3/6/2018 1 Oncologic Emergencies Ellen Alberts MSN, ARNP-CNS, AGCNS-BC, AOCNS PSONS Fundamentals of Oncology Spring 201 Overview The Basics Oncologic emergencies are life-threatening medical emergencies and must be treated as such! Why do they occur? • Malignancy • Treatment of malignancy When do they occur? • Early in disease process (initial manifestation of malignancy itself) • Late in disease process (manifestation of treatment of malignancy) Structural Emergencies • Spinal Cord Compression • Superior Vena Cava (SVC) Syndrome • Increased Intracranial Pressure (ICP) • Cardiac Tamponade Metabolic Emergencies • Tumor Lysis Syndrome (TLS) • SIRS/Sepsis/Septic Shock • Disseminated Intravascular Coagulation (DIC) • Thrombotic Thrombocytopenia (TTP) • Hypercalcemia • Inappropriate Antidiuretic Hormone Secretion (SIADH) • Anaphylaxis • Hypersensitivity (Maloney, 2016; Vogel 2016) The Basics
19
Embed
Oncologic Emergencies Ellen Alberts MSN, ARNP …psons.org/wp-content/uploads/2018/03/17-Oncologic-Emergencies... · Managment: •Fluid ... •GI: tarry stools, hematemesis, abdominal
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
3/6/2018
1
Oncologic Emergencies
Ellen Alberts MSN, ARNP-CNS, AGCNS-BC, AOCNS
PSONS Fundamentals of Oncology
Spring 201
Overview
The Basics Oncologic emergencies are life-threatening medical
emergencies and must be treated as such!
Why do they occur?
• Malignancy
• Treatment of malignancy
When do they occur?
• Early in disease process (initial manifestation of malignancy itself)
• Late in disease process (manifestation of treatment of malignancy)
Mr. J: Clinical presentation at 0730 in AM after admit to floor and transfer to ICU
•Disoriented, lethargic
•Skin pale, cool, fingertips cyanotic
• ↓ breath sounds lower lobes bilaterally with diffuse
bilateral rales, hemoptysis
•RR 28 on 2 lpm via nasal cannula, O2 sat 88%
•Abdomen distended, rebound tenderness
•Still no urine output
•Oozing blood from venipuncture sites
•HR 136 irregular, weak
•BP 78/37
• Temp 103.1oF
DIC Case Study
Laboratory
Value
Labs from ED 0730 Normal
Values
Hemoglobin 10 g/dl 8.9 g/dl 14 – 18 g/dl
(male)
Platelets 30,000/mm3 12,000/mm3 150,000 –
400,000/mm3
Fibrinogen 96 mg/dl 170 – 410
mg/dl
PT 15.8 seconds 11.3 – 13.1
seconds
Fibrin
Degradation
Products
60 mcg/ml > 10 mcg/ml
Mr. J’s labs at:
3/6/2018
11
Managment:
1. Treat underlying cause!!
May include:
✴ Transfusions (platelets, FFP,
cryopreciptate)
✴ Anticoagulants
✴ Fibrinolytic agents
✴ Anticoagulant factor concentrates
(Maloney, 2016; Viele, 2008)
Disseminated Intravascular Coagulation
Nursing Management
(Vogel, 2016)
• Early recognition!
• Good assessments
• VS
• Hemodynamics
• Oxygenation
• Fluid status
• Ensure patient safety
• Manage active bleeding
• Administration of anticoag therapy,
other meds, fluids, blood products
• Assist in patient coping
Disseminated Intravascular Coagulation
DIC Case Study
Orders for Mr. J:
• IV Heparin per hospital protocol
• 2 units PRBCs
• Strict I/O
• VS Q_ hours
• Supplemental O2 titrate to O2sat >92%
Spinal Cord Compression
3/6/2018
12
Spinal Cord Compression
Definition:
A neurological
emergency where the
spinal cord or cauda
equina is compromised by direct pressure,
vertebral collapse, or
both caused by direct
extension or
metastatic spread of
malignancy.
(Schulmeister & Gatlin, 2008; Vogel, 2016)
http://www.medscape.com/viewarticle/442735
Spinal Level % Involvement Associated Cancers
Cervical 10 Lung, breast, kidney,
lymphoma, myeloma,
melanoma
Thoracic 70 Lung, breast, kidney,
lymphoma, myeloma,
prostate
Lumbosacral 20 Lung, breast, kidney,
lymphoma, myeloma,
melanoma, prostate, GI
Cancers associated with spinal cord compression:
(Schulmeister & Gatlin, 2008)
Spinal Cord Compression
Risk Factors:
• Cancers that have a natural history of spreading to the bone
• Cancers that have a natural history of spreading to the brain and spinal cord
• Primary cancers of the spinal cord
• History of vertebral compression fractures
(Vogel, 2016)
Spinal Cord Compression
Pathophysiology: • Compression of spinal cord ✴Direct tumor pressure on cord ✴Tumor invasion of the vertebral column causing collapse & pressure on cord
• Compression leads to: ✴Edema ✴Inflammation
• Resulting in: ✴Direct neural injury to cord ✴Vascular damage
90% of patients with SCC experience back pain as the first symptom.
Late signs:
• Loss of sensation for deep pressure, vibration, and position
• Incontinence or retention
• Impotence
• Paralysis
• Muscle atrophy
• Loss of sweating below lesion
(Vogel, 2016)
Spinal Cord Compression Spinal Cord Compression
Signs & Symptoms
•Pain
•Motor weakness or gait
changes
•Sensory Loss (numbness,
tingling, sensory changes)
•Constipation and/or bladder
retention
•Bowel and/or bladder
incontinence
•Paralysis
Time Frame
Early
Late
Back pain characteristics:
• Localized: usually occurs at level of lesion, described as dull and constant, more severe with movement, coughing, weight bearing, during a Valsalva maneuver
• Radicular: along dermatomes
• Referred: in a non-radicular pattern
May be a combination of all three!
(Schulmeister & Gatlin, 2008)
Spinal Cord Compression SCC Case Study
Mr. B is a 56-year-old male with stage IV prostate cancer, with wide-spread metastases to the bone He previously failed several cycles of chemotherapy and is being treated with hormonal therapy
3/6/2018
14
Mr. B presents to Emergency Department with:
–Bi-lateral weakness in lower extremities
•Initial onset 5 days ago
•Difficulty ambulating, reports falling this
morning
–Numbness in the lower extremities
•Began earlier in the day
–Increasing back pain
•Has been taking oxycodone every 4 hours
which controlled his pain well until 4-5 days ago
•Currently rates his pain as 7 out of 10
SCC Case Study
Diagnosis: • MRI
– Gold standard for diagnosis – Accurate, sensitive, and specific diagnostic for malignant spinal cord compression
• Other diagnostic tests – Spinal x-rays
– CT scan – Bone scan and/or PET scan
(Vogel, 2016)
Spinal Cord Compression
Nonpharmacologic:
• Radiation
• Surgery
• Surgery followed by radiation
Treatment:
Immediate and aggressive!
Pharmacologic:
• Corticosteroids
• Chemotherapy
• Analgesics
• Bone remodeling
agents
(Vogel, 2016)
Spinal Cord Compression
Nursing Management:
(Vogel, 2016)
Spinal Cord Compression
• Manage pain and increase comfort • Promote physical mobility
• Improve or maintain neurologic function • Improve or maintain skin integrity • Increase knowledge of disease process
and therapeutic interventions • Preserve self-image and role performance
• Administer treatment as ordered!
3/6/2018
15
(Vogel, 2016)
•Mr. B received a loading dose of dexamethasone
10 mg, followed by tapering doses.
•He was admitted to the inpatient oncology unit
with initial activity orders for bed rest with only
log-rolling
•Surgical & radiation therapy consults were
ordered
SCC Case Study
•Three days after initiating radiation therapy, Mr.
B. developed urinary retention
•The following day he developed paraplegia,
urinary & bowel incontinence.
•Surgical consult re-evaluated Mr. B for emergent
decompression of spinal cord
•After family conference, Mr. B and his family
decided against surgical intervention and decided
on palliative care
SCC Case Study
Spinal Cord Compression
Nursing Interventions Early recognition:
• Thorough assessment of neck & back pain in high risk patients
Neurological assessments Assess effectiveness pain control Monitor bowel & bladder function PT, OT referrals, as appropriate
• Assess need for home care referrals and supportive medical equipment
Treatment: Goal is relief of obstruction and addressing of underlying cause. Determined by rate of onset.
Pharmacologic:
• Chemotherapy
• Chemotherapy + radiation
• Corticosteroids
• Diuretics
• Thrombolytic therapy
(Vogel, 2016)
Superior Vena Cava Syndrome
3/6/2018
19
SVC Case Study
Mr. A started chemotherapy immediately.
Additional orders included:
• VS Q_hours
• Maintain O2 saturation > __%
• Elevate head of bed
• Scheduled lasix and methylprednisolone
He responded quickly and was able to breath
easily when he was eventually discharged home.
Nursing Management:
(Vogel, 2016)
Superior Vena Cava Syndrome
• Maintain adequate gas exchange • Maintain adequate cardiac output
• Decrease anxiety • Increase knowledge of disease process and
therapeutic interventions
• Prevent injury • Administer treatment as ordered
Clinical Pearls Know your patient! Know the risk factors! Know how to complete a good physical assessment! Early recognition may save a life!
References Brashers, V. L. (2014). Alterations in Cardiovascular Function. In K. L. McCance & S. E. Huether (Authors) & V. L.
Brashers & N. S. Rote (Eds.), Pathophysiology: The Biologic Basis for Disease in Adults and Children (7th ed., pp. 1129-1193). St. Louis, MO: Elsevier.
Camp-Sorrell, D. (2008). Cardiac Tamponade. In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 513-517). St. Louis, MO: Mosby Elsevier.
Holmes Gobel, B. (2013). Tumor Lysis Syndrome. In Kaplan, M (Ed). Understanding and managing oncologic emergencies: A resource for nurses. (2nd ed., pp. 433-459). Pittsburgh, PA. Oncology Nursing Society.
Jensen, G. (2008). Hypercalcemia of Malignancy (HCM). In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 523-527). St. Louis, MO: Mosby Elsevier.
Kaplan, M. (2013). Spinal Cord Compression. In Kaplan, M (Ed). Understanding and managing oncologic emergencies: A resource for nurses. (2nd ed., pp. 337-383). Pittsburgh, PA. Oncology Nursing Society.
Mack, K. C., & Becker, C. (2008). Superior Vena Cava Syndrome. In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 551-556). St. Louis, MO: Mosby Elsevier.
Maloney, K. W. (2016). Metabolic Emergencies (J. M. Brant, F. A. Conde, & M. G. Saria, Eds.). In J. K. Itano (Ed.), Core Curriculum for Oncology Nursing (5th ed., pp. 478-494). St. Louis, MO: Elsevier.
National Comprehensive Cancer Network (2016). Non-Hodgkin’s Lymphomas, Version 3.2016. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf
Sanofi-Aventis US (2016). Elitek Package Insert. Retrieved from http://products.sanofi.us/elitek/elitek.html#section-4.1
Schulmeister, L., & Gatlin, C. G. (2008). Spinal Cord Compression. In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 546-550). St. Louis, MO: Mosby Elsevier.
Viele, C. S. (2008). Disseminated Intravascular Coagulation (DIC). In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 518-522). St. Louis, MO: Mosby Elsevier.
Vogel, W. H. (2016). Structural Emergencies (J. M. Brant, F. A. Conde, & M. G. Saria, Eds.). In J. K. Itano (Ed.), Core Curriculum for Oncology Nursing (5th ed., pp. 495-508). St. Louis, MO: Elsevier.
Zobec, A. (2008). Tumor Lysis Syndrome (TLS). In R. A. Gates (Author) & R. M. Fink (Ed.), Oncology Nursing Secrets (3rd ed., Nursing Secrets Series, pp. 557-560). St. Louis, MO: Mosby Elsevier.