Oncologic Emergencies
Objectives • Identify the major oncologic emergencies
• Describe the assessment for each emergency
• Outline the standard of care of patients
experiencing oncologic emergencies
Structural • Spinal Cord Compression • Superior Vena Cava Syndrome • Increased Intracranial Pressure • Cardiac Tamponade • Malignant Pleural Effusion • Bleeding/Thrombosis
Metabolic • Desseminated Intravascular Coagulation • Syndrome of Inappropriate Antidiuretic
Hormone Secretion • Tumor Lysis Syndrome • Hypercalcemia • Sepsis • Anaphylaxis/Infusion Reaction
Spinal Cord Compression SCC • Description
– Extension of tumor into epidural space – Pathologically collapsed vertebral bone impinging the
spinal cord • Manifestation
– Back pain, weakness, sensory loss, autonomic dysfunction, paraplegia
• Evaluation/Diagnosis – MRI
Spinal Cord Compression SCC • Treatment
– Steroids – Surgery – Radiation – chemotherapy
• Nursing Management – Recognize early signs – Pain management – Emotional support – rehab
Superior Vena Cava Syndrome SVC • Description
– Tumor or thrombus invasion or impingement – Venous output restriction/congestion – Decreased cardiac output
• Manifestation – Dyspnea – Edema – Dysphagia – Headache – Dizziness – syncope
Superior Vena Cava Syndrome SVC • Evaluation/Diagnosis
– CT with contrast • Treatment (based on the cause)
– Radiation – Chemotherapy – Surgery-stent placement – Thrombolytics
• Nursing Management – Airway protection – Cardiovascular support – Emotional support
Increased Intracranial Pressure ICP • Description
– Tumor or fluid causing compression within the brain case
• Manifestation – Altered mental status, nausea, headache,
hypertension, focal neurological deficits
• Evaluation/Diagnosis – CT, Brain MRI, NO LP
Increased Intracranial Pressure ICP • Treatment
– Reduce fluid in the brain • Osmotic diuretics-mannitol • corticosteroids
– Surgery – Radiation
• Nursing Management – Neuro assessment – Bed/chair elevation – Support for neuro deficits
Cardiac Tamponade • Description
– Excessive fluid in the pericardial sac – Decreases cardiac output
• Manifestation – Dyspnea, anxiety, tachycardia, restlessness, fatigue,
chest pain, restless, MS changes, lethargy, LOC changes
• Evaluation/Diagnosis – Echocardiogram, chest xray, pulsus paradoxus
Cardiac Tamponade • Treatment
– Immediate pericardiocentesis – Sclerosis – Pericardial catheter or window – pericardiectomy
• Nursing Management – Early recognition – Assessment of cardiac, respiratory and neuro systems – Tube/dressing management
Malignant Pleural Effusion • Description
– Fluid collection in the pleural space that can lead to respiratory distress/failure
• Manifestation – Dyspnea, cough, pleuritic chest pain, orthopnea,
anxiety, fear of suffocation
• Evaluation/Diagnosis – Chest xray, CT
Malignant Pleural Effusion • Treatment
– Thoracentesis – Chest tube/tunneled pleural catheter
• Nursing Management – Respiratory and cardiac assessment – Tube/device care – Patient/family education – Comfort measures
Bleeding
• Description – Reduction of platelets, esp. <20K – Heme malignancies – Altered platelet function (NSAIDs, antibx) – Tumor invasion – Anti-VEGF treatment regimens
• Manifestation – Gums, nose, GI, cranial, intraperitoneal
Bleeding • Evaluation/Diagnosis
– Risk assessment – Platelet counts – Clotting factor deficiency – hemoccult
• Treatment – Transfusion, growth factors, tx the source or cause
• Nursing Management – safety
Thrombosis
• Description – 7 fold risk in cancer patients for venous
thromboembolism ( VTE)
• Manifestation – DVT – Pulmonary Embolism
Thrombosis • Evaluation/Diagnosis
– Radiology/ECG – Blood gases – Ultrasound/angiography
• Treatment – Embolectomy – Subsequent anticoagulation/Vitamin K
• Nursing Management • Respiratory/hemodynamic support
Disseminated Intravascular Coagulation DIC
• Description – Coagulation disorder involving widespread intravascular
thormobisis
• Manifestation – Bleeding, organ damage/failure
Disseminated Intravascular Coagulation DIC • Evaluation/Diagnosis
– Rapid plt decline – Prolonged coagulation tests – Fibrin degradation products/D-dimer
• Treatment – Underlying disease – Blood components – Restore anticoagulation
DIC
• Nursing Management – Symptom recognition – Monitoring – Oxygen – Administration of blood
products/factors
Syndrome of Inappropriate Antidiuretic Hormone SIADH
• Description – Tumor secretion of antidiuretic hormone
• Manifestation – Water retention/hyponatremia/concentrated
urine
• Evaluation/Diagnosis – Electrolytes/serum and urine osmolality
Degree of Hyponatremia
Sodium Level Signs/Symptoms
Normal sodium 135-145 mEq/L
Mild 131-135 mEq/L
Thirst, anorexia, nausea, fatigue, weakness, muscle cramps, headache
Moderate 126-130 mEq/L
Weight gain, oliguria, neurologic symptoms
Severe <120 mEq/L Secondary to cerebral edema, papilledema, delirium, hypoactive reflexes, ataxia, gait disturbances, seizures, coma, death
SIADH • Treatment
– Underlying disease – Fluid restriction/hypertonic saline – Demeclocycline and vaptans
• Nursing Management – Fluids – I/O – high sodium diet – Neuro checks
Tumor Lysis Syndrome-TLS • Description
– Rapid, high volume destruction of cancer cells after treatment
• Manifestation – Hyper: potassium, phosphate, uric acid – Hypo: calcium
• Evaluation/Diagnosis – CBC, Chemistry, urinalysis
Tumor Lysis Syndrome-TLS
• Treatment – Hydration/diuresis – Allopurinol/rasburicase – Alkalinization of the urine
• Nursing Management – Know patients at risk – prophylaxis
Hypercalcemia
• Description – Release of calcium in advanced bone involving
cancers
• Manifestation – Organ systems – CNS – kidneys
Hypercalcemia • Evaluation/Diagnosis
– Serum/corrected calcium – Renal function/status
• Treatment – Hydration/diuresis – Treat underlying disease – Biphosphonates-long term
• Nursing Management
Sepsis
• Description – Body’s failure to mount adequate immune
response to an overwhelming infection
• Manifestation – Fever/tachycardia/tachypnea/shaking chills – Hypotension/hypoperfusion/organ failure – Metabolic acidosis
Sepsis • Evaluation/Diagnosis
– CBC w/differential, chemistry – Cultures – radiology
• Treatment – IV fluids, pressors – Blood products – antibiotics
• Nursing Management
Anaphylaxis/Infusion Reaction • Description
– Systemic immune reaction to the infusion of agents
• Manifestation • Mild: sense of doom or not right, itching,
wheezing • Severe: bronchospasm, angioedema,
hypotension
Anaphylaxis/Infusion Reaction • Evaluation/Diagnosis
– Based on symptoms – Tryptase/allergy testing
• Treatment – Antihistimines/steroids – Epinenphrine – Cardiovascular/respiratory support
• Nursing Management