Emergency Contraception Sue Turner: Clinical Nurse Specialist: Sexual Health 1.
Emergency rt for nurse
-
Upload
techno-uch -
Category
Health & Medicine
-
view
419 -
download
1
description
Transcript of Emergency rt for nurse
![Page 1: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/1.jpg)
Emergency RT
Sirentra Wanglikitkoon, MD.
![Page 2: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/2.jpg)
Contents • Brain metastasis
• Spinal cord compression
• SVC obstruction
• Others
• Airway obstruction
![Page 3: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/3.jpg)
BRAIN METASTASIS
![Page 4: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/4.jpg)
![Page 5: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/5.jpg)
• Survival ?
• Symptom ?
• Treatment
• RT
• ?
•Complication?
![Page 6: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/6.jpg)
Epidemiology
• The most common intracranial tumors in adults
![Page 7: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/7.jpg)
Epidemiology
![Page 8: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/8.jpg)
Pathogenesis
• Most common mechanism is hematogenous spread
• Usually located at gray white junction
• Distribution of metastases
• Cerebral hemispheres : approximately 80 %
• Cerebellum : 15 %
• Brainstem : 5 %
![Page 9: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/9.jpg)
Clinical presentation
![Page 10: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/10.jpg)
Prognosis
• Age
• Performance status
• Primary un/controlled
• Pathology
• Metastasis disease
• Number of brain metastasis
•RPA
•GPA
•Diagnosis-specific GPA
![Page 11: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/11.jpg)
Prognosis - RPA
Recursive Partitioning
Analysis
![Page 12: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/12.jpg)
Prognosis - RPA
RPA Median survival
Class I 7.1 months
Class II 4.2 months
Class III 2.3 months
![Page 13: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/13.jpg)
Prognosis - GPA
![Page 14: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/14.jpg)
Prognosis - GPA
![Page 15: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/15.jpg)
Prognosis: Diagnosis-specific GPA
2.8 mo 25.3 mo
![Page 16: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/16.jpg)
A 58-year-old patient with Rt hemiparesis
CT brain: ring enhancing lesions with vasogenic edema at both frontoparietal region. DDx: Brain metastasis
Imaging: CT brain
![Page 17: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/17.jpg)
Imaging: MRI brain
MRI will frequently pick up smaller lesions not seen on CT scans
Significant effect on the patient’s prognosis and treatment course.
![Page 18: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/18.jpg)
![Page 19: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/19.jpg)
Imaging: NCCN 2013
![Page 20: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/20.jpg)
Imaging: NCCN 2013
![Page 21: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/21.jpg)
Investigation
![Page 22: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/22.jpg)
Management
• Symptomatic treatment
• Prevent and control cerebral edema: corticosteroids
• Anticonvulsants
• Specific treatment: local brain
• Radiotherapy • Conventional whole brain RT: Standard treatment
• Stereotactic radiosurgery (SRS)
• Surgical resection
![Page 23: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/23.jpg)
Management
• Symptomatic treatment • Prevent and control cerebral edema: corticosteroids
• Anticonvulsants
• Specific treatment: local brain
• Radiotherapy • Conventional whole brain RT: Standard treatment
• Stereotactic radiosurgery (SRS)
• Surgical resection
![Page 24: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/24.jpg)
Corticosteroids
• Improve edema and neurologic deficits
• Approximately two-thirds of pts Improve
• Should promptly start with dexamethasone 10 mg IV or oral bolus 4-6 mg q 6-8 hrs
• With concurrent PPI
• In asymptomatic pts with little edema and mass effect may be reserved until the first sign of neurologic symptoms.
![Page 25: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/25.jpg)
Anticonvulsants
![Page 26: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/26.jpg)
Management
• Symptomatic treatment
• Prevent and control cerebral edema: corticosteroids
• Anticonvulsants
• Specific treatment: local brain • Radiotherapy
• Conventional whole brain RT: Standard treatment
• Stereotactic radiosurgery (SRS)
• Surgical resection
![Page 27: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/27.jpg)
Whole-brain radiotherapy • WBRT and appropriated steroid use are still standard
treatment of brain metastasis
• Average Median survival of brain metastasis
• Without treatment : approximately 1 month
• With corticosteroids use : 2 months
• With WBRT : 3-4 months
APRIL F. EICHLER,The Oncologist 2007;12:884–898
![Page 28: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/28.jpg)
Whole-brain radiotherapy
• Standard of care in pts with brain metastasis
• Radiographic and clinical response rates: 50-75%
• Standard dose and fractionation: 30 Gy in 10 fractions
![Page 29: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/29.jpg)
WBRT: Dose & fractionation
20Gy/5F = 36Gy/6F = 30Gy/10F,15F = 40Gy/15F,20F
![Page 30: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/30.jpg)
Stereotactic radiosurgery • High dose per fraction
• High conformity
• Rapid dose fall-off
• Minimizing radiation dose to surrounding normal tissue
• Radiation tolerance of normal tissue is volume dependent
• Precisely directed target (usually ≤ 1mm)
• Strictly Immobilization head flame
![Page 31: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/31.jpg)
Stereotactic radiosurgery
Tumor size Max. Dose
< 20mm 24 Gy
21-30 mm 18 Gy
31-40 mm 15 Gy
Maximum tolerated doses of SRS
Int. J. Radiation Oncology Biol. Phys., Vol. 47, No. 2,
pp. 291–298, 2000
![Page 32: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/32.jpg)
Surgical resection
Role of surgery
• Pathology: tissue diagnosis
• Relieving mass effect due to large symptomatic metastases
• Improve local control and survival
![Page 33: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/33.jpg)
Surgery + WBRT vs WBRT alone: Single brain metastasis • KPS ≥70
KPS ≥70
KPS ≥50
WHO≤2
40 wks 15 wks
10 mo 6 mo
NS
![Page 34: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/34.jpg)
![Page 35: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/35.jpg)
![Page 36: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/36.jpg)
Brain complications
• Acute complication
• Acute Encephalopathy
• Late-delayed complication
1. Radiation Necrosis
2. Cognitive Dysfunction
3. Radiation induced brain tumor
Perez 5th edition p 730
![Page 37: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/37.jpg)
Acute Encephalopathy
• Pathogenesis:
• RT open the BBB acutely exacerbate preexisting peritumoral edema
• Onset
• generally most severe following the first radiation dose and gradually lessens in severity thereafter
• Clinical presentation
• nausea and vomiting, drowsiness, headache, and worsening of preexisting neurologic deficits
![Page 38: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/38.jpg)
Acute Encephalopathy
• Management
• Small dose per fraction (<300 cGy)
• Routine use of corticosteroids in pts with peritumoral edema
![Page 39: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/39.jpg)
For Nurse
• Prognosis
• Observe neuro sign
• Observe RT complication
• Dexamethasone • DM
• PPI
• Infection
![Page 40: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/40.jpg)
Spinal cord compression
![Page 41: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/41.jpg)
Introduction
• 5-14% of all cancer patients
• 1/3 survival beyond 1 yr
• Most common cancer
• breast cancer 29%
• lung cancer 17%
• prostate cancer 14%
![Page 42: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/42.jpg)
Introduction
• Location of the site of compression
• cervical spine 4-15%
• thoracic spine 59-78%
• lumbosacral spine 16-33%
•multiple sites 50%
![Page 43: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/43.jpg)
Spinal
cord compression
Continued growth
vertebral bone metastasis
Paraspinal mass into
neural foramen
Destruction of vertebral
cortical bone
Pathophysiology
![Page 44: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/44.jpg)
Spinal cord compression
Epidural venous plexus compression
Spinal cord edema
Increased vascular permeability and edema
Decreased capillary blood flow
White matter ischemia
![Page 45: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/45.jpg)
Clinical manifestations
• Bone pain 88-96% : earliest symptom
• Muscle weakness 76-86%
• Sensory loss 51-80% : examined spinal sensory level is typically 1-5 levels below the actual level of cord compression
• Bowel or bladder dysfunction 50-60%
![Page 46: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/46.jpg)
Imaging
Plain film
• False negative 10-17%
• might not detect paraspinal masses
J Clin Oncol 23:2028-2037
![Page 47: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/47.jpg)
Imaging
MRI (Whole spine)
• Method of choice
• Accuracy 95%
• sensitivity 93%
• specificity 97 %
![Page 48: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/48.jpg)
Goals of treatment
• Pain control
• Avoidance of complications
• Preservation or improvement of neurologic function
![Page 49: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/49.jpg)
Prognosis
• Time from start of any symptoms to development of motor deficits
• Pathology and primary cancer
• Pretherapy ambulatory status
![Page 50: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/50.jpg)
Management
•Corticosteroid
•Surgery
•RT
![Page 51: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/51.jpg)
Corticosteroid
•Must be started as soon as possible (even before radiographic diagnosis)
•PPI for GI prophylaxis
![Page 52: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/52.jpg)
Corticosteroid
• Sorensen et al, 1994
• Vecht et al, 1989 Comparison: Dexa 100 mg vs 10 mg IV oral 16mg/d Conclusion : no differences on pain, ambulation, or bladder function
RCT Dexa (before RT) 96 mg IV then oral 96mg/day
then 10 day taper No Dexa
3-mo ambulatory rate 81% 63%
6-mo ambulatory rate 59% 33%
![Page 53: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/53.jpg)
Corticosteroid
• Dexamethasone dose: loading dose 10 mg iv then 4-6 mg q 6 – 8 hrs then tapering
![Page 54: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/54.jpg)
Surgery
Advantage • Immediate cord decompression and provoids an
opportunity to stablize spine
Indication • Spinal instability or bony compression
• Single site of cord compression
• Neurologic progression during or after RT
• Unknown primary site
• Radioresistant tumors
![Page 55: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/55.jpg)
Patchell, 2005 - Surgery within 24 hr - Single area of spinal compression
Surgical plus RT All/walk entry (50)
RT alone All/walk entry (51)
Combined ambulatory rate 84% (42/50) 57% (29/51)
Retained ability to walk 122 days 13 days
Walk at entry 94% (32/34) 74% (26/35)
Retained ability to walk 153 days 54 days
Unable to walk at entry 62% (10/16) 19% (3/16)
Retained ability to walk 59 days 0 days
J Clin Oncol 23:2028-2037 Lancet 2005; 366: 643–48
![Page 56: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/56.jpg)
Radiation
Volume of treatment
• Superior-inferior
• To cover 1 level of upper and lower spine, if definite level from MRI
• Lateral
• Adequate margin vertebral body
Radiation dose
• Commonly use 30 Gy in 10 Fx
![Page 57: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/57.jpg)
• Compared short course (8Gyx1F, 4Gyx5F) vs long course (3Gyx10F, 2.5Gyx15F, 2Gyx20F)
• Better local control in long course (81%vs61%)
• Improve motor not different
• Long course prefer to favorable expected survival
![Page 58: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/58.jpg)
For nurse
• Early detection: Patient with bone metastasis developed weakness
• Prevent bed sore
• PM&R
![Page 59: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/59.jpg)
Superior Vena Cava Syndrome (SVC) with Malignancy Causes
![Page 60: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/60.jpg)
Introduction
• Syndrome results from any condition that leads to obstruction of blood flow through the SVC
• Obstruction by
• invasion or external compression of SVC by adjacent pathologic structure eg, right lung, LN or mediastinal structures
• thrombosis of blood within the SVC
![Page 61: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/61.jpg)
Introduction
Causes of SVC obstruction
• Malignancy 60-80%
• NSCLC 50%
• SCLC 25%
• Lymphoma
• Metastasis tumor at mediastinum
• Benign 20-40%
• Thrombosis due to using intravascular devices
• Infection
![Page 62: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/62.jpg)
Clinical manifestation
![Page 63: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/63.jpg)
Imaging
• Chest X-ray: 25% negative
• CT scan with contrast
• Most useful image shows level and extent of blockage
• Venogram
• Only when an intervention (placement of a stent or surgery) is planned.
• MRI
• Patients cannot tolerate contrast medium
• PET-CT
• For design radiotherapy field
![Page 64: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/64.jpg)
Definite diagnosis Pathology
• Minimal invasive procedures
• Sputum cytology
• pleural fluid cytology
• biopsy SPC
• More invasive procedures
• Bronchoscopy
• Mediastinoscopy
• Video-assisted thoracoscopy
• Thoracotomy
• Percutaneous transthoracic CT-guided biopsy
Before RT
![Page 65: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/65.jpg)
Management
• Considered treatment of cancer and relief symptoms of obstruction
• Current management guidelines stress the importance of accurate histologic diagnosis prior to starting therapy
![Page 66: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/66.jpg)
Supportive treatment
• Head should be raised to decrease head and neck edema
• Avoid intramuscular/intravascular injections in arms
• Glucocorticoids
• Diuretics
![Page 67: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/67.jpg)
Management
Chemo-responsive tumor: SCLC, lymphoma , germ cell tumor
• Initial chemotherapy is treatment of choice for patients with symptomatic SVC syndrome
• Rapid clinical response
![Page 68: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/68.jpg)
Management
Radiation therapy • RT complete relief of symptoms within two weeks
• 78% in SCLC and 63% in NSCLC
• Target: gross disease and adjacent nodal region
• Dose: lymphoma is recommended conventional Fx
SCLC/NSCLC are recommended hypofractionation
![Page 69: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/69.jpg)
Management
Endovascular stenting • For True emergency condition
• stridor due to central airway obstruction
• coma from cerebral edema
• Recommend emergent treatment with endovascular stenting followed by radiation therapy (RT)
![Page 70: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/70.jpg)
Airway obstruction
![Page 71: Emergency rt for nurse](https://reader034.fdocuments.in/reader034/viewer/2022051513/5466132caf795983338b500b/html5/thumbnails/71.jpg)