Okay, so cancer is a broad, difficult topic that I will never be able to cover in one blog post. But we just had a very informative lecture by our very own, behind enemy lines, EM/IM master: the He-Gore. So I’ll touch on a few of the possible cancer related emergencies that he helpfully walked us through.
Don’t miss the neutropenia (ANC <500) , don’t miss the fever (T> 38C) .
BUT! Unlike your Step studies convinced you – not everyone needs to be admitted with broad spectrum IV abx. Use CISNE or MASCC to decide if the patient is low enough risk to avoid the hospital stay. (Be careful: a low score on CISNE means low risk, and a high score on MASCC means low risk.)
Either way: always talk to their oncologist. They know the patient and their likelihood of follow up way better than you or I. If together you decide that they can go home, still give them oral antibiotics. Start with a floroquinolone and Augmentin. Be sure to cover Pseudomonas, and those grams ( both pos and neg.)
Inpatient abx coverage gets a little more complicated; unlike our typical scary infection admits, we don’t automatically add Vanc on these patients! <Insert pleasantly surprised face> Start with Cefepime instead. Add Vanc if there are clinical signs of line infection, evidence of PNA on XRay OR they have a hx of MRSA positive blood cultures on previous micro. Otherwise skip the vanc and keep the line. Remember to draw blood cultures (at Rush we do at one from their line, one from another site) before starting abx. (Fun fact for those of us who venture upstairs: If these BCx return positive for staph- by all means add the Vanc, and pull that line no matter what it looks like clinically! )
Tumor Lysis Syndrome
Second up is the sneaky fella Tumor Lysis Syndrome.This is exactly what it sounds like – abnormalities secondary to lysis of multiple tumor cells. This occurs within 3-7 days of chemotherapy and more often in patients with Lymphoma (esp Burkitt’s) or leukemia. The patient’s chief complaint could be literally anything, from myopathy to cardiac arrest. There is a score, the cairo- bishop score to help diagnose TLS. BUT, what I say is this: use caution ignoring even slightly abnormal basic labs in a patient on chemo, even “just an AKI.” Add on a Uric acid, LDH and phos. Basically patient’s typically have hyperkalemia, hyperphosphatemia which leads to low free calcium, and hyperuricemia.
Obviously, these lab abnormalities are bad- but why not just treat the abnormalities? In a way you do. Give fluids and lots of it. Admit the patient with continuous cardiac monitoring – treat the hyperkalemia as this is what may lead to the most rapid adverse outcomes HOWEVER try to limit the use of calcium if at all possible. Free calcium may be low in the blood, so patient may even be undergoing hypocalcemic symptoms BUT giving more calcium may in fact just increase the calcium-phosphorus deposits that are likely already contributing to the AKI (symbiotically alongside the uric acid precipitants. ) So long story short- fluids, fluids, fluids and consider dialysis early.
Patients are at higher risk for hyperviscosity if they have leukemia, PCV, Waldenstrom. Basically the patient can get leukostasis because the viscosity of their blood, plasma or serum becomes too elevated. This leads to thrombus formation and/or hemorrhagic complications. You can imagine what this means for presenting complaints- symptoms could be vague or focal, neuro to cardiac. But once you catch it on labs- give fluids. Again give tons of fluids. Add on other labs to look for possible Tumor lysis syndrome as above and to look for DIC. Official treatment will be leukapharesis/plasmapharesis depending on underlying problem.
BUT if the situation arises and you are not able to attain this for a patient: for once in your life time, you can change into a tunic, don a plague mask, paint the mona lisa and BLOOD LET. That’s right. Take off 2 Li of blood, and replace with 2 Li of fluid. No leeches needed.
These are not the only three cancer emergencies, but they are common and can be quickly life threatening. And what I think is really interesting is that, when you pay close enough attention, all three can be caught with just your basic labs: CBC, BMP and vitals.
Three more knowledge drops from Dr. Gore:
- Don’t forget SVC in a patient with intermittent facial swelling after lying flat- get CT and keep the HOB elevated.
- Look up typhilitis- also called neutropenic enterocolitis: treat with empiric belly abx and get a CT to make sure there are no complications.
- Remember a patient with the classic bones, moans, stones, groans and loans (oh wait that one’s me) could be hypercalcemia from a paraneoplastic syndrome.