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Unit IV: Cancer: Cancer Emergencies Hypercalcemia of Malignancy (Remember: normal calcium level is 8.5 to 10.

5 mg/dl) Most common life-threatening metabolic disorder in cancer patients. Occurs in 10 20% of all adults with cancer. Solid tumors (e.g. lung ca or breast ca) and certain hematologic cancers (particularly multiple myeloma(solid tumor of the bone marrow)) are the most frequently associated. Causes: o Increased bone resorption (resorption is the lysis and assimilation of a substance) caused by circulating tumor factors: PTHrP (ParaThyroidHormone-related peptide)- most common (Just know that the increased born resorption is caused by the systemic toxic effect of the cancer)- or osteolytic bone metastases (where the bone is broken down. That calcium from that bone has to go somewhere.) o with mobilization of calcium in the extracellular fluid, along with inadequate renal calcium clearance.

53 yr old woman with pathologic fracture d/t metastatic breast cancer. (The easy fractures are caused by the increased bone resorption that is caused by PTHRP which is produced by some solid tumors. It will cause the calcium in your bones to leak out.) Hypercalcemia of Malignancy Contributing factors: o Immobility, dehydration (if you dont have enough fluid your blood constituents are going to be more concentrated), anorexia, nausea/vomiting exacerbate the problem. o Hormonal therapy (e.g. androgens, estrogens, progestins, antiestrogens) may precipiate hypercalcemia. Signs and symptoms (Can be s/s of hypercalcaemia of any cause): weakness, Deep Tendon Reflexes, impaired muscle strength, polyuria, CNS impairment with progressive obtundation (refers to less than full mental capacity), cardiac bradyarrhythmias (Where the heart slows down), heart block, asystole, and cardiac arrest. Hypercalcemia of Malignancy Medical management: o Medications to inhibit bone resorption: bisphosphonates (like boniva. The same ones we give to people suffereing from osteoperosis); calcitonin (Another parathyroid hormone that lays down bone. Is given as a IV infusion or can be given as a nasal spray)

o IV fluids to correct water loss from polyuria o Moderate doses of furosemide (Lasix) may increase calcium excretion. (but you have to be careful because you dont want to dehydrate the patient with the lasix because then the blood will become concentrated with calcium again and you will have the same exact problem.) o Corticosteroids, phosphates, prostaglandin synthesis inhibitors (NSAIDS) like celebrex, ibuprofen, and naproxen: all cause calcium loss o Dialysis can get rid of calcium o Most definitive therapy: effective management of the cancer Hypercalcemia of Malignancy Nursing management: o Prevent the problem from happening by: ensuring adequate hydration (3 4 L/day if not contraindicated) and adequate salt intake (to keep the person hydrated.) Control of nausea and vomiting Encourage mobility (because when you are immobile you start resorbing bone) Management of febrile episodes Patient/family education o Supportive care during treatment. (Can be something big. The patient may even come in with cardiac arrest) Spinal Cord Compression Etiology: tumors growing within spine put pressure on the cord (Can be a primary tumor of the spine or can be metastasis), causing the cord to be compressed between the vertebrae. Must be treated to prevent nerve damage/ paralysis. (Usually nerve damage happens to the lower extremities) Causes: Usually metastasis to spine from tumors. Most common: lung, breast, prostate. Signs/Symptoms: new back pain (most common)(in a cancer patient that didnt have back pain before); extremity weakness or sensory changes (Particularly in the lower extremeties). Can progress to loss of bowel and bladder control; loss of movement and/or sensation below level of tumor. Spinal Cord Compression

Spinal Cord Compression Medical Management Surgery (To decompress the spinal cord), radiation, steroid therapy (to shrink the tumor) Nursing management: Frequent neurologic checks: Deep Tendon Reflexes, motor and sensory function (In the extremities.) Pain control (This tends to be painful) Nursing measures to prevent complications from surgery, radiations, steroids, prolonged immobility, or paralysis. (We are particularly interested in skin break down from the patient being paralyzed or immobile. You also need to think about pneumonia and DVT from immobility) Superior Vena Cava Syndrome

Etiology: characterized by slow, insidious compression/ obstruction of the superior vena cava. Symptoms usually come on gradually. Can be life threatening. (This is the large vein that drains blood from the head and the neck and returns it to the heart.) Causes: underlying malignancy that grows in size or invasiveness. SVC is a thin-walled, low pressure vessel that can be easily compressed or thrombosed. Signs and Symptoms: dyspnea (most common. This is dyspnea in a patient that you wouldnt expect to have dyspnea.); facial swelling (You are getting venous congestiong because the head and neck arent getting drained well through the venous system.), cough (From laryngeal congestion), orthopnea, headache, nasal stuffiness, light-headedness.

*Veins start to dilate to accommodate for this increased amount of blood because the tumor is obstructing the drainage back to the heart. Superior Vena Cava Syndrome SVCS is an emergency due to possibility of airway obstruction. (Because of all that edema) Medical Management: Airway stabilization (They may have to intubate) Steroids (probably to decreased inflammation and swelling) Radiation and chemo to shrink tumor size (so that is not pressing against the superior vena cava.) Endovascular shunt devices (may be used to shunt blood around the obstuction if they cant shrink it enough.) Thrombolytics (if an acute thrombus is present)(anytime you have blood sitting there like this it can cause a clot.) Nursing Management ABCs Assessment for worsening of edema or obstruction Assessment for complications of steroids (like immunosupression and glucose monitoring even if they arent diabetic because it will effect their ability to handle glucose.), radiation and chemo Patient/family teaching (Meds and s/s to report to the doctor) Supportive care Tumor Lysis Syndrome Etiology: occurs when large numbers of tumor cells are killed rapidly, releasing large amounts of intracellular ions (such as potassium) and metabolic by-products into the circulation. (The kidneys dont like this. The patient can even get acute renal failure.) Causes: occurs most often in patients with acute leukemia with high WBC counts, and lymphomas responding to aggressive chemo. Signs and symptoms: o Labs: hyperuricemia, hyperkalemia (can stop the heart), hyperphosphatemia (if phosphate goes up calcium will go down. If calcium goes up phosphate will go down.), hypocalcemia, and acute renal failure. o Physical: N/V, lethargy, edema, fluid overload (probably from acute renal failure), CHF (also probably because of acute renal failure.), cardiac arrhythmias, seizures, tetany, syncope and sudden death (from cardiac arrhythmia.) within 72 hours of receiving chemo.

Chemotherapy may also contribute to the acute renal failure because a lot of the chemotherapy agents have renal toxicity. Tumor Lysis Syndrome TLS is an emergency because it can lead to fatal arrhythmias, respiratory muscle paralysis (from the tetany. Tetany is a medical sign consisting of the involuntary contraction of muscles. You get this from the high phosphate and low calcium levels. Respiratory muscles can get tetany too and the person will not be able to breathe.), pulmonary edema (fluid overload from kidney failure). Medical management: o Prevention by meticulous surveillance of labs during chemotherapy. o Cardiac monitoring o Renal function labs at least 3 times per day o Allopurinol to control hyperuricemia. (this can be a test question. Allopurinol is a drug used primarily to treat hyperuricemia (excess uric acid in blood plasma) and its complications, including chronic gout. Allopurinol can be given profilactically for people who are at risk from chemotherapy.)) o IV hydration o Isotonic sodium bicarb solutions IV to promote alkaline diuresis and prevent uric acid precipitation in renal tubules. (so you wont have those crystals. It will get peed ouyt instead,) o Aggressive rx for hyperkalemia (because hyperkalemia can kill a patient. They can go into cardiac waste. Hyperkalemia is treated with IV regular insulin in a glucose solution. It wont get rid of the potassium. It will make it go back into the cells. Then you put them on kayexalate. Kayexalate affects the exchange of sodium and potassium in the blood. It helps the patient eliminate it through the bowels. The patient can either drink it, it can be put down an NG tube, or it can be given as an enema. If you give it as an enema the patients body will try and expel it and so you will have to use something such as a catheter with an inflatable balloon to keep it in but be careful not to keep too much pressure for too long because it can cause bowel necrosis.) o Withhold chemo until labs are corrected o Dialysis if all else fails. Tumor Lysis Syndrome Nursing Management o ID patients at risk o Monitor labs closely and report results o Continuous cardiac monitoring Assess for s/s of hyperkalemia, hypocalcemia (such as the tetany), and uremia. Daily weights, strict I&O (because of fluid and electrolyte problems.)

Assess for neuromuscular irritability (Trousseaus and Cvosteks signs. Cvosteks sign is an indication of tetany in which a unilateral spasm of the oris muscle is initiated by a slight tap over the facial nerve. If the face twitches its a positive sign and so that means trouble. To elicit the Trousseaus sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm) o Supportive care o Patient/Family teaching. SIADH: Syndrome of Inappropriate ADH Etiology in cancer patients: relatively uncommon, but often associated with small cell lung cancer. (This is because small cell lung cancer puts out an ADH like substance that fools the kidneys into thinking that there is more ADH in the body than there is.) Tumor produces ectopic ADH, causing massive water retention, dilutional hyponatremia, weight gain. Generalized and cerebral edema occurs as water shifts from extracellular to intracellular space (Can cause seizuers.) Signs and symptoms: weight gain, generalized edema, headache, confusion, irritability,(From ICP) decreased urine output, n/v, diarrhea

Mechanism of SIADH in lung cancer Small cell lung cancer SIADH in Cancer Mechanism of SIADH in lung cancer o Small cell lung cancer o SIADH: Syndrome of Inappropriate ADH o Medical Management: o Fluid restriction: < 1L/day until sodium is NL (You have to get out enough fluid until their sodium levels come back to normal) o Chemotherapy or radiation to shrink ADH producing tumor. o Demeclocycline- antibiotic that limits ADH action on the renal distal tubules.(in this case we are using this drug for its side effect of limiting ADH instead of its intended purpose of being an antibiotic.) Side effects: infection, photosensitivity, nausea, hepatotoxicity, reversible DI. o For severe hyponatremia: diuretics, IV therapy with 3% - 5% NS (To raise sodium level in the blood if it is very severe.) SIADH: Syndrome of Inappropriate ADH Nursing Management o Daily weights, strict I&O o Frequent neuro assessments (Because of ICP) o Monitor and report lab results o Seizure precautions (because of the hyponatremia.)

o Discharge teaching re: daily weights (discharge teaching is importantbecause some of these patients may go home still having this same trouble and so they need to report rapid weight gain, decreased urine output, or recurrent s/s.) Pericardial Effusion and Tamponade Etiology: can be caused by primary tumors but is usually caused by tumor metastasis to heart and pericardium that cause fluid to build up in pericardial sac. This causes compression of myocardium (tamponade). Untreated, cardiac tamponade quickly causes death due to cardiac arrest. Causes: Malignancies with the highest prevalence of pericardial effusion include lung (37% of malignant effusions), breast (22%), and leukemia/lymphoma (17%).

Malignant pericardial effusion: note the water bottle appearanceof cardiac silhouette caused by fluid accumulation. Pericardial Effusion and Tamponade Signs and symptoms (tamponade): hypotension, dyspnea, cardiac arrhythmias, pulsus paradoxus (is at least a 10 mm or more drop in blood pressure on inspiration.), dysphoria (feeling of depression) Tamponade is a medical emergency; without quick intervention it is universally fatal. Medical management: o Pericardiocentesis (various methods) o Pericardial window o Pericardial-abdominal shunt o Inotropes (dobutamine) and volume expanders until the above interventions can be done.

Pericardiocentesis procedure guided by an EKG. The EKG lead is put on the end of the needle. It is highly effective. It is one of those few times that something works real well. The patient can look like their dying and then once they do this they look a lot better. Pericardial Effusion and Tamponade Nursing Management: o Administer oxygen

o Place patient in trendelenberg position.

o o o o o

Titrate inotropes and fluids to maintain B/P until they can getthe fluid off. Assist with surgical interventions such as pericardiocentesis Continuous cardiac monitoring Hemodynamic monitoring Monitor and report changes in vital signs, hemodynamics, and ABGs