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

You may also see this

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 – 40-80 mg IV Q 2-4 hours Excrete calcium

Potassium and phosphate repletion

Bisphosphates – pamidronate, zoledronic acid – inhibit osteoblasts

Hydrocortisone – 25-200 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