1. Oncologic challenges in the ED (besides not getting the old chart from TBCC) Grand Rounds Gord McNeil

2. 6 Cases 6 CasesApproachManagement Calgary perspective

3. Case 1 52 year old female with breast cancer presents to the ED with mid back discomfort, progressive weakness of left leg X 1 week and today urinary incontinence Recent radiation at TBCC (no old chart available)

4. Approach Physical T=37.3 Hr=92, RR=14, BP=172/89 T=37.3 Hr=92, RR=14, BP=172/89 Decreased sensation left abdominal wall and right lower leg Decreased sensation left abdominal wall and right lower leg Decreased power at right knee and ankle Decreased power at right knee and ankleLabs Hg=109, Plts =302, WBC =6.8, normal lytes and INR. Hg=109, Plts =302, WBC =6.8, normal lytes and INR.

5. Differential diagnosis Epidural abscess Epidural hematoma Metastatic spinal cord compression Routine causes of back pain

6. Treatment Dexamethasone IV 10mg prior to MRI, then 4-8 mg q6-8hours Emergent MRI of entire spine (because pt can have synchronous, multifocal, asymptomatic MSCC.

7. Treatment Call Spine service Decompression of spinal cord is the key to salvage of function Decompression of spinal cord is the key to salvage of function Patchell et al 2 in 2005 - radiation for 10 days and decompressive surgery within 24 hours improved outcomes of ambulation, continence and functional abilities from 84% compared to radiation alone for 57%

8. Metastatic spinal cord compression Causes breast(30%), breast(30%), lung (15%) lung (15%) prostate (15%) prostate (15%) Other OtherSites thoracic, then lumbar then cervical thoracic, then lumbar then cervical

9. MSCC - causes 1. Expansion of vertebral bone metastasis into epidural space causing cord compression – radiation helps 2. Neural foramina extension by a paraspinal mass. – radiation helps 3. Destruction of vertebral cortical bone - requires surgical intervention.

10. Prognosis Start of onset of symptoms: Onset:1-7 days8-14days>14 days Ambulate: 35% 55% 86% (1) Faster onset = worse prognosis Faster onset = worse prognosis Start of therapy: dexamethasone and time to surgery Favorable histology - radiosensitive tumors

11. Treatment Radiation only arrests the progression of nonradiosensitive tumors and does not stabilize the spine Surgery allows immediate cord decompression whereas radiotherapy typically takes several days to weeks.

13. Calgary perspective Radiation oncology – Dr. Elizabeth Yan Radiation did have an important initial role prior to 2005. Now acute surgical decompression and post op radiation is the standard of care. Radiation did have an important initial role prior to 2005. Now acute surgical decompression and post op radiation is the standard of care.

14. Calgary perspective Case scenarios Highly suspicious for occult CA and back pain then plain films and MRI – no steroids Highly suspicious for occult CA and back pain then plain films and MRI – no steroids Known CA and back pain without neuro deficit then MRI, steroids and radiation oncology Known CA and back pain without neuro deficit then MRI, steroids and radiation oncology Known CA with neuro deficit, then steroids, MRI and spine service Known CA with neuro deficit, then steroids, MRI and spine service

15. Case 2 48 yr old male presents to ED with large hemoptysis X 2 Recently treated at TBCC for lung CA (old chart not available) HR =129, RR=32, sat=90% 5L, BP=167/96

16. Approach Mobilize team early Pulmonary Pulmonary DI/ IR DI/ IR ICU ICU Thoracics Thoracics

17. Approach Stabilize Unstable airway Unstable airway ETT – large size to faciliate bronchoscope Not the panacea Not the panacea Pulmonary toilet – very important Selective placement of ETT

18. Approach Stabilize CXR –localizes bleeding CXR –localizes bleeding Patient position – bleeding side down Patient position – bleeding side down Blood products/ fluids prn Blood products/ fluids prn

19. Approach Imaging CT scan can be done if pt not intubated and has stable airway prior to interventional radiology for bronchial artery emobilization CT scan can be done if pt not intubated and has stable airway prior to interventional radiology for bronchial artery emobilization If ETT then often bronch before IR to localize bleeding If ETT then often bronch before IR to localize bleeding

20. Approach Hemoglobin not important patients die of hypoxia not anemia patients die of hypoxia not anemia not like GI bleed not like GI bleed

21. Causes 1.Friable endobronchial tumors 2.tumor eroding into a small intrapleural vessel 3.tumour eroding in to one of the major vessels of the thorax. 4.Large vessels bleeds = death

22. Calgary perspective Dr. Alain Tremblay One of the few indications for stat call for pulmonary in the middle if the night – involve pulmonary early One of the few indications for stat call for pulmonary in the middle if the night – involve pulmonary early Mobilize CT and Interventional radiology early Mobilize CT and Interventional radiology early Supportive management essential Supportive management essential

23. Case 3 73 yr old male with thyroid cancer c/o increased secretions, stridor and SOB. HR = 112, RR=36, BP=178/102, sat=91%on NRB

24. Approach Stabilize O2, suctioning of secretions and allowing patient to sit up O2, suctioning of secretions and allowing patient to sit up Labs, CXR Labs, CXR

25. Why is it happening? Usually a subacute process unless an already marginal airway is suddenly compromised by an acute infection, bleeding or the patient’s inability to handle secretions. Thyroid and esophageal carcinomas may compress the trachea by invading the surrounding soft tissue Can occur from scarring from prolonged intubation or from radiation therapy

26. Treatment Consultant Consultant Pulmonary – Rigid scope for endobronchial stenting or laser abalation Pulmonary – Rigid scope for endobronchial stenting or laser abalation Steroids – not helpful (only if known lymphoma) Steroids – not helpful (only if known lymphoma)

27. Calgary perspective Needs rigid scope Drs Tremblay and Michaud only 2 pulmonologist in Calgary who do rigid scope (Some thoracic surgeons do as well) Drs Tremblay and Michaud only 2 pulmonologist in Calgary who do rigid scope (Some thoracic surgeons do as well) Can call pulmonary at any site and then can help management patient and arrange for rigid scope Can call pulmonary at any site and then can help management patient and arrange for rigid scope

28. Case 4 86 yr old female with metastatic lung CA with progressive SOBOE over last 2 weeks, now SOB at rest. Nonproductive cough, no fever. HR =92, RR=24, BP 164/92 Sat=94% on 2L

29. Effusion CXR

30. Approach StabilizeLabsCXRPleurocentesis

31. Why is it happening ? Most common from lung, breast, ovary and lymphoma Pleural seeding by neoplastic cells increases capillary permeability and produces an exudative effusion Direct erosion into a blood vessel can cause an abrupt hemorrhagic effusion

32. Calgary perspective Dyspnea clinic Run by Dr. Trembaly and Dr. Michaud Run by Dr. Trembaly and Dr. Michaud Refer if known CA with symptomatic effusion or if highly suspicious for cancer Don’t necessarily need tissue diagnosis Don’t necessarily need tissue diagnosis

33. Dyspnea Clinic Tap in ED, send referral. Appt usually in 2 weeks Clinic places pleurodex catheter and have home care drain it off as necessary If tapped in ED and return prior to appt, may need admission to pulmonary Clinic number -521 3511 – Pat Barkley

34. Case 5 64 yr old female with metastatic breast CA to liver “flu –like” symptoms, N/V, lethargy, weakness X 2 weeks HR =110, RR=16, BP=100/56, Sat =84% RA GCS = 13, no focal deficit, clinically “dry”

35. Approach Labs Hg =112, WBC =9.4 Plts =186 Hg =112, WBC =9.4 Plts =186 Glc = 7.5, Na =132, K = 3.5 Glc = 7.5, Na =132, K = 3.5 Creatinine =364 (new) Creatinine =364 (new) Calcium= 3.64 albumin =29 Calcium= 3.64 albumin =29Management

36. Treatment Measure ionized calcium ABG ABG Corrected calcium = measured calcium + (0.02 X(40 – measured albumin) Corrected calcium = measured calcium + (0.02 X(40 – measured albumin) Lower the albumin and the corrected calcium goes up Lower the albumin and the corrected calcium goes up

37. Treatment Replace volume first Sodium inhibits reabsorption of calcium Sodium inhibits reabsorption of calcium Need urine output – 100cc/hr Need urine output – 100cc/hr After euvolemic, then lasix with volume maintenance Follow K and Mg closely

38. Causes of hypercalcemia in malignancy One of the most common complications of cancer - 10-20% MC caused by breast, lung, renal and cholangiocarcioma and multiple myeloma and lymphoma Mobilization of bone calcium more rapidly than it can be cleared by the kidneys Secretion of parathyroid hormone Presence of bone mets that cause local destruction

39. Case 6 62 yr old male with CML with a recent exacerbation of COPD put on prednisone and levaquin Acute onset of flank pain then new tonic clonic seizure x 3 minutes Hr =48, RR =28, BP = 88/52, sat =94%NRB, T=37.6, C/S=6.8

40. Approach StabilizeLabs Hg = 109, WBC =38, plts=201 Hg = 109, WBC =38, plts=201 K = 6.8, Na = 132, glc = 6.9 K = 6.8, Na = 132, glc = 6.9 Cr= 342, urea =32 Cr= 342, urea =32 Calcium = 1.87, Phosphate = 2.78, albumin =38 Calcium = 1.87, Phosphate = 2.78, albumin =38 Diagnosis ?

41. Tumor Lysis Syndrome HyperkalemiaHyperphosphatemiaHypocalcemia Renal failure Renal colic

42. Tumour lysis syndrome - causes Large burden of tumor is rapidly and acutely destroyed causes outpouring of potassium, nucleic acids and phosphates. Sudden build up of electrolytes MC seen with lymphoma and leukemia, but can also occur with solid organ tumors Usually within 6 hours to 6 days after the initiation of therapy Can occur with the administration of corticosteroids to a susceptible patient

43. Symptoms of hyperkalemia - weakness and altered MS and arrthymias - weakness and altered MS and arrthymiasHyperphosphotemia Causes acute precipitation of calcium in the kidneys and tissues leading to…. Causes acute precipitation of calcium in the kidneys and tissues leading to…. Symptoms of hypocalcemia carpopedal spasm and seizures carpopedal spasm and seizures Renal failure secondary to increased uric acid levels producing renal tubular necrosis secondary to increased uric acid levels producing renal tubular necrosis Symptoms of renal colic secondary to increased uric acid levels producing renal tubular necrosis secondary to increased uric acid levels producing renal tubular necrosis

44. Treatment -Tumor lysis syndrome Aggressive hydration if urine output exists Alkalinization of urine to pH 7 (can worsen hypocalcemia) Correct electrolytes and follow closely Lasix Allopurinol – 600- 900mg loading dose Hemodialysis

45. Rad onc, Med onc, no onc…who goes where? Radiation therapy Patient with active radiation – usually gets s/e 2 weeks after starting radiation until 2 weeks after completing radiation – eg diarrhea Patient with active radiation – usually gets s/e 2 weeks after starting radiation until 2 weeks after completing radiation – eg diarrhea Medical oncology Patient with chemo within the last month Patient with chemo within the last month Usually febrile neutropenia at 5 days Usually febrile neutropenia at 5 days No oncology No tissue diagnosis?? – hospitalist

46. Questions