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Oncologic Emergencies
Melissa Davis, MSN, APRN, AOCNP
Objectives
For each oncologic emergency, review:• Definition• Signs and symptoms• Risk factors• Diagnostics•Management
Metabolic Emergencies:
• Disseminated intravascular coagulation (DIC)
• Sepsis• Tumor Lysis Syndrome (TLS)• Hypercalcemia• Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
• Anaphylaxis
Structural Emergencies:
• Increased intracranial pressure (ICP)
• Spinal cord compression (SCC)
• Superior vena cava syndrome (SVCS)
• Cardiac tamponade
Metabolic Emergencies
• Disseminated intravascular coagulation (DIC)• Sepsis• Tumor Lysis Syndrome (TLS)• Hypercalcemia• Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
• Anaphylaxis
Disseminated Intravascular Coagulation (DIC)
• Definition: Inappropriate, accelerated and systemic activation of the coagulation cascade. Results in thrombosis and subsequent bleeding and hemorrhage
• Simultaneous clotting and bleeding
DIC Signs and Symptomsclotting and bleeding
• Skin: Bleeding• GI: Tarry stools, hematemesis, abd distention/pain• GU: Hematuria, decreased UOP• Resp: Dyspnea, tachypnea, hypoxia, hemoptysis, cyanosis, SOB
• Neuro: HA, restlessness, confusion, lethargy, altered LOC, obtundation, seizures, coma
• CV: Tachycardia, hypotension, decreased peripheral pulses, change in color and temp of extremities
Diagnostics: Labs• Increased: D‐dimer assay, FDP titer • Decreased: Platelet count, fibrinogen• Prolonged: PT/PTT
• Infection and sepsis (most common cause)• Malignancy (especially acute promyelocytic leukemia)• Trauma• Pregnancy
DIC Risk Factors
Management of DIC
1. Treat underlying condition (chemo, antibiotics)2. Hemodynamic support (fluids, oxygen)3. Blood component therapy
Nursing Considerations• Monitor bleeding, I/O, assess tissue perfusion• Apply pressure dressings to sites of active bleeding
Sepsis
• Definition: Systemic inflammatory response to pathogenic microorganisms and associated endotoxins in the blood.
• Presents with 2 or more of the following:• Temp > 38 or <36 Celsius • HR >90 beats/min• RR >20 breaths/min• WBC >12k or less than 4K, or >10% bands
• Septic shock hemodynamic instability despite aggressive fluid challenge
Sepsis• Risk factors: Immunosuppression, comorbidities, age >65 yo, lines and tubes, hospitalization, invasive procedures, loss of mucosal integrity
• Organisms: Most often bacterial (40% gram neg)
• Prognosis: Untreated bacteremia with associated neutropenia and septic shock is associated with 50‐70% mortality rate
Sepsis Signs and Symptoms
• Constitutional: Fever, shaking chills• Neuro: Confused, anxious, restless, decreased LOC• Resp: Cough, tachypnea, dyspnea, ARDS• CV: Tachycardia, hypotension• GI: N/V/D/C, anorexia• GU: Decreased UOP progressing to anuria and ARF• Skin: Warm, flushed then cool, clammy
Management of Sepsis
1. Labs: Blood cultures, CBC, CMP2. Chest x‐ray3. UA and urine culture4. Cultures of other potential sources of infection:
throat, stool, sites of exudate5. Treat infection‐ start with broad spectrum ABX6. Hemodynamic support: Fluids, blood components,
vasopressors, O2
Tumor Lysis Syndrome
• Definition: Metabolic imbalance caused by the rapid release of intracellular potassium, phosphorus, and nucleic acid into the blood. Occurs as a result of rapid tumor cell kill.
• Electrolyte abnormalities place pt at risk for cardiac arrhythmias and renal failure.
Labs
• Elevated: Uric acid, potassium, phos, LDH, BUN/Cr• Decreased: Calcium
• High growth fraction and large bulky tumors• Leukemia, lymphoma, small cell lung ca• Large tumor burden: LAD, splenomegaly, incr LDH
• Concurrent renal or cardiac disease
TLS Risk Factors
Tumor Lysis Signs and Symptoms
• Hyperkalemia: Sx generally when >6.5 • EKG changes, N/V/D, muscle weakness
• Hyperphosphatemia• Edema, oliguria, renal insufficiency, ARF
• Hyperuricemia: Sx generally when >10• Oliguria, azotemia, edema, uric acid nephropathy, N/V/D, pruritis, hematuria, lethargy, seizure
• Hypocalcemia• EKG changes, hypotension, muscle cramps, twitching, paresthesias, diarrhea, seizures, tetany, AMS
Management of Tumor Lysis
• IV Hydration with UOP of 150‐200 mL/hr• Allopurinol or rasburicase• Forced diuresis: loop diuretics• Hyperkalemia:
• Mild (<6.5): Na Polystyrene Sulfonate (Kayexalate)• Severe (>6.5 +/‐ EKG change): Ca gluconate, glucose + insulin
• Dialysis
Hypercalcemia
Etiology• Bone destruction from tumor invasion• Tumors secrete hormones and/or cytokines that act locally or systemically to induce bone resorption
Hypercalcemia Signs and Symptoms
• Early: Confusion, lethargy, weakness, hypotonia, constipation, N/V, polyuria, dehydration
• Late: Seizure, obtundation, coma, obstipation/ileus, renal failure
• Monitor electrolytes, albumin, renal function• If concern for bony involvement of disease, check
phosphorus and alkaline phosphatase• Check EKG
Labs
• Breast, lung, head & neck and renal cancer, MM, lymphoma
Hypercalcemia Risk Factors
Management of HypercalcemiaMild/Asymptomatic
• PO fluids
Mod/Severe (Ca >12 mg/dL)• Vigorous IV hydration +/‐ furosemide• Anti‐resorptive therapy: bisphosphonates +/‐ calcitonin (nasal)
Non‐pharmacologic• Exercise, weight‐bearing activity• Active or passive ROM for bedridden patients• Seizure precautions if calcium >12 mg/dl
*** Treat the cancer: chemo or radiation for metastatic tumors ***
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
• Definition: Endocrine paraneoplasticsyndrome which results in inappropriate production and release of antidiuretic hormone (ADH), leading to impaired renal (free‐water) excretion.
• Results in dilutional serum hyponatremia, high urine osmolality, intracellular edema
• Complications: neuro sx, cerebral edema
SIADH Signs and Symptoms
Mild (Na 125‐134 mEq/L): Generally asymptomatic. May experience nausea, anorexia,
malaise, fatigue, weakness, muscle cramps
Moderate (Na 115‐125 mEq/L): Thirst, HA, confusion, vomiting,
lethargy, weight gain, combativeness, psychosis
Severe (Na <115 mEq/L): Delirium, obtundation, refractory
seizures, coma and death
• Most symptomatic if Na <115 mEq/L or if hyponatremiaoccurs in <48 hrs
• Symptoms are related to cerebral edema
• Decreased: Serum sodium and osmolality• Increased: Urine sodium, osmolality, specific gravity
SIADH Labs
SIADH Risk Factors• ***Small cell lung cancer*** (also seen in NSCLC, head & neck)• Infections (PNA, TB, abscess)• Chemotherapy (especially high dose cyclophosphamide)• Medications (narcotics, anesthesia, diuretics, NSAID, TCA, SSRI)• CNS (meningitis, intracranial hemorrhage, head trauma)• Pain, stress
Management of SIADHTreat the underlying cause and correct hyponatremia
• Mild (Na 125‐134 mEq/L): Fluid restriction of 500 to 1000 mL/day. Corrects over 3 to 5 days.
• Mod (Na 115‐124 mEq/L): Demeclocycline if fluid restriction cannot be maintained or hyponatremia persists. Onset in 3 to 5 days. Severe (Na <115 mEq/L) : Hypertonic (3% to 5%) saline +/‐ concurrent lasix. Vasopressin antagonists: Tolvaptan, Conivaptan
Anaphylaxis• Definition: Immediate, systemic hypersensitivity reaction which usually occurs within seconds to minutes after the administration of a foreign protein.
• Mediated by IgE• Can result in respiratory failure, cardiovascular collapse, and possibly death.
• High risk agents: Taxanes, platinums,asparaginase, epipodophyllotoxins, rituximab
Testing for Anaphylaxis• Intradermal skin test for agents with a high suspicion for hypersensitivity reactions (ie asparaginase)
• Test dose of agents (ie 1/10th of dose) if prior history of allergy with drug exposure
Preventionof Anaphylaxis• Premedication: acetaminophen, H1 blocker (diphenhydramine), H2 blocker (famotidine), corticosteroids
Signs and Symptoms of Anaphylaxis
• Urticaria, pruritis, angioedema• Dyspnea, wheezing• Dizziness• Hypotension, tachycardia, shock• Nausea, vomiting• Abdominal pain• Flushing• Headache• Chest tightness, substernal chest pain• Feeling of “impending doom”
Management of Anaphylaxis
• Stop offending agent• ABCs: Airway, breathing , circulation• IVF• Anaphylaxis meds:
• Epinephrine 1:1000 (if angioedema, hypotension)• Diphenhydramine• Corticosteroids• H2 antagonist (famotidine)• Beta‐2 agonist/Inhaled bronchodilator (albuterol)• Vasopressors (if hypotension)• Antiarrhythmia meds
Structural Emergencies
• Increased intracranial pressure (ICP)• Spinal cord compression (SCC)• Superior vena cava syndrome (SVCS)• Cardiac tamponade
Increased Intracranial Pressure (ICP)
Primary/metastatic tumors or bleeding within intracranial cavity
Displace brain tissue, cause edema of brain tissue, obstruct CSF flow and/or cause increased vascularity (from
tumor growth)
Increases intracranial pressure, which can result in nerve cell damage and death.
Signs and Symptoms of Increased ICPEarly Signs:• HA, especially early morning• Changes in vision: blurred
vision, diplopia, decreased visual fields
• Changes in LOC: lethargic, confused, restless
• GI: anorexia, nausea, vomiting
Late Signs:• CV: Bradycardia• Resp: Slow, shallow
respirations, tachypnea• Neuro: Decreased LOC,
hemiparesis, seizures, pupillary changes, papilledema
• Very late= Cushing’s triad: HTN, bradycardia, abnormal respirations
Diagnostic Tests• Head CT‐ quick, often first test• Brain MRI• Cerebral angiography (vascular abn vs tumor)• CT‐guided or MRI‐directed stereotactic bx
Risk Factors for Increased ICP• Tumors that are more likely to metastasize to the brain: Lung, breast, testes, thyroid, stomach or kidney, melanoma
• Primary tumor of brain or spinal cord• Leukemia• Thrombocytopenia
Management of Increased ICPNonpharmacologic:• Emergent surgery • Shunt placement• Hyperventilation (ICU)• Radiation therapy
Pharmacologic:• Chemotherapy• Corticosteroids• Osmotherapy (mannitol)• Anticonvulsants, if needed
Nursing Considerations:• Maintain bed rest, avoid prone position, elevate HOB 30 degrees• Avoid isometric muscle contractions and neck flexion/extension • Avoid Valsalva’s maneuver• Manage N/V
Spinal Cord Compression (SCC)
Neurologic emergency when primary tumors or vertebral metastases compress neural tissue and its blood supply, resulting in compromised neurologic
function. Requires emergent treatment.
Signs and Symptoms of SCC
• Early: • Neck or back pain (96%): local and/or radicular• Motor symptoms: heaviness, stiffness, weakness• Sensory loss for light touch, pain or temp
• Late: • Sensory loss for deep pressure, vibrations, position• Incontinence or retention of urine/stool• Sexual impotence• Paralysis• Muscle atrophy
Risk Factors for SCC:• Cancers that metastasize to bone: breast, lung, prostate,
renal, melanoma, myeloma• Cancers that metastasize to the spinal cord: lymphoma,
seminoma, neuroblastoma• Primary cancer of the spinal cord
Diagnostic Tests:• MRI: diagnostic procedure of choice for evaluating SCC• Spinal x‐ray, bone scan, CT and/or myelogram may be used to help evaluate metastasis, bone abn, and bone stability
Management of SCC• Radiation: Most common treatment• Surgery: If tumor not responsive to RT or if max radiation dose
already achieved• Surgery followed by radiation• Corticosteroids: Reduce edema, pain• Chemotherapy (adjunct to RT and/or surgery)• Analgesics/pain management
Nursing Considerations• Neuro checks q8hrs, strict I/O, monitor for urinary retention• Request PT/OT consult• Pain management, bowel and bladder program
Superior Vena Cava Syndrome (SVCS)
• Obstruction of the superior vena cava, resulting in compromised venous drainage of the head, neck, upper extremities and thorax
• Caused by tumor invasion, enlarged lymph nodes, thrombus
www.aboutcancer.com
Signs and Symptoms of SVCS:Symptoms can develop slowly or acutely. Slow
progression allows for the development of collateral bloodEarly s/sx Late s/sx
• Facial swelling on arising• Periorbital edema• Swelling & erythema of arms,
face, neck, hands• Cyanosis of upper torso• ***Dyspnea***, dry cough• Hoarseness• Prominent venous pattern
(dilated veins of face, neck, thorax)
• Severe HA• Irritability• Visual disturbances, blurred
vision• Dizziness, syncope• Changes in mental status• Stridor• Tachycardia• CHF• Decreased BP• Horner’s Syndrome• Dysphagia• Hemoptysis
Diagnostic Tests• CXR‐ often initial evaluation• Chest CT (with contrast)‐ most useful diagnostic information• MRI very sensitive, but pt generally unable to tolerate supine
position
Risk Factors for SVCS• Lymphoma involving the mediastinum; lung cancer; metastatic breast or germ cell cancer
• Kaposi’s sarcoma• Presence of central venous catheter (CVC)• Previous RT to the mediastinum
Management of SVCS:Treat underlying cause
• Radiation• Pharmacologic management:
• Chemotherapy (+/‐ RT)• Remove CVC and anticoagulate if catheter‐induced• Corticosteroids, diuretics (controversial)
• Surgical management: Stent placement, surgical reconstruction• Symptom management: Oxygen therapy
• Avoid venipuncture/measurement of BP in upper extremities; Remove rings and restrictive clothing; Elevate HOB; Avoid Valsalva
Nursing Considerations
Cardiac Tamponade
• Excess accumulation of fluid in the pericardial sac, resulting in decreased cardiac output and compromised cardiac function
Signs and Symptoms of Cardiac Tamponade
Early• Retrosternal chest pain
– Worse when supine– Relieved by leaning forward
• Dyspnea• Cough• Muffled heart sounds, weak
apical pulse
Late• Tachycardic, tachypneic
hypotensive• Pulsus paradoxus• Narrow pulse pressure• Altered mental status• Peripheral edema• Oliguria• Beck’s triad
Risk Factors for Cardiac Tamponade• Primary tumor of the heart (rare)• Metastatic tumors to the pericardium (lung, breast, GI tract,
leukemia, lymphoma, sarcoma, melanoma)• Radiation to field which includes heart
Diagnostic Tests• Echocardiogram (ECHO)‐ most precise diagnostic test• Chest x‐ray or CT may show pericardial effusion, masses, enlarged pericardium. Limited diagnostic ability
• EKG with non‐specific abnormalities
Management of Cardiac Tamponade• Remove fluid: pericardiocentesis, pericardial window• Pericardial sclerosis• Radiation• Chemotherapy
Nursing Considerations• Oxygen, elevate HOB, manage pain• Monitor BP, HR, respiratory status, volume status, mental status
Thank you!
Questions?