Oncological emergencies

Oncological Emergencies are the group of conditions that occur as a direct or indirect results of cancer or its treatment that are potentially life-threatening.
after definition it consist of classification and descriptive explanation of each disease and in the end NURSES ROLE

1. ONCOLOGICAL EMERGENCIES

2. DEFINITION Oncological Emergencies are the group of conditions that occur as a direct or indirect results of cancer or its treatment that are potentially life-threatening.

3. CLASSIFICATION OF ONCOLOGICAL EMERGENCIES Structural/ Obstructive Emergencies Due to Metabolic/ Hormonal Problems Secondary to Complications Arising from Treatment Effects Superior Vana Cava Syndrome (SVCS) Pericardial Effusion/ Temponade Spinal Cord Compression (SCC) Increased ICP Urinary Tract Obstruction Hemoptysis Airway Obstruction Hypercalcaemia Syndrome of Inappropriate Anti-diuretic Hormone (SIADH) Lactic Acidosis Tumor Lysis Syndrome Haemorrhagic Cystitis Anaphylactic Reactions Related to Chemotherapeutic Agents Neutropenic Fever

4. SUPERIOR VANA CAVA SYNDROME Superior vena cava syndrome (SVCS) encompasses a range of signs and symptoms resulting from external compression or intrinsic obstruction of the superior vena cava (SVC) or associated greater veins.

5. Principal Causes of SVCS Lung cancer • Small-cell cancer • Non-small-cell cancer • Diffuse large-cell cancer Lymphoma • Lymphoblastic Metastatic disease to mediastinum • Breast cancer • Germ cell cancer • Gastrointestinal cancers • Other Primary mediastinal tumours • Thymoma • Sarcomas (e.g. malignant fibrous histiocytoma) • Melanomas • Thymic carcinoma Non-malignant causes • Infectious disease – syphilis, tuberculosis and histioplasmosis • Central line thrombus and other iatrogenic causes • Idiopathic fibrosing mediastinitis • Congestive heart failure • Goitre

6. INVESTIGATIONS OF SVCS

7. Clinical Evaluation Of SVCS Symptoms of SVCS Signs of SVCS Dyspnoea Nasal stuffiness Facial oedema Tongue swelling Cough Nausea Headache Light headedness Distorted vision Stridor Hoarseness Jugular venous distension Lethargy, stupor and coma Upper extremity swelling Syncope Facial and upper body plethora Cyanosis Chemosis Papilloedema Mental status changes

8. Radiological Evaluation Chest X-ray Contrast computed tomography (CT) m agnetic resonance imaging (MRI)

9. Management Algorithm of SVCS

10. Pericardial Effusion/ Temponade It is usually associated with advanced lung and breast cancer, leukemia or lymphoma. The spectrum of malignant pericardial involvement includes pericarditis , pericardial infusion , cardiac temponade , and constructive pericarditis .

11. It may be due to direct extension of disease, from spread through mediastinal lymphatic or blood vessels, obstruction of lymphatic drainage, or a direct effect of chemotherapy or radiotherapy.

12. Clinical Manifestations Dyspnoea Orthopnoea Raised JVP Preicardial Rub Pulses paradoxus Chest discomfort/pain Cough Muffled heart sounds Low BP

13. Diagnosis Chest X-ray CT scan MRI ECG Management Pericardiocentesis and Catheter Drainage Allowing for the relief of the temponade and cytologic analysis of fluid.

14. SPINAL CORD COMPRESSION Lung, prostate and breast cancer are leading causes of SCC. Other significant causes of SCC are non- hodgkin’s lymphoma, renal cell carcinoma, multiple myeloma, sarcoma.

15. Clinical Manifestations of SCC Pain : Localized to spine or radicular in nature . May be aggravated by movement ,straining and coughing. Muscular weakness or sensory loss. Numbness, paraesthesia , ataxia. Urinary Incontinence or Retention Faecal incontinence or constipation

16. Investigations of SCC Magnetic resonance imaging (MRI) is the gold standard method for SCC Diagnosis. Myelography Bone scan Computed tomography (CT) Positron emission tomography (PET)

17. Management of SCC

18. INCREASED ICP (INTRACRANIAL PRESSURE) Cranial metastasis affect around a quarter of patients who die from cancer. Lung, breast, and melanoma are the tumors' that most commonly metastasise to the brain.

19. Clinical Manifestations Headache Behavioural changes Focal neurological defects Papilloedema Unilateral ptosis or 3 rd and 6 th cranial nerve palsies Nausea and vomiting Seizures Falling level of consciousness Bradycardia

20. Diagnosis Computed tomography(CT) Magnetic resonance imaging (MRI) Management Hyperventi lation Mannitol ( Hyperosmotic agent) Dexamethasone Injection(Corticosteroid)

21. Urinary Tract Obstruction Definition : Urinary tract obstruction (UO) is defined as the complete interruption of urine natural flow. This complication may occur iatrogenically , or as a result of the underlying cancer. It concerns patients with primary tumours in the pelvis (such as gynaecological or urological malignant neoplasm's), but may also result from metastatic disease from any primary cancer to the pelvic area.

22. Lower Urinary Tract Obstruction Mechanisms and causes: Low UO is due to obstruction of urine output at the level of the urethra, prostate or bladder. It can be related to urethral strictures, BPH, prostate cancer, i atrogenic causes (like, Foley catheter obstruction, previous extensive pelvic surgery, or the use of anticholinergics ). Presentation: The pivotal symptom is the inability to urinate (incontinence).

23. Diagnosis: At physical examination ( suprapubic tenderness) Ultrasound (to confirm the diagnosis, if not clinically clear ) Treatment : Urinary Foley catheter placement, or use of a suprapubic tube if there is a tight urethral stricture.

24. Upper Urinary Tract Obstruction Mechanisms and causes: Stones and cancer growth are the two most frequent causes of upper UO. Ureter flow may be compromised in one or both sides, due to neoplasm (like prostate , bladder, cervical or colon cancer). Presentation: If there is bilateral upper UO or involvement of a solitary kidney, or poor renal function, the signs and symptoms will be those of uraemia .

25. Diagnosis: Ultrasound computed tomography (CT) without contrast magnetic resonance imaging (MRI ) Treatment: If the cause is not reversible in the short term and/or there are severe symptoms and/or renal failure, diversion of the urinary tract is indicated. Two methods are available: 1 ) Placement of percutaneous nephrostomy tubes , 2) Addition of indwelling ureteral stents through cystoscopy . These devices need to be changed every 3–6 months. Reversible causes such as distal ureter stones can be treated medically ( eg . T amsulosin 0.4 mg qd ).

26. Haemoptysis Haemoptysis is defined as blood expectoration coming directly from the bronchial tree. For assessing the risk and seriousness of haemoptysis there are three main prognostic factors: haemoptysis volume, bleeding speed and patients’ previous lung functional capacity. Massive haemoptysis is defined as the loss of ≥500 ml of expectorated blood over a 24-hour period or a bleeding rate of ≥100 ml/h.

27. Causes of Haemoptysis Bronchial disease Bronchiectasis Tumours ( squamous cell lung carcinoma, small-cell lung carcinoma, metastatic melanoma, metastatic colorectal cancer, metastatic breast cancer, bronchial carcinoid ) Trauma Aorto -bronchial fistula Pulmonary disease Pneumonia Rheumatic/immune pathology Coagulopathy Hereditary Anticoagulants Pharmacological Bevacizumab Other antiangiogenic agents Cocaine Nitrogen dioxide exposure

28. Diagnosis In case of Non-massive Haemoptysis In case of Massive Haemoptysis History and Physical examination (To localize the source of bleeding) Laboratory Tests: CBC RFT LFT Coagulation Profile Other tests: Sputum Culture Specific antibody test Imaging Studies: Chest Radiography Computed Tomography (CT) Bronchoscopy ABG (Arterial Blood Gas) Coagulation Test Bronchoscopy Arteriography

29. Treatment or Supportive Care F ocused on the underlying cause Fresh Frozen Plasma(In case of elevated INR) Antiplatelet agents, Platelet transfusion(In case of Thrombopaenia )

30. HYPERCALCAEMIA Hypocalcaemia is an elevated serum calcium level above 11.0 mg/dl. Malignancies most commonly associated include lung, breast, head, neck, kidney, lymphoma, and myeloma.

31. Clinical Manifestations Polydipsia Dehydration Constipation Drowsiness Nausea and vomiting Bradycardia Changes in mental status Polyuria Abdominal discomfort Increased gastric acid secretion Muscle weakness

32. Management Intensive rehydration for 12-24 hours with 4-6 litre of normal saline. Loop Diuretics:- Furosemide 40-80mg, IV Bisphosphonate :- Pamidronate 90mg (2-4 hour infusion); Zoledronic acid 4mg(15 minute infusion) Adjunctive Therapies:- Corticosteroids, calcitonin . Haemodialysis:- In case of refractory hypercalcemia

33. SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMONE Syndrome of Inappropriate Anti-diuretic Hormone (SIADH) result from abnormal and sustained production of anti-diuretic hormone (ADH) by tumor cells with resultant water retention and hyponatremia .

34. Causes Carcinoma of lung, pancrease , duodenum, brain, oesophagus, colon, ovary, prostate, bronchus, nasopharynx . Leukemia Hodgkin’s lymphoma Clinical Manifestations Weight gain without oedema Anorexia Oliguria Coma Weakness Nausea and vomiting seizures Decrease in reflexes

35. Management Correct the sodium-water imbalance, including:- Fluid restriction Oral salt tablets or isotonic saline administration In severe cases, IV administration of 3% sodium chloride solution Furosemide

36. LACTIC ACIDOSIS Lactic acidosis is a frequent cause of life-threatening metabolic acidosis and is characterised by lactate levels >5 mmol /l and serum pH <7.35. Lactic acidosis in cancer patients may be due to excessive production( tumor derived) as well as due to impaired elimination(hepatic metabolism and renal clearance).

37. Clinical Manifestations Nausea and vomiting Diarrhoea Loss of consciousness Hypotension Abdominal pain Altered sensorium Dehydration Circulatory cpllapse Diagnosis Blood lactate level ≥2mmol/L (venous plasma) Arterial pH<7.25 Anion gap>22meq/L Treatment Chemotherapy to treat the underlying haematological malignancy is the only effective treatment.

38. TUMOR LYSIS SYNDROME This syndrome is due to the effects of treatment of malignancy. There is a reaction to the sudden and large releases of cellular lysis products caused by tumor destruction. The body me unable to excrete and neutralize such toxic products.

39. Clinical Manifestations and Diagnosis Symptoms are non specific an include:- Routine uric acid and electrolyte measurement are indicated to find out the cardinal biochemical features:- Nausea and vomiting Fatigue Weakness Myalgia Dark urine Neuromuscular irritability Arrhythmias Seizures Sudden death Hyperkalaemia Hyperphosphataemia Hyperuricaemia Hypocalcemia

40. Management IV hydration with NS 3-4Lit./24 hours, with sodium bicarbonate Acetazolamide is used to alkalinise the urine Allopurinol is used as prophylactic for Hyperuricaemia Diuresis with Furosemide / Mannitol Oral Aluminium Hydroxide to treat Hyperphosphatemia Dialysis; in case of refractory Hyperkalaemia and severe acute renal failure

41. HAEMORRHAGIC CYSTITIS Management of cervical cancer by external pelvic radiation and brachytherapy may cause haemorrhagic cystitis, particularly if radiation is given after removal of uterus. It is also observed in patients receiving high doses of chemotherapeutic agents as Ifosfamide or cyclophosphamide for longer periods. Clinical Manifestations Dysuria Frequency Urgency Burning sensation Gross haematuria Incontinence

42. Management Oral and IV hydration :- Increase urine flow and reduce contact of acrolein with bladder mucosa Mensa administered with Ifosfamide or high dose cyclophosphamide :- To detoxify acrolein and it’s metabolites in urine Bladder irritation with formalin solution for 10 minutes. Systemic Aminocaproic Acid as first line treatment follower by Fulguration. Internal iliac ligation or embolization , urinary diversion. Cystectomy

43. NEUTROPENIC FEVER Neutropenia arises mostly from treatment of malignancy by chemotherapy and is defined by Absolute Neutrophil Counts ( ANC) less than 1500cells/ml[1000-1500:Mild ; 500-999:Moderate; <500:Severe] Fever: defined as a single oral temperature measurement of ≥38.3°C or a temperature of ≥38.0°C sustained over a 1-hour period. n

44. Causes and Risk Factors Bacteria 1) Gram Positive Cocci 2) Gram Negative Cocci S.aurues Streptococci Staphylococci E.coli Klebsiella species P.aeuginosa Risk Factors IV devices High dose chemotherapy regimens Corticosteroid use Mucositis Bone marrow incompetence

45. Diagnosis History & Physical Examination [Try to elucidate the source of infection by avoiding invasive procedures; like Urinary catheterization, Digital Rectal Examination, Vaginal examination, lumber puncture, chest tube insertion, etc.] CBC, RFT, LFT Blood culture [ minimum of 2 sets ] including culture from indwelling IV catheter. Urinanalysis and culture Stool microscopy and culture Skin Lesion [Aspirate/Biopsy/Swab] Sputum microscopy and culture Chest radiography

46. Management Broad spectrum antibiotics [Cephalosporin] like cefepime are 1 st line antibiotic with other drugs like ceftriaxone / gentamicin / ceftazidime or piperacillin / tazobactam . Ciprofloxacin, aztreonam and vancomycin can be considered in patients hypersensitive to penicillins Vancomycin -> In patents with suspected central line infection. Removal of central line -> In case of persistent infection .

47. Role Of Oncology Nurses’ Patient assessment Patient and care giver education Patient care Symptom management Supportive care