Hematologic/Oncologic Emergencies
Jan 29, 2016
Hematologic/Oncologic Emergencies
Scenario 1
48 year old male presents to the ED with Altered mental status, patient is confused and lethargic. On laboratory studies platelet count is 75,000 and Hgb is 9.5 mg/dL with no history of heparin exposure or hx of heart valves, schistocytes seen on peripheral smear.
TTP
Schistocytes = bad (think about microangiopathic hemolytic anemia)
This patient satisfies 3/5 for TTP: Thrombocytopenia and neurologic as well
What are other two?
Thrombotic Thromobocytopenic purpura
Mortality up to 80% if left untreated
Pathology from microthrombi in vessels
Exists on a spectrum with Hemolytic Uremic Syndrome (HUS) Renal abnormalities more common in HUS
TTP
Can see elevated LDH and decreased haptoglobin (markers of hemolysis)
TTP is a platelet problem rather than consumptive like in DIC
Tx: Steroids – methylprednisolone 125mg IV Dialysis for renal failure PLASMA exchange – Replete ADAMTS13 enzyme
FFP if plasma exchange is delayed or chronic Avoid platelet transfusion
Scenario 2
19 year old girl with history of Sickle cell disease (SS trait) presents to the ED with complaints of chest pain, pleuritic in nature, associated with shortness of breath and fever, sat is 90% on RA
Acute chest syndrome
Chest radiograph shows:
this can be seen in SS, SC, sickle-thalassemia
Present with cough, fever, chest pain, SOB
Sickle Cell Disease
Acute Chest syndrome Tx: Supplemental 02 , hydration and antibx
Vaso-occulsive crisis Severe unremitting pain
Aplastic crisis Decreased retic count
Scenario 3
A 50 year old female with hx of breast cancer complains of being tired, weak, nauseated with generalized abdominal pain. Vital WNL and physical exam unremarkable, family reports she appears a little more confused (slower to answer) but oriented.
Hypercalcemia
CBC and urinalysis normal
Calcium found to be 14 mg/dL
Most common life threatening disorder associated with cancer
You may also see this
Hypercalcemia
“Stones, Bones, Groans, Moans”
From bone destruction, PTH-like substance release, osteoclast activating factor
Labs: elevated Ca – check ionized Ca Phos normal or decreased Alk phos – normal or increased Potassium – decreased in 50 % of patients Albumin - decreased
Management
IV fluids – usually improves with just this
Furosemide – 40-80 mg IV Q 2-4 hours Excrete calcium
Potassium and phosphate repletion
Bisphosphates – pamidronate, zoledronic acid – inhibit osteoblasts
Hydrocortisone – 25-200 mg IV q 6-8 H Shown to decrease intestinal absorption of calcium and Vit D
Tumor Lysis syndrome
Usually Occurs within 5 days after radiation/chemotherapy
Due to repaid release of cell contents into blood stream
Most common Leukemias Lymphomas Small cell ca Metastatic adenoca
What you see
Hallmarks: Hyperuricemia (DNA breakdown) Hyper kalemia ( cytosol breakdown) Hyperphosphotemia (protein breakdown)
Secondary hypocalcemia
Acute kidney failure
Arrhythmias
Management
Stop the chemotherapy
Aggressive IV hydration with diuresis
Allopurinol or Rasburicase