Hematologic/Oncologic Emergencies

Scenario 1 48 year old male presents to the ED with Altered mental status, patient is confused and lethargic. On laboratory studies platelet count is 75,000 and Hgb is 9.5 mg/dL with no history of heparin exposure or hx of heart valves, schistocytes seen on peripheral smear.

TTP Schistocytes = bad (think about microangiopathic hemolytic anemia) This patient satisfies 3/5 for TTP: Thrombocytopenia and neurologic as well What are other two?

Thrombotic Thromobocytopenic purpura Mortality up to 80% if left untreated Pathology from microthrombi in vessels Exists on a spectrum with Hemolytic Uremic Syndrome (HUS)  Renal abnormalities more common in HUS

TTP Can see elevated LDH and decreased haptoglobin (markers of hemolysis) TTP is a platelet problem rather than consumptive like in DIC Tx: Steroids – methylprednisolone 125mg IV  Dialysis for renal failure  PLASMA exchange – Replete ADAMTS13 enzyme  FFP if plasma exchange is delayed or chronic  Avoid platelet transfusion

Scenario 2 19 year old girl with history of Sickle cell disease (SS trait) presents to the ED with complaints of chest pain, pleuritic in nature, associated with shortness of breath and fever, sat is 90% on RA

Acute chest syndrome Chest radiograph shows: this can be seen in SS, SC, sickle-thalassemia Present with cough, fever, chest pain, SOB

Sickle Cell Disease Acute Chest syndrome  Tx: Supplemental 02, hydration and antibx Vaso-occulsive crisis  Severe unremitting pain Aplastic crisis  Decreased retic count

Scenario 3 A 50 year old female with hx of breast cancer complains of being tired, weak, nauseated with generalized abdominal pain. Vital WNL and physical exam unremarkable, family reports she appears a little more confused (slower to answer) but oriented.

Hypercalcemia CBC and urinalysis normal Calcium found to be 14 mg/dL Most common life threatening disorder associated with cancer

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Hypercalcemia “Stones, Bones, Groans, Moans” From bone destruction, PTH-like substance release, osteoclast activating factor Labs:  elevated Ca – check ionized Ca  Phos normal or decreased  Alk phos – normal or increased  Potassium – decreased in 50 % of patients  Albumin - decreased

Management IV fluids – usually improves with just this Furosemide – mg IV Q 2-4 hours  Excrete calcium Potassium and phosphate repletion Bisphosphates – pamidronate, zoledronic acid – inhibit osteoblasts Hydrocortisone – mg IV q 6-8 H  Shown to decrease intestinal absorption of calcium and Vit D

Tumor Lysis syndrome Usually Occurs within 5 days after radiation/chemotherapy Due to repaid release of cell contents into blood stream Most common  Leukemias  Lymphomas  Small cell ca  Metastatic adenoca

What you see Hallmarks:  Hyperuricemia (DNA breakdown)  Hyper kalemia ( cytosol breakdown)  Hyperphosphotemia (protein breakdown)  Secondary hypocalcemia Acute kidney failure Arrhythmias

Management Stop the chemotherapy Aggressive IV hydration with diuresis Allopurinol or Rasburicase