Oncology Emergencies

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Oncology Emergencies

• Luisa Josiah
• Primary care Oncology Nurse Specialist
• 2012

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Aim

• To increase knowledge and gain an understanding
  of the types of oncology emergencies and the
  subsequent management of the symptoms.

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• Emergencies can arise in oncology, palliative,
  hospice and terminal care. They can cause
  confusion, panic and suffering for both the
  patient and their family. The management of
  emergency situations is therefore important, even
  when the treatment may not prolong life.
  Kaye (1994)
  

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Emergencies

• Spinal Cord compression
• Superior vena cava obstruction (SVCO)
• Neutropenia
• Hypercalcaemia

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Group work

• Group 1 - Spinal Cord Compression
• Group 2 Superior vena cava obstruction
• Group 3 Neutropenia
• Group 4 -Hypercalcaemia
• 10 mins Discuss signs and symptoms and possible
  management of emergency.

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Group 1 feedback

• Spinal Cord Compression

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Spinal Cord compression

• Damage caused by tumour to the vertebral column,
  the spinal meninges, or the spinal cord, or by
  pressure from collapsed vertebrae after
  pathological fracture.

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Incidence

• 5 10 of oncology patients.
• 10 of patients with spinal metastases develop
  cord compression.
• Response dependent upon speed of diagnosis,
  treatment degree of damage
• Patients at risk of cord compression should be
  informed of possible signs and symptoms

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Cancers that can result in cord compression

• Lymphoma
• myeloma 19
• Lung 17
• Breast 12

• Prostate 12
• Urinary Tract 11
• Sarcoma 8
• (Twycross 2001)

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Symptoms

• Pain back or neck
• In 90 of patients
• Localised, present for weeks or months
• Exacerbated by movement, weight bearing
  coughing,
• Radicular pain

• Pain often precedes other neurological symptoms
• Diagnosis often delayed until further
  neurological symptoms develop.

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• Neurological
• Sensory loss -numbness in toes ascending to level
  of compression
• Motor weakness
• Urinary hesitancy retention.
• Bowel dysfunction constipation
• Peri anal numbness

• Signs helpful in defining level of compression
• Motor
• Reflex
• Babinski
• Sensory
• Sphincter

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Risk of Paraplegia

• Progression can be rapid.
• Early diagnosis and treatment essential
• Back pain, sensation of weakness in legs and
  vague sensory symptoms are urgent early
  manifestations
• Patients should be informed and encouraged to
  report symptoms

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Psychological Issues.

• Fear
• Immobility
• Pain
• Feel they are rapidly dying.
• Embarrassed and ashamed loss of bladder and
  bowel control.

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Patient and Family Issues

• Awareness of the cancer becoming metastatic
  palliative focus.
• Visibly more poorly and disabled.

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• Challenge of being presenting symptom of
  diagnosis
• Family helplessness.
• Care may be impossible at home due to practical
  issues

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Management - urgent

• Confirm Diagnosis - MRI scan ASAP (Gold Standard)
• If diagnosis confirmed, Oncology opinion re
  options e.g.
• Radiotherapy, if surgery not possible
• Chemotherapy, if tumour sensitive (rare)
• Surgical opinion for decompression and/or
  diagnosis
• Symptom Control

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Symptom Control

• Dexamethasone (e.g. 8 - 16mg once daily) given on
  suspicion
• Pain Control
• Comfort Measures
• Psychological, emotional, social, spiritual
• Positioning, equipment, nursing care etc
• Communication and breaking bad news
• Bowel and Urinary Management
• E.g. Urinary catheter for retention

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Management continued

• Surgical decompression, depending on condition
  and prognosis.
• Rehabilitation physiotherapy and occupational
  therapy
• Increased nursing and home care

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Spinal Cord Compression

• A medical emergency
• functional outcome dependent upon degree of
  neurological impairment at diagnosis and initial
  response to therapy
• The less extensive the injury to the spinal cord
  before treatment, the greater the likelihood of
  recovery

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Group 2 feedback.

• Superior Vena Cava

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Superior Vena Cava Obstruction (SVCO)

• A narrowing or blockage of a large vein called
  the superior vena cava, which is usually caused
  by cancer.

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Causes

• Usually by an underlying lung cancer. The cancer
  itself maybe pressing directly on the SVC, or it
  may have spread to the lymph nodes nearby which
  have become swollen.
• Other cancers, such as lymphomas or testicular,
  breast, bowel or oesophageal cancers affecting
  the lymph nodes in the chest.
• A blood clot forming in the vein and blocking the
  blood flow-this can result from having a small
  plastic tube (central line) threaded into the
  vein to give treatments such as chemotherapy.

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Signs and symptoms

• Can develop over days or weeks
• Breathlessness swelling around trachea
• Headaches which worsen on leaning forward or
  bending over
• Facial swelling and redness
• Confusion-cerebral oedema
• Visual disturbances
• Swollen neck
• Swollen arms and hands
• Visible swollen blue veins on the chest
• Cyanosis
• Dizziness
• Stridor-laryngeal oedema

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Diagnosis

• Usually by chest X-ray.
• Other tests may be needed particularly if the
  patient is not known to have cancer.

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Management

• Bed rest-ideally with head of bed raised, sitting
  in upright position
• Oxygen therapy
• Medication-diuretics, steroids, anti-coagulants,
  analgesia
• Radiotherapy
• Chemotherapy (only if tumour sensitive to
  chemotherapy e.g. breast cancer, lymphoma)
• Stent

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Psychological Issues

• Very frightening experience because of the
  feeling of swelling, breathlessness and choking
• Maybe the first indication of illness

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Group 3 feedback.

• Neutropenia

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Neutropenia

• Definition-
• Neutropenia is defined as an absolute neutrophils
  count of-
• lt500/mm3 or a count of lt 1000/mm3 and dropping-
  serious
• gt500-1000/mm mild
• gt1000mm/3- 1.5mm/3 acceptable
• Neutropenia is associated with an increased risk
  of potentially life-threatening infection
• Incidence of neutropenic sepsis in the population
  receiving chemotherapy is 10-20

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Chemotherapy

• The side effects of chemotherapy severely
  interferes with cell division in particular the
  production and maintenance of blood products via
  the bone marrow
• Neutrophils are the bodys first line defence
  against bacterial infection and is often one of
  the first category of rapidly dividing cells to
  be affected

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Signs and Symptoms

• Vague
• Pyrexia above 38C
• Hypothermia
• Shivering
• Hot/Cold
• Spontaneous rigor
• Nausea or diarrhoea
• Often looks well- be alert and orientated

• Tachycardia
• Restlessness
• Confusion
• Hypotension
• Hypothermia
• Unconscious
• Obvious signs of infection.
• Feeling unwell

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Management

• HISTORY
• EXAMINE
• ACTION
• TREAT

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Reducing Risks

• Thermometer
• Avoid enclosed spaces with public contact
• Avoid reheated foods
• Chemo-alert cards
• Information
• Phone availability
• Patients that have consistently low white blood
  cell counts may be given granulocyte-colony
  stimulating factor (GCSF) to stimulate white
  blood cell production.

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High Risk patients

• Elderly
• Other co-morbidities
• Poor social conditions
• Patients with CVAD
• Anorexia
• Patients are most susceptible to neutropenia 7-10
  days after chemotherapy

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Learning Points

• How many days is the patient post chemo?
• How long has the patient felt unwell?
• What are the signs and symptoms?
• Paracetamol can mask symptom's
• Patients can deteriorate very quickly!
• Local guidelines
• Aware of those patients at greatest risk
• DEATH within hours!

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Group 4 feedback

• Hypercalcaemia

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Hypercalcaemia

• Tumour induced hypercalcaemia is the most common
  metabolic disorder associated with cancer
  (Heatley 2004)
• Diagnosed when the corrected serum calcium level
  is above 2.6mmol/l Salt 2003)

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Causes

• Release of calcium from the bones is the main
  causative factor in patients with cancer.
• Bone metastases are not always present
• Up to 80 of patients develop hypercalcaemia as
  the result of parathyroid hormone-related
  peptide, which causes increased resorption of
  bone and reduced bone formation with a
  corresponding increase in serum calcium
  (Downing2001)
• Bone metabolism may also be influenced by the
  production of cytokines. Myeloma and Lymphoma
  cytokines in particular cause osteoclasts to be
  activated.

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Symptoms

• Mild (patient ambulatory)
• Fatigue
• Lethargy
• Mental dullness
• Weakness
• Anorexia
• Constipation

• Severe (patient increasingly incapacitated)
• Nausea
• Vomiting
• Ileus
• Delirium
• Drowsiness

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Indications for treatment

• Corrected calcium levels gt 2.8mmols/l
• First episode or long interval since previous
• Previous good quality of life
• Medical judgment that treatment will achieve a
  good response
• Patients willing to have IV therapy and blood
  tests

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Management

• Oral fluids
• IV fluids (saline improves hypocalcaemia by
  improving glomerular filtration rate and
  promoting a calcium diuresis. Can reduce plasma
  concentrations by 0.2-0.4 mmol/l
• Diuretics not appropriate

• Biphosphonates
• Pamidronate
• Zolendronate
• Inhibit osteoclast activity
• Inhibit bone reabsorption
• Given intravenously
• Generally repeated every 3-4 weeks (assess for
  need)
• Oral biphosphonates Bonefos
• Used as oral maintenance therapy

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Acute Oncology
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Any questions ??