ED Rounds – May 2018
Dr. Paul Frankish
Take Home Points
- In patients on Immunotherapy for cancer beware of diarrhea or dyspnea, as it may represent an autoimmune side effect.
-
LMWH is the treatment of choice for the duration of Malignancy associated PE.
-
SVC obstruction is “sneaky” and new dyspnea is far more common than facial swelling.
Immunotherapy
Febrile Neutropenia
A single oral temperature >38.3 deg C
or
A sustained oral temperature >38 deg C
with
An absolute neutrophil count (ANC) less than 500 cells per microliter (0.5 x 109/L)
*Far and away one of the most common oncologic presentations to the ED
*70% hematologic and 30% solid organ malignancies
*Treatment Timelines (as per IDSA):
1.STAT CBC within 10 minutes
2.Broad empiric antibiotics within 60 minutes
History
1.Diagnosis
2.Date and type of last Chemo
3.Use of G-CSF
4.Use of antimicrobials
5.History of prior infection
6.PMH/surgical history
7.Medications/Allergies
Exam
1.Mental Status
2.Volume Status
3.Oral Mucosa
4.Skin/Catheter Sites
5.Respiratory
6.Cardiovascular
7.Abdomen
Treatment
*Imipenem 500 mg IV Q6H or
*Pip/Tazo 3.375 gram IV Q6H or
*Cipro 400 mg IV and Vanco 1 gram IV Q12H if penicillin allergic
*Consider adding Vanco to monotherapy if:
1.IV Catheter Infection
2.Gram positive organism not yet identified
3.MRSA Colonization
4.Hypotension/Shock
SVC Obstruction
*Subacute SVCO results in milder symptoms like facial swelling, cough, dyspnea, facial redness, dilated superficial veins.
*Acute SVCO is more severe and can result in altered LOC, increased ICP, airway obstruction.
*Test of choice is a contrast enhanced CT chest
Treatment
1.Elevate HOB
2.Dexamethasone 10 mg IV
3.Symptom control
4.Airway management if indicated
5.Urgent Radiation Oncology Consult
6.If known Small Cell Lung Cancer, then worth a call to Medical Oncology
Pulmonary Embolus
*New dyspnea of unknown etiology in patient with active malignancy is a PE until proven otherwise
*Alternate explanations for new dyspnea are pericardial effusion, SVCO, lung tumor burden, anemia.
*Preferred treatment is LMWH indefinitely
Investigation of choice is CTPA
ECG may show S1QT3 – But don’t rely on this sign
PoCUS may also be helpful for initial triage of acute dyspneic patient – look for dilated RV and IVC
Treatment
*Dalteparin 200 units/kg sc for 1 month
then
*Dalteparin 150 untis/kg sc thereafter
*Main evidence for LMWH over warfarin comes from CLOT trial
*50% reduction in recurrent VTE with LMWH vs. warfarin
*Presumed to be because of poor tolerance of PO meds in patients with cancer nauseated from chemo
*May not be relevant in era of modern anti-emetics and anticoagulants, data pending
Epidural Spinal Cord Compression
1.Back pain (90% of cases)
2.Motor weakness
3.Sensory impairment
4.Autonomic dysfunction
5.Perianal numbness
6.Conus medullaris syndrome
Investigations and Treatment
*Dexamethasone 10-20 mg IV immediately if SCC is suspected
*MRI is preferred (generally T/L spine)
*Radiation Oncology if previously diagnosed malignancy
*Neurosurgery if new diagnosis of malignancy
SJRH Oncology Services – On Call Consults
Full Presentation
