Oncology EmergenciesPresenting to the Non-Specialist

Dr Mike RickardsConsultant Emergency Medicine

Northumbria Healthcare Trust

• Neutropenic sepsis• Malignant spinal cord compression• Supra vena cava obstruction• Pleural effusion• Cerebral metastases• Nausea and vomiting• Hypercalcaemia• Diarrhoea

Most Likely to present to an Emergency Department

Most frequent life threatening emergency you will encounter in cancer patients

Definition: neutrophil count <1.0 x 109 per L Aim for a ‘door to antibiotic’ time of 1 hour

Neutropenic sepsis

• Be suspicious in any patient receiving active treatment or with a haematological malignancy

• Patients may not show classic signs of infection, don’t be falsely reassured

• Don’t wait for FBC or other result before giving broad spectrum antibiotics in a patient with clinical signs of infection

• Follow the trusts antibiotic and sepsis guidelines

Neutropenic Sepsis

True neurological emergency that can develop in up to 10% of cancer patients

Can lead to partial or complete paralysis Both the RVI and James Cook have a Spinal Cord

Compression Co-ordinator If you are suspicious of MSCC contact them at an early

stage

Metastatic spinal cord compression

Back pain present in 95% of cases, usually presenting symptom

Limb weakness Tingling or numbness Bladder/bowel function problems Altered perception of hot and cold Can be very vague and non-specific!

SCC Symptoms

Level of Compression

Cervical spine 10%

Thoracic spine 70%

Lumbar spine 20%

Direct compression of the spinal cord or cauda equina by tumour in a vertebral body or paravertebral spaces 75-85%

Collapse of a vertebral body infiltrated by tumour 75-85%

Direct invaion of the epidural space with no bony destruction 10-15%

Primary tumours of the spinal cord

Underlying pathology

Manage patient lying flat on their back until the diagnosis is confirmed or excluded.

Diagnosis requires whole spine MRI. Where this happens will depend on MRI facilities (see following flow chart)

Contact SCC Co-ordinator once diagnosis suspected Consider thromboprophylaxis and discuss the need for

steroids with SSC Co-ordinator

Management

Patients who may present: Lung cancer (bronchogenic) – 82% Lymphoma Metastatic carcinoma

Superior Vena Cava Syndrome(inc obstruction)

Presenting Symptoms

External compression by extrinsic mass/tumour or lymph node enlargement

Intravascular obstruction by tumour or thrombosis Intraluminal reaction to tumour invasion or inflammation

Underlying pathology

Presenting symptoms with rationale

Early symptoms:Dyspnoea, orthopnoea, facialoedema, upper thoracic engorgement

Physical findings:Distended veins neck, scalp, ant post chest and shoulders

• Respiratory compromise

• Oedema of the upper extremeties

• Increased jugular venous pressure

• Dilatation and prominence of the collateral veins in neck and thorax

Presenting symptoms

Advanced Disease

• Hoarseness• Stridor• Engorged conjunctiva• Symptoms of RICP• Respiratory distress• Seizures

• Decreased cerebral perfusion• Hypoxia• Headache• Visual disturbance• Laryngeal & cerebral oedema

Severity of symptoms relates to the rate of degree of obstruction and the development of compensatory collateral drainage

Symptoms often made worse by lying flat or bending forward

SVCO

Maintain airway patency-sit patient forwards and give oxygen

Monitor fluid and electrolytes Monitor vital signs including GCS Avoid venous access in affected upper extremity

Immediate management

FBC, U&Es, LFTs, clotting CXR Contrast CT scan

Depending on results: MRI Arm venogram

Investigations

Pharmacological:Includes: steroids, diuretics, thrombolyitcs

Surgery: stenting of SVC Radiotherapy Chemotherapy

Management

The abnormal collection of fluid in the pleural space as the result of both overproduction and under absorption of fluid

Pleural effusion

Pleural effusion

Dyspnoea Chest pain – pleuritic Chest pain – dull ache Cough Anxiety Malaise Weight loss

Pleural effusionPresenting symptoms

Vital signs Oxygen if required Sit patient up, consider sitting in a chair Pain relief if appropriate Therapeutic thoracentises (urgency will depend on patients

symptoms)

Initial management

Chest drain insertion Pleurodesis Thoracoscopy with talc poudrage Pleuroperitoneal shunt Tunneled ICD and intermittent drainage.

Ongoing management

Cerebral metastases are ten times more common than primary tumours

Raised intracranial pressure once compensating mechanisms fail.

Brain metastases and raised intracranial pressure

Presenting symptoms

Headache 24% Hemiparesis 20% Cognitive disturbance 14% Seizures 12% Ataxia 7%

Nausea Vomiting Change in conscious level Change in personality Dysphagia

Basic pathology investigations CT head with contrast

Investigation

Seizures: Lorazepam/Diazepam Intracranial hypertension: Steroids/Mannitol Intracranial tumour: Radiotherapy/surgery

Treatment

Cancer patients receiving: Chemotherapy patients Radiotherapy treatment-especially to the

brain, liver and GI tract

Cancer patients with: Advanced disease (40-70%) Terminal disease (30-60%)

Patients presenting with nausea and vomiting

Criteria for grading severity of nausea and vomiting

  Grade 1  Grade 2  Grade 3  Grade 4  Grade 5 

Nausea Loss of appetite without alteration in eating habits

Oral intake decreased without significant weight loss, dehydration, or malnutrition; IV fluids indicated <24 h

Inadequate oral caloric or fluid intake; IV fluids, tube feedings, or TPN indicated ≥24 h

Life-threatening consequences

Death

Vomiting 1 episode in 24 h

2–5 episodes in 24 h; IV fluids indicated <24 h

≥6 episodes in 24 h; IV fluids, or TPN indicated ≥24 h

Life-threatening consequences

Death

Adapted from Cancer Therapy Evaluation Program, NCI 2006

May be related to current treatment Think about other causes:

Bowel obstruction Constipation Gastritis Infection Electrolyte imbalance

Nausea & Vomiting - Causes

Nausea & Vomiting - Management

Dopamine antagonists

e.g. Prochloperazine

Prokinetics

e.g. Metoclopramide

Domperidone

Serotonin antagonistse.g. Granisetron

Ondansetron

Antihistamines e.g. Cyclizine

Antiemetic Management

Anti-spasmodic / Antisecretory Bowel obstruction Intractable vomiting

Example Octreotide

Somatostatin analogue Hyoscine-n-

butylbromide A Ch (muscarinic)

antagonist

Anti-Inflammatory Raised ICP Chemotherapy (+/- 5HT3

antagonist) Bowel obstruction

Example Dexamethasone

Corticosteroid Acts on GI tract and

cerebral cortex

Cause Therapy Brain metastasis Radiation therapy

Hypercalcemia Bisphosphonates

Hyponateremia (SIADH) Demeclocycline

Abdominal Ascites Paracentesis

Medication Substitute, discontinue or reintroduce (in the case of withdrawal reaction)

Gastritis Discontinue the irritant drug or add proton pump inhibitor

Infection Antibiotic therapy

Bowel obstruction Gastric venting tube, disimpaction

Ongoing Management

‘Occurs when plasma calcium level rise above normal parameters’. Serum [ Ca++ > 3.0 mM].

Hypercalcaemia

Hypercalcaemia

Diagnosis is made on an estimate of corrected serum calcium

Corrected calcium = total calcium + 0.02 (40 – serum albumin)

Usual range 2.1 - 2.6 mmol/L Levels above 3.4 mmol/L are life threatening Asymptomatic if serum level is below 3.2 mmol/L

• Neurological- Impaired concentration- Confusion - Disturbing nightmares- Depression- Psychosis- Stupor - Decreased deep tendon reflexes- Coma

due to the direct depressant effect on the transmission of nerve impulse

elevated calcium causesdecrease in neuromuscular response to stimulation, causing hypotonicity of smooth and striated muscle

• Musculoskeletal - Muscle weakness- Lethargy- Bone pain- Fatigue- Ataxia

Presenting symptoms

• Gastrointestinal- Delayed gastric emptying

- Nausea

- Vomiting

- Constipation

- Anorexia

Due to the depressive effects on the autonomic nervous system → hypotonicity of smooth muscle in the GI tract.

It depresses the electrical conduction system of the heart → increased cardiac muscle contractility and irritability.

•Cardiac- Early = Raised HR & BP- Late = decreased HR & ECG. Abnormalities can lead to asystole. (ECG may show QT interval shortening and PR interval prolongation)

Presenting symptoms

• Renal- Polyuria - Polydipsia- Dehydration- Nocturia- Renal failure

• It is toxic to the renal tubules• Impairs the ability of the kidneys to

concentrate urine → polydipsia, polyuria, nocturia.

• Prolonged hypercalcemia may cause Ca+ to be deposited in soft tissue especially when associated with hyperphosphatemia → renal failure

Presenting symptoms

Hydration (1st step) if Calcium >3.0 mmol/L or symptomatic • IV access • IV saline infusion of 4-6 litres over 24hrs• Monitor input and output of fluids• Monitor electrolyte levels during hydration• Administer antiemetics

Immediate management

Give Bisphosphonates• Analogues of pyrophosphate.• Inhibit bone resorption by osteoclasts.• No effect on renal tubular absorption of Ca++. • Zometa is the most potent and simplest to give (4mg iv over

15 minutes in the day treatment unit) and is most commonly used.

Presenting symptoms

NCI Grading of Diarrhoea for Patients

Grading 0 1 2 3 4

Frequency of Stool

(Patients with and without

colostomy)

Normal Increase of < 4 stools/day over pre-treatment;

mild increase in ostomy output compared to

baseline

Increase of 4-6 stools/day or

nocturnal stools; increase in

ostomy output compared to

baseline

Increase of ≥ 7 stools/day; severe increase in ostomy

output

> 10 stools/day

Symptoms None None Moderate cramping, not interfering with normal activity

Severe cramping and incontinence,

interfering with daily activities

Grossly bloody and need for parenteral

support.

Life-threatening consequences (e.g.

haemodynamic collapse)

Diarrhoea

Patients at risk

Cancer Patients

Patient receiving Chemotherapy in particular 5FU, Capecitabine, Irinotecan, methotrexate.

Patients receiving radiotherapy to pelvic organs for Cervical, uterine, bladder or prostate cancers

Immediate management

FBC, U&E’s to assess hydration status/neutropenia If neutropenic with diarrhoea Grade 3 need admission,

with treatment for neutropenia as well If on oral chemotherapy, seek advice re discontinuation

Management

Loperamide 4mg stat Loperamide 2mg every 4 hrs until diarrhoea stops Patient needs re-assessment 12-24hours later

Grades I and II

Management

Admit to hospital Physical examination Stool sample – if positive commence antibiotics If neutropenic should commence broad-spectrum

antibiotics Replace fluid and electrolytes Give Loperamide 4mg stat then 2mg every 2 hrs (max

16mg/24 hrs) If non-responsive to Loperamide, start Octreotide

300microgram s/c infusion

Grades III and IV

Ongoing management

Chemotherapy must be deferred until diarrhoea resolved. Chemotherapy team should be made aware as dose adjustments may be required

Give advice on dietary modification Review stool culture results

Any Questions?

Start with the basics: ABCs O2, fluids, antibiotics

Ask the patient/family for any information they have been given

Contact the on call Oncologist/Haematologist for assistance

Don’t forget problems not related to the malignancy

Summary