Oncologic Emergencies: Recognize and Act
What the exam tests
Rapid recognition and first actions for febrile neutropenia and sepsis, tumor lysis syndrome, hypercalcemia, SIADH, spinal cord compression, superior vena cava syndrome, hyperviscosity, DIC, cardiac tamponade, anaphylaxis, extravasation, and cytokine release syndrome.
Febrile neutropenia
A single oral temperature ≥38.3 °C, or ≥38.0 °C sustained over one hour, with an ANC below 500 (or below 1000 and falling). Draw blood cultures, obtain a CBC, and give empiric broad-spectrum antibiotics within 60 minutes. No rectal temperatures, suppositories, or enemas.
Tumor lysis syndrome
Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and rising creatinine. Prevention in high-risk patients centers on vigorous hydration plus allopurinol or rasburicase.
Hypercalcemia
"Stones, bones, groans, and psychiatric moans" - polyuria, constipation, weakness, confusion. Treat with isotonic saline and a bisphosphonate.
Spinal cord compression
New back pain, motor weakness, sensory change, or bowel/bladder dysfunction. Give dexamethasone and obtain an urgent MRI; plain films are not adequate and delay care.
SVC syndrome
Facial and upper-extremity edema, distended neck veins, dyspnea, and prominent chest veins. Elevate the head of the bed, give oxygen, and obtain an urgent oncology consult; avoid new upper-extremity IV access.
Traps
A low or unknown ANC with fever in a patient who received chemotherapy a week ago is febrile neutropenia until proven otherwise - do not wait for the ANC result to start antibiotics. Also, do not insert a rectal probe or give rectal medications.
Rule of thumb
Fever plus recent chemotherapy equals sepsis until proven otherwise - treat within the hour.