Oncologic Emergencies. Melissa Davis, MSN, APRN, AOCNP

Transcription

1 Oncologic Emergencies Melissa Davis, MSN, APRN, AOCNP

2 Objectives For each oncologic emergency, review: Definition Signs and symptoms Risk factors Diagnostics Management

3 Metabolic Emergencies: Disseminated intravascular coagulation (DIC) Sepsis Tumor Lysis Syndrome (TLS) Hypercalcemia Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Anaphylaxis Structural Emergencies: Increased intracranial pressure (ICP) Spinal cord compression (SCC) Superior vena cava syndrome (SVCS) Cardiac tamponade

4 Metabolic Emergencies Disseminated intravascular coagulation (DIC) Sepsis Tumor Lysis Syndrome (TLS) Hypercalcemia Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Anaphylaxis

5 Disseminated Intravascular Coagulation (DIC) Definition: Inappropriate, accelerated and systemic activation of the coagulation cascade. Results in thrombosis and subsequent bleeding and hemorrhage Simultaneous clotting and bleeding

6 DIC Signs and Symptoms clotting and bleeding Skin: Bleeding GI: Tarry stools, hematemesis, abd distention/pain GU: Hematuria, decreased UOP Resp: Dyspnea, tachypnea, hypoxia, hemoptysis, cyanosis, SOB Neuro: HA, restlessness, confusion, lethargy, altered LOC, obtundation, seizures, coma CV: Tachycardia, hypotension, decreased peripheral pulses, change in color and temp of extremities

7 DIC Risk Factors Infection and sepsis (most common cause) Malignancy (especially acute promyelocytic leukemia) Trauma Pregnancy Diagnostics: Labs Increased: D dimer assay, FDP titer Decreased: Platelet count, fibrinogen Prolonged: PT/PTT

8 Management of DIC 1. Treat underlying condition (chemo, antibiotics) 2. Hemodynamic support (fluids, oxygen) 3. Blood component therapy Nursing Considerations Monitor bleeding, I/O, assess tissue perfusion Apply pressure dressings to sites of active bleeding

9 Sepsis Definition: Systemic inflammatory response to pathogenic microorganisms and associated endotoxins in the blood. Presents with 2 or more of the following: Temp > 38 or <36 Celsius HR >90 beats/min RR >20 breaths/min WBC >12k or less than 4K, or >10% bands Septic shock hemodynamic instability despite aggressive fluid challenge

10 Sepsis Risk factors: Immunosuppression, comorbidities, age >65 yo, lines and tubes, hospitalization, invasive procedures, loss of mucosal integrity Organisms: Most often bacterial (40% gram neg) Prognosis: Untreated bacteremia with associated neutropenia and septic shock is associated with 50 70% mortality rate

11 Sepsis Signs and Symptoms Constitutional: Fever, shaking chills Neuro: Confused, anxious, restless, decreased LOC Resp: Cough, tachypnea, dyspnea, ARDS CV: Tachycardia, hypotension GI: N/V/D/C, anorexia GU: Decreased UOP progressing to anuria and ARF Skin: Warm, flushed then cool, clammy

12 Management of Sepsis 1. Labs: Blood cultures, CBC, CMP 2. Chest x ray 3. UA and urine culture 4. Cultures of other potential sources of infection: throat, stool, sites of exudate 5. Treat infection start with broad spectrum ABX 6. Hemodynamic support: Fluids, blood components, vasopressors, O2

13 Tumor Lysis Syndrome Definition: Metabolic imbalance caused by the rapid release of intracellular potassium, phosphorus, and nucleic acid into the blood. Occurs as a result of rapid tumor cell kill. Electrolyte abnormalities place pt at risk for cardiac arrhythmias and renal failure.

14 TLS Risk Factors High growth fraction and large bulky tumors Leukemia, lymphoma, small cell lung ca Large tumor burden: LAD, splenomegaly, incr LDH Concurrent renal or cardiac disease Labs Elevated: Uric acid, potassium, phos, LDH, BUN/Cr Decreased: Calcium

15 Tumor Lysis Signs and Symptoms Hyperkalemia: Sx generally when >6.5 EKG changes, N/V/D, muscle weakness Hyperphosphatemia Edema, oliguria, renal insufficiency, ARF Hyperuricemia: Sx generally when >10 Oliguria, azotemia, edema, uric acid nephropathy, N/V/D, pruritis, hematuria, lethargy, seizure Hypocalcemia EKG changes, hypotension, muscle cramps, twitching, paresthesias, diarrhea, seizures, tetany, AMS

16 Management of Tumor Lysis IV Hydration with UOP of ml/hr Allopurinol or rasburicase Forced diuresis: loop diuretics Hyperkalemia: Dialysis Mild (<6.5): Na Polystyrene Sulfonate (Kayexalate) Severe (>6.5 +/ EKG change): Ca gluconate, glucose + insulin

17 Hypercalcemia Etiology Bone destruction from tumor invasion Tumors secrete hormones and/or cytokines that act locally or systemically to induce bone resorption

18 Hypercalcemia Signs and Symptoms Early: Confusion, lethargy, weakness, hypotonia, constipation, N/V, polyuria, dehydration Late: Seizure, obtundation, coma, obstipation/ileus, renal failure

19 Hypercalcemia Risk Factors Breast, lung, head & neck and renal cancer, MM, lymphoma Labs Monitor electrolytes, albumin, renal function If concern for bony involvement of disease, check phosphorus and alkaline phosphatase Check EKG

20 Management of Hypercalcemia Mild/Asymptomatic PO fluids Mod/Severe (Ca >12 mg/dl) Vigorous IV hydration +/ furosemide Anti resorptive therapy: bisphosphonates +/ calcitonin (nasal) Non pharmacologic Exercise, weight bearing activity Active or passive ROM for bedridden patients Seizure precautions if calcium >12 mg/dl *** Treat the cancer: chemo or radiation for metastatic tumors ***

21 Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) Definition: Endocrine paraneoplastic syndrome which results in inappropriate production and release of antidiuretic hormone (ADH), leading to impaired renal (free water) excretion. Results in dilutional serum hyponatremia, high urine osmolality, intracellular edema Complications: neuro sx, cerebral edema

22 SIADH Signs and Symptoms Most symptomatic if Na <115 meq/l or if hyponatremia occurs in <48 hrs Symptoms are related to cerebral edema Mild (Na meq/l): Generally asymptomatic. May experience nausea, anorexia, malaise, fatigue, weakness, muscle cramps Moderate (Na meq/l): Thirst, HA, confusion, vomiting, lethargy, weight gain, combativeness, psychosis Severe (Na <115 meq/l): Delirium, obtundation, refractory seizures, coma and death

23 SIADH Risk Factors ***Small cell lung cancer*** (also seen in NSCLC, head & neck) Infections (PNA, TB, abscess) Chemotherapy (especially high dose cyclophosphamide) Medications (narcotics, anesthesia, diuretics, NSAID, TCA, SSRI) CNS (meningitis, intracranial hemorrhage, head trauma) Pain, stress SIADH Labs Decreased: Serum sodium and osmolality Increased: Urine sodium, osmolality, specific gravity

24 Management of SIADH Treat the underlying cause and correct hyponatremia Mild (Na meq/l): Fluid restriction of 500 to 1000 ml/day. Corrects over 3 to 5 days. Mod (Na meq/l): Demeclocycline if fluid restriction cannot be maintained or hyponatremia persists. Onset in 3 to 5 days. Severe (Na <115 meq/l) : Hypertonic (3% to 5%) saline +/ concurrent lasix. Vasopressin antagonists: Tolvaptan, Conivaptan

25 Anaphylaxis Definition: Immediate, systemic hypersensitivity reaction which usually occurs within seconds to minutes after the administration of a foreign protein. Mediated by IgE Can result in respiratory failure, cardiovascular collapse, and possibly death. High risk agents: Taxanes, platinums, asparaginase, epipodophyllotoxins, rituximab

26 Testing for Anaphylaxis Intradermal skin test for agents with a high suspicion for hypersensitivity reactions (ie asparaginase) Test dose of agents (ie 1/10 th of dose) if prior history of allergy with drug exposure Preventionof Anaphylaxis Premedication: acetaminophen, H1 blocker (diphenhydramine), H2 blocker (famotidine), corticosteroids

27 Signs and Symptoms of Anaphylaxis Urticaria, pruritis, angioedema Dyspnea, wheezing Dizziness Hypotension, tachycardia, shock Nausea, vomiting Abdominal pain Flushing Headache Chest tightness, substernal chest pain Feeling of impending doom

28 Management of Anaphylaxis Stop offending agent ABCs: Airway, breathing, circulation IVF Anaphylaxis meds: Epinephrine 1:1000 (if angioedema, hypotension) Diphenhydramine Corticosteroids H2 antagonist (famotidine) Beta 2 agonist/inhaled bronchodilator (albuterol) Vasopressors (if hypotension) Antiarrhythmia meds

29 Structural Emergencies Increased intracranial pressure (ICP) Spinal cord compression (SCC) Superior vena cava syndrome (SVCS) Cardiac tamponade

30 Increased Intracranial Pressure (ICP) Primary/metastatic tumors or bleeding within intracranial cavity Displace brain tissue, cause edema of brain tissue, obstruct CSF flow and/or cause increased vascularity (from tumor growth) Increases intracranial pressure, which can result in nerve cell damage and death.

31 Signs and Symptoms of Increased ICP Early Signs: HA, especially early morning Changes in vision: blurred vision, diplopia, decreased visual fields Changes in LOC: lethargic, confused, restless GI: anorexia, nausea, vomiting Late Signs: CV: Bradycardia Resp: Slow, shallow respirations, tachypnea Neuro: Decreased LOC, hemiparesis, seizures, pupillary changes, papilledema Very late= Cushing s triad: HTN, bradycardia, abnormal respirations

32 Risk Factors for Increased ICP Tumors that are more likely to metastasize to the brain: Lung, breast, testes, thyroid, stomach or kidney, melanoma Primary tumor of brain or spinal cord Leukemia Thrombocytopenia Diagnostic Tests Head CT quick, often first test Brain MRI Cerebral angiography (vascular abn vs tumor) CT guided or MRI directed stereotactic bx

33 Management of Increased ICP Nonpharmacologic: Emergent surgery Shunt placement Hyperventilation (ICU) Radiation therapy Pharmacologic: Chemotherapy Corticosteroids Osmotherapy (mannitol) Anticonvulsants, if needed Nursing Considerations: Maintain bed rest, avoid prone position, elevate HOB 30 degrees Avoid isometric muscle contractions and neck flexion/extension Avoid Valsalva s maneuver Manage N/V

34 Spinal Cord Compression (SCC) Neurologic emergency when primary tumors or vertebral metastases compress neural tissue and its blood supply, resulting in compromised neurologic function. Requires emergent treatment.

35 Signs and Symptoms of SCC Early: Neck or back pain (96%): local and/or radicular Motor symptoms: heaviness, stiffness, weakness Sensory loss for light touch, pain or temp Late: Sensory loss for deep pressure, vibrations, position Incontinence or retention of urine/stool Sexual impotence Paralysis Muscle atrophy

36 Risk Factors for SCC: Cancers that metastasize to bone: breast, lung, prostate, renal, melanoma, myeloma Cancers that metastasize to the spinal cord: lymphoma, seminoma, neuroblastoma Primary cancer of the spinal cord Diagnostic Tests: MRI: diagnostic procedure of choice for evaluating SCC Spinal x ray, bone scan, CT and/or myelogram may be used to help evaluate metastasis, bone abn, and bone stability

37 Management of SCC Radiation: Most common treatment Surgery: If tumor not responsive to RT or if max radiation dose already achieved Surgery followed by radiation Corticosteroids: Reduce edema, pain Chemotherapy (adjunct to RT and/or surgery) Analgesics/pain management Nursing Considerations Neuro checks q8hrs, strict I/O, monitor for urinary retention Request PT/OT consult Pain management, bowel and bladder program

38 Superior Vena Cava Syndrome (SVCS) Obstruction of the superior vena cava, resulting in compromised venous drainage of the head, neck, upper extremities and thorax Caused by tumor invasion, enlarged lymph nodes, thrombus

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40 Signs and Symptoms of SVCS: Symptoms can develop slowly or acutely. Slow progression allows for the development of collateral blood Early s/sx Facial swelling on arising Periorbital edema Swelling & erythema of arms, face, neck, hands Cyanosis of upper torso ***Dyspnea***, dry cough Hoarseness Prominent venous pattern (dilated veins of face, neck, thorax) Late s/sx Severe HA Irritability Visual disturbances, blurred vision Dizziness, syncope Changes in mental status Stridor Tachycardia CHF Decreased BP Horner s Syndrome Dysphagia Hemoptysis

41 Risk Factors for SVCS Lymphoma involving the mediastinum; lung cancer; metastatic breast or germ cell cancer Kaposi s sarcoma Presence of central venous catheter (CVC) Previous RT to the mediastinum Diagnostic Tests CXR often initial evaluation Chest CT (with contrast) most useful diagnostic information MRI very sensitive, but pt generally unable to tolerate supine position

42 Management of SVCS: Treat underlying cause Radiation Pharmacologic management: Chemotherapy (+/ RT) Remove CVC and anticoagulate if catheter induced Corticosteroids, diuretics (controversial) Surgical management: Stent placement, surgical reconstruction Symptom management: Oxygen therapy Nursing Considerations Avoid venipuncture/measurement of BP in upper extremities; Remove rings and restrictive clothing; Elevate HOB; Avoid Valsalva

43 Cardiac Tamponade Excess accumulation of fluid in the pericardial sac, resulting in decreased cardiac output and compromised cardiac function

44 Signs and Symptoms of Cardiac Tamponade Early Retrosternal chest pain Worse when supine Relieved by leaning forward Dyspnea Cough Muffled heart sounds, weak apical pulse Late Tachycardic, tachypneic hypotensive Pulsus paradoxus Narrow pulse pressure Altered mental status Peripheral edema Oliguria Beck s triad

45 Risk Factors for Cardiac Tamponade Primary tumor of the heart (rare) Metastatic tumors to the pericardium (lung, breast, GI tract, leukemia, lymphoma, sarcoma, melanoma) Radiation to field which includes heart Diagnostic Tests Echocardiogram (ECHO) most precise diagnostic test Chest x ray or CT may show pericardial effusion, masses, enlarged pericardium. Limited diagnostic ability EKG with non specific abnormalities

46 Management of Cardiac Tamponade Remove fluid: pericardiocentesis, pericardial window Pericardial sclerosis Radiation Chemotherapy Nursing Considerations Oxygen, elevate HOB, manage pain Monitor BP, HR, respiratory status, volume status, mental status

47 Thank you! Questions?