1. Hem-Onc Emergencies Ratnoff/Weisman
Katia Khoury
PGY3

2. Outline Welcome to Seidman Helpful tips Febrile neutropenia
Tumor lysis syndrome
Acute Chest
Acute leukemia
Cord compression

3. Welcome to Seidman Patients are sicker (mini-ICU)
Check your own pulse first
Do not hesitate to ask for help

4. Welcome to Seidman Ratnoff: Hem-Onc attending
Weisman: Hospitalist, consulting services
Cap is 8 per intern (10 with AI)
Interdisciplinary meetings on T Th at 1pm (seniors)
Daily huddle on S4 at 8am (seniors)
Teaching Wednesdays at 1pm

5. Welcome to Seidman, and UH
x= floor number
Seidman floors: 63xxx
Towers: 420x0
Lakeside: 415x0
Lakeside 55: 47405
ED: 43723
Plasmapheresis is back at UH!
Seidman 3 nutrition room: 4321*
Seidman 4 nutrition room: 1379*
Wolfgang: 63830
Seidman appointments: 43951

6. Oncologic History Who is their oncologist?
When was their last chemo? (Check on EMR IV chemo)
What was their last chemo? (know your acronyms)
Did they get any medications with chemo? (G-CSF)
What is their previous oncologic course?
What access do they have? (mediport, PICC?)
Sickle cell: check care path in portal and OARRS
Inform primary oncologist of patient’s admission

7. Helpful tips
Write your consultants’ pagers and frequently used numbers on the board; it will help the whole team
Keep a small notebook with helpful and common numbers and tips you fill frequently use
Communicate with the nurses and social workers
Communicate with your patients and their families
Write clinical event notes with major updates

8. Febrile Neutropenia
ANC<500 or ANC<1000 with expected nadir <500 over next 48 hours
T 38.0 for >1 hour or T>38.3 once
ANC=WBC count x neutrophils
Is patient HDS? Check set of vitals. Stable for floor?
Examine patient: any localizing symptoms? Any role for imaging?
Cultures STAT (2 sets bld cx peripheral, culture from lines or ports, sputum or stool cx/C Diff or wound cx as indicated), UA, UCx, CXR 2 view

9. Febrile Neutropenia
Cover broadly (G+/G- /pseudomonas/fungals) TIME SENSITIVE
Check previous culture data (in portal)
Neutropenic diet, neutropenic precautions, CBC with differential

11. Tumor Lysis Syndrome K+ PO4 uric acid Ca2+ CaPO4   v 
Laboratory Value
Direction of change
Mechanism K+ 
tumor cell lysis
PO4
DNA release
Uric acid
Ca++ 
PO4 binding

12. Tumor Lysis Syndrome TLS Type Definition Primary Spontaneous Secondary
Treatment-induced
Laboratory
≥ 2 laboratory abnormalities OR
≥ 25% change in 2 values from baseline value
Clinical
Laboratory TLS + end-organ damage

13. Tumor Lysis Syndrome
Seen in high grade liquid tumors like leukemias with leukocytosis, high grade lymphomas, and some solid tumors like small cell lung ca
Clinical Features: weakness, arrhythmias, paralysis, acute renal failure, tetany, altered mental status, seizures
Treatment and prevention: fluids fluids fluids fluids fluids
Rasburicase, HD, allopurinol
Check G6PD before administering rasburicase (risk of AHA, methemoglobinemia)
BID RFP, phos, ionized calcium, uric acid, LDH, PT/PTT
Keep UOP around 100cc/hr

14. Acute Chest
Both routine and life threatening admissions will involve pain
Care path and OARRS
CBC, CMP, retic, LDH, bilirubin
CXR
UA/ UCx, Bld cx if indicated

15. Acute Chest Hypoxia, chest pain, and new infiltrate on CXR
Red flags: Hgb<2g below baseline, RR>22, Sa02<92%, worst HA of life (SAH), new LUQ pain (spl sequestration), fever
Treatment: T&S, pain control, good IV access, urgent heme consult, consider MICU for exchange transfusion
Can use simple transfusion to bridge to exchange transfusion while waiting for MICU bed (does not remove Hgb S)

16. Acute Leukemias (blast crisis)
You do not have to diagnose acute leukemia, just suspect it in the appropriate clinical setting, conduct the workup, and support patients
Clinical presentation: malaise, infection, bleeding (thrombocytopenia, DIC), TLS, hypoxia, leukostasis (high blast count hyperviscosity decreased tissue perfusion MI, ARDS, bowel ischemia, CVA, retinal hemorrhages)
Culture on admission, even if afebrile and asymptomatic
CBC with diff, peripheral smear, peripheral flow cytometry, coags, fibrinogen, D-dimer, RFP
Involve consultants early!

17. Cord compression
Patients may not present with pain, and symptoms may be underwhelming
Obtain a good history and neurologic exam
Steroids: dexamethasone 10mg STAT then 4mg q6 (IV or PO)
Consulting teams: ortho/ neurosurgery, radiation oncology
Pain control
**Cord compression protocol at UH