emDocs - August 21, 2015 - By Brit Long
"Summary
- Consult heme/onc quickly for all heme/onc emergencies.
- Leukostasis occurs with WBC count greater than 50,000 with symptoms (usually 100,000), predominantly pulmonary and neurologic symptoms.
- 80% of patients will have fever, so treat for infection concurrently.
- Chemotherapy is the only treatment that decreases mortality, but if not available, leukopheresis is the next step.
- DIC and TLS are major risks of treatment.
- Neutropenic is defined as a single oral temperature greater than 38.3 oC or temperature >38.0 oC for one hour, with absolute neutrophil count (ANC) of < 1500 cells/microL, with severe defined as an ANC less than 500 cells/microL or an expected drop to < 500 over 48 hours
- 30% of fevers are due to infection, with gram positives accounting for 60% of infections.
- MASCC risk index can be helpful and is validated.
- Broad coverage targeting gram positives and pseudomonas is needed.
- VTE is common in cancer, with 15% of patients with malignancy experiencing DVT/PE.
- Risks are broken down into patient, cancer, biochemical, and treatment related.
- Khorana score is validated for VTE risk stratification in this patient population
- CT PE and DVT US are the best tests.
- Anticoagulation with LMWH has the best literature support for treatment.
- Drug extravasation is exceedingly rare, with 0.01% of patients over a 15yr period experiencing extravasation.
- Two classes exist: irritant vs. vesicant.
- Best approach is prevention.
- If extravasation occurs, maintain the line to aspirate and inject antidote.
- Apply heat for alkaloids and etoposide, but ice for everything else.
- Consult plastic surgery."
http://www.emdocs.net/oncologic-emergencies-part-ii-pearls-and-pitfalls/
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