy.

Hypercalcaemia

10-29% of those with cancer, especially myeloma

Aetiology

Lytic bone mets, production of osteoclast activating factor

Symptoms

Lethergy, anorexia, nausea, polydipsia, polyuria, constipation, dehydration, confusion, weakness

Treatment

Rehydrate w IV saline over 24h. Avoid diuretics. Bisphosphonates IV.

Raised Intracranial Pressure

Due to primary or secondary

Clinical

Headache (classically worse in morning), nausea/vomiting, papilloedema, fits, focal neuro signs

Investigation

Urgent CT: expanding mass, cystic degeneration, haemorrhage, oedema, hydrocephalus

Treatment

Dexamethasone, radiotherapy, surgery if approp

Tumour Lysis syndrome

Rapid cell death on starting chemo for rapidly proliferating leukaemia, lymphoma, myeloma, and some GCTs can cause hyperkalaemia, hyperphosphatataemia and renal failure

Prevention

Hydration, allopurinol 24h before chemo. Haemodialysis may be needed in renal failure.
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