Oncologic EmergenciesDiagnosis and Management•Hypercalcemia•Spinal Cord Compression•Superior vena cava syndrome•Disseminated intravascular coagulopathy (DIC)•Cardiac tamponade•Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Hypercalcemia• Calcium in serum is increased

• Serum calcium greater than 11 and signs are– Fatigue– Confusion– Muscle weakness– Decreased tone– Constipation– Nausea/vomiting– Abdominal pain– Diminished deep tendon reflexes

Hypercalcemia

• Cancer blocks the uptake of calcium by the bone tissue which causes an increased serum level

• Bone breaks down and dumps calcium into the serum

• Prostaglandin may be released which forces calcium from the bone

Hypercalcemia

• Kidneys try to get rid of excess calcium and polyuria follows

• Leads to dehydration

• Increasing levels lead to– Stupor, coma, kidney stones, renal failure

Hypercalcemia

• Affects cardiac system– Hypertension– Bounding pulse/tachycardia– Conduction is affected, leading to arrhythmias

Hypercalcemia

• If level is less than 13, then IV saline is given and the sodium pushes the calcium out

• If level is 13 or greater: Lasix is given (loop diuretics) Thiazide diuretics are not given because they cause calcium retention

• If 15 or greater, then IV mithramycin is given

Hypercalcemia

• Monitor strict I/O

• Watch for fluid overload– Tachycardia, increased BP, and crackles

– Limit dietary sources of vitamin D and calcium

Spinal Cord Compression

• Occurs secondary to pressure from expanding tumors

Early Symptoms

• Back and leg pain• Coldness• Numbness• Tingling• Paresthesia

• Later comes bowel and bladder dysfunction, weakness, and paralysis

• Early detection is key• Treatment is aimed at reducing the size of the

tumor

Superior vena cava syndrome

• Compression or obstruction of the superior vena cava (SVC)

• Usually associated with cancer of the lungs and lymphomas

• Signs and symptoms are the result of blockage to the venous circulation of the head, neck and upper trunk

Signs and Symptoms

• Early = periorbital edema and facial edema

• Later = edema of neck, arms, and hands• Difficulty swallowing and shortness of breath

• Late signs = cyanosis, altered mental status, headache and hypotension

Treatments

• High dose radiation• Corticosteroids• Prepare for tracheostomy• Initiate seizure precautions

Disseminated intravascular coagulopathy (DIC)

• Severe disorder of coagulation, often triggered by sepsis

• Depletes the clotting factors and platelets, allowing extensive bleeding to occur

• Tissue hypoxia occurs as a result of the blockage of blood vessels from the clots

DIC

• Normal clotting speeds up

• Strands of fibrin lodge in capillaries which increase clot risk

• The clotting factor is being used up, so bleeding occurs

DIC• There is an increase in fibrin split products, which are an

accumulation of coagulation degradation products and these have an anticoagulant effect

• Patients at risk are– Septic– Transfusion reactions– Reactions to meds such as vincristine, methotrexate,

predinsone– Certain cancers release substances that can lead to DIC

DIC

• Diagnosed by low platelets which occur due to high fibrin split products

• EARLIEST SIGN IS PROLONGED BLEEDING FROM VENAPUNCTURE SITE IN A PATIENT WHO IS NOT ON ANTICOAGULANTS

DIC

• Low platelet count• Low PT• Petechiae/ecchymosis• Stroke like symptoms• Severe hemorrhage• Shock• hypotension

DIC• Treat with heparin

• Platelets

• FFP

• Blood

• Bleeding precautions

Cardiac Tamponade

• Pericardial effusion secondary to metastases or esophageal cancer which leads to compression of the heart, restricting heart movement and resulting in cardiac tamponade

Signs and Symptoms

• Anxiety, cyanosis, dyspnea, hypotension, tachycardia, impaired level of consciousness and increased central venous pressure

Treatment

• Pericardiocentesis

• Administration of vasopressor agents

Nursing Interventions

• Administer oxygen• Maintain IV line• Monitor Vital Signs• Administer meds as ordered – vasopressor

agents

SIADH

• Thoracic or mediastinal tumors may push on major vessels and impede cardiac output

• Cytoxin and Vincristine precipitate this

• The pituitary thinks that there is a decrease in fluid volume and tries to fix the problem by secreting antidiuretic hormone

SIADH

• This stops urine output

• The body is holding onto fluids, so the sodium level is diluted

• Too much fluid leads to water intoxication

• The sodium level is 120-130: anorexia, nausea, vomiting, weakness, lethargy

SIADH• If less than 120: confusion and psychotic behavior

• IF not treated, seizure and coma

• Treatment– Limit fluids to 500cc/day and ice chips– I/O– Diuretics are not ordered until condition is severe because more

electrolyte imbalance will ensue