Oncologic Emergencies

Objectives • Identify the major oncologic emergencies

• Describe the assessment for each emergency

• Outline the standard of care of patients

experiencing oncologic emergencies

Structural • Spinal Cord Compression • Superior Vena Cava Syndrome • Increased Intracranial Pressure • Cardiac Tamponade • Malignant Pleural Effusion • Bleeding/Thrombosis

Metabolic • Desseminated Intravascular Coagulation • Syndrome of Inappropriate Antidiuretic

Hormone Secretion • Tumor Lysis Syndrome • Hypercalcemia • Sepsis • Anaphylaxis/Infusion Reaction

Spinal Cord Compression

Spinal Cord Compression SCC • Description

– Extension of tumor into epidural space – Pathologically collapsed vertebral bone impinging the

spinal cord • Manifestation

– Back pain, weakness, sensory loss, autonomic dysfunction, paraplegia

• Evaluation/Diagnosis – MRI

Spinal Cord Compression SCC • Treatment

– Steroids – Surgery – Radiation – chemotherapy

• Nursing Management – Recognize early signs – Pain management – Emotional support – rehab

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome SVC • Description

– Tumor or thrombus invasion or impingement – Venous output restriction/congestion – Decreased cardiac output

• Manifestation – Dyspnea – Edema – Dysphagia – Headache – Dizziness – syncope

Superior Vena Cava Syndrome SVC • Evaluation/Diagnosis

– CT with contrast • Treatment (based on the cause)

– Radiation – Chemotherapy – Surgery-stent placement – Thrombolytics

• Nursing Management – Airway protection – Cardiovascular support – Emotional support

Increased Intracranial Pressure

Increased Intracranial Pressure ICP • Description

– Tumor or fluid causing compression within the brain case

• Manifestation – Altered mental status, nausea, headache,

hypertension, focal neurological deficits

• Evaluation/Diagnosis – CT, Brain MRI, NO LP

Increased Intracranial Pressure ICP • Treatment

– Reduce fluid in the brain • Osmotic diuretics-mannitol • corticosteroids

– Surgery – Radiation

• Nursing Management – Neuro assessment – Bed/chair elevation – Support for neuro deficits

Cardiac Tamponade

Cardiac Tamponade • Description

– Excessive fluid in the pericardial sac – Decreases cardiac output

• Manifestation – Dyspnea, anxiety, tachycardia, restlessness, fatigue,

chest pain, restless, MS changes, lethargy, LOC changes

• Evaluation/Diagnosis – Echocardiogram, chest xray, pulsus paradoxus

Cardiac Tamponade • Treatment

– Immediate pericardiocentesis – Sclerosis – Pericardial catheter or window – pericardiectomy

• Nursing Management – Early recognition – Assessment of cardiac, respiratory and neuro systems – Tube/dressing management

Malignant Pleural Effusion

Malignant Pleural Effusion • Description

– Fluid collection in the pleural space that can lead to respiratory distress/failure

• Manifestation – Dyspnea, cough, pleuritic chest pain, orthopnea,

anxiety, fear of suffocation

• Evaluation/Diagnosis – Chest xray, CT

Malignant Pleural Effusion • Treatment

– Thoracentesis – Chest tube/tunneled pleural catheter

• Nursing Management – Respiratory and cardiac assessment – Tube/device care – Patient/family education – Comfort measures

Bleeding

Bleeding

• Description – Reduction of platelets, esp. <20K – Heme malignancies – Altered platelet function (NSAIDs, antibx) – Tumor invasion – Anti-VEGF treatment regimens

• Manifestation – Gums, nose, GI, cranial, intraperitoneal

Bleeding • Evaluation/Diagnosis

– Risk assessment – Platelet counts – Clotting factor deficiency – hemoccult

• Treatment – Transfusion, growth factors, tx the source or cause

• Nursing Management – safety

Thrombosis

Thrombosis

• Description – 7 fold risk in cancer patients for venous

thromboembolism ( VTE)

• Manifestation – DVT – Pulmonary Embolism

Thrombosis • Evaluation/Diagnosis

– Radiology/ECG – Blood gases – Ultrasound/angiography

• Treatment – Embolectomy – Subsequent anticoagulation/Vitamin K

• Nursing Management • Respiratory/hemodynamic support

Disseminated Intravascular Coagulation DIC

• Description – Coagulation disorder involving widespread intravascular

thormobisis

• Manifestation – Bleeding, organ damage/failure

Disseminated Intravascular Coagulation DIC • Evaluation/Diagnosis

– Rapid plt decline – Prolonged coagulation tests – Fibrin degradation products/D-dimer

• Treatment – Underlying disease – Blood components – Restore anticoagulation

DIC

• Nursing Management – Symptom recognition – Monitoring – Oxygen – Administration of blood

products/factors

Syndrome of Inappropriate Antidiuretic Hormone SIADH

• Description – Tumor secretion of antidiuretic hormone

• Manifestation – Water retention/hyponatremia/concentrated

urine

• Evaluation/Diagnosis – Electrolytes/serum and urine osmolality

Degree of Hyponatremia

Sodium Level Signs/Symptoms

Normal sodium 135-145 mEq/L

Mild 131-135 mEq/L

Thirst, anorexia, nausea, fatigue, weakness, muscle cramps, headache

Moderate 126-130 mEq/L

Weight gain, oliguria, neurologic symptoms

Severe <120 mEq/L Secondary to cerebral edema, papilledema, delirium, hypoactive reflexes, ataxia, gait disturbances, seizures, coma, death

SIADH • Treatment

– Underlying disease – Fluid restriction/hypertonic saline – Demeclocycline and vaptans

• Nursing Management – Fluids – I/O – high sodium diet – Neuro checks

Tumor Lysis Syndrome-TLS • Description

– Rapid, high volume destruction of cancer cells after treatment

• Manifestation – Hyper: potassium, phosphate, uric acid – Hypo: calcium

• Evaluation/Diagnosis – CBC, Chemistry, urinalysis

Tumor Lysis Syndrome-TLS

• Treatment – Hydration/diuresis – Allopurinol/rasburicase – Alkalinization of the urine

• Nursing Management – Know patients at risk – prophylaxis

Hypercalcemia

• Description – Release of calcium in advanced bone involving

cancers

• Manifestation – Organ systems – CNS – kidneys

Hypercalcemia • Evaluation/Diagnosis

– Serum/corrected calcium – Renal function/status

• Treatment – Hydration/diuresis – Treat underlying disease – Biphosphonates-long term

• Nursing Management

Sepsis

• Description – Body’s failure to mount adequate immune

response to an overwhelming infection

• Manifestation – Fever/tachycardia/tachypnea/shaking chills – Hypotension/hypoperfusion/organ failure – Metabolic acidosis

Septic Shock Cascade

Sepsis • Evaluation/Diagnosis

– CBC w/differential, chemistry – Cultures – radiology

• Treatment – IV fluids, pressors – Blood products – antibiotics

• Nursing Management

Anahylaxis

Anaphylaxis/Infusion Reaction • Description

– Systemic immune reaction to the infusion of agents

• Manifestation • Mild: sense of doom or not right, itching,

wheezing • Severe: bronchospasm, angioedema,

hypotension

Anaphylaxis/Infusion Reaction • Evaluation/Diagnosis

– Based on symptoms – Tryptase/allergy testing

• Treatment – Antihistimines/steroids – Epinenphrine – Cardiovascular/respiratory support

• Nursing Management

Questions???