ONCOLOGICAL EMERGENCIES

Presented By:
Mrs. Mamta Toppo
Associate Professor
R.I.M.S.C.O.N.
DEFINITION
 Oncological emergency is defined as an acute
,life-threatening events related to patient’s
neoplasm or its treatment.
CLASSIFICATION OF ONCOLOGICAL EMERGENCIES
Structural/ Due to Metabolic/ Secondary to
Obstructive Hormonal Complications
Emergencies Problems Arising from
Treatment Effects
•Superior Vana Cava •Hypercalcaemia •Tumor Lysis
Syndrome (SVCS) •Syndrome of Syndrome
•Pericardial Effusion/ InappropriateAnti- •Haemorrhagic Cystitis
Temponade diuretic Hormone •Anaphylactic
•Spinal Cord (SIADH) Reactions Related to
Compression (SCC) •Lactic Acidosis Chemotherapeutic
•Increased ICP Agents
•Urinary Tract •Neutropenic Fever
Obstruction
•Hemoptysis
•Airway Obstruction
1. SUPERIOR VENACAVA SYNDROME
(SVCS)
SUPERIOR VENACAVA SYNDROME
(SVCS)
DEFINITION :
 The superior vena cava is the major vein that
carries blood from the upper part of the body into
the heart .A restriction of the blood flow
(occlusion) through this vein can cause superior
vena cava syndrome.
 It encompasses a range of signs and symptoms
resulting from external compression or intrinsic
obstruction of the superior vena cava (SVC) or
associated greater veins.
CAUSES
 Compression of the superior vena cava by tumor
 Enlarged lymph nodes.
 Intraluminal thrombus that obstructs venous
circulation.
 Drainage of the head , neck , arms , & thorax.
 SVCS can also occur with lung cancer , breast
cancer , Kaposi's sarcoma , thymoma , lymphoma
& mediastinal metastases.
 If untreated , SVCS may lead to cerebral anoxia ,
laryngeal edema , bronchial obstruction , & death
RADIOLOGICAL EVALUATION
• Chest X-ray
• Contrast computed tomography (CT)
• Magnetic Resonance Imaging (MRI)
 SURGICAL MANAGEMENT

 Less common, such as vena cava bypass graft to redirect

blood flow around the obstruction.
 MEDICAL MANAGEMENT

- Give radiation therapy to shrink tumor size & relieve

symptoms.
- - Give chemotherapy for chemosensitive cancers. eg.
lymphoma, small cell lung cancer or when the
mediastinum has been irradiated to maximum tolerance.
- - Give Anticoagulant or thrombolytic therapy for
intraluminal thrombosis.
- - Give supportive measures such as oxygen therapy,
corticosteroids & diuretics.
 NURSING MANAGEMENT


- Identify patients at risk for superior vena cava syndrome.

- - Monitor & report clinical manifestation of SVCS.
- - Monitor cardiopulmonary & neurologic status.
- - Avoid upper extremity venipuncture & BP
measurement.
- Facilitate breathing by positioning the patient properly.
This helps to promote comfort & reduce anxiety produced
by difficulty breathing resulting from progressive edema.


 CONT….
- - Promote energy conservation to minimize shortness of
breath.
- - Monitor the patient’s fluid volume status & administer
fluids cautiously to minimize edema.
- - Assess for thoracic radiation- related problems such as
dysphagia & esophagitis.
- - Monitor for chemotherapy related problems such as
myelosuppressioon.
2.PERICARDIAL EFFUSION
& CARDIAC TEMPONADE
PERICARDIAL EFFUSION & CARDIAC
TEMPONADE :
DEFINITION :
 Pericardial effusion & Cardiac temponade is the
compression of the heart caused by blood or fluid
accumulation in the space between the pericardium. It is
a life-threatening condition.
 It is usually associated with advanced lung and breast
cancer, leukemia or lyphoma.
 The spectrum of malignant pericardial involvement
includes pericarditis, pericardial
infusion,cardiactemponade and constructive
pericarditis.
CAUSES
 It may be due to
 -direct extension of disease

 -from spread through mediastinal lympatic or

blood vessels obstruction of lympatic drainage
 A direct effect of chemotherapy or radiotherapy
CLINICAL MANIFESTATION
 Dysnea
 Orthopnoea
 Raised jugular venus
pressure (JVP)
 Pericardial Rub
 Pulses Paradoxus
 Facial swelling, Edema
of neck , arms , hands ,
& thorax
 Sensation of skin
tightness & difficulty
swallowing
 Nasal stuffiness
 Chest discomfort/pain
 Cough
 Muffled heart sound
 Low BP
 Cynosis , drooping
eyelid
 Increased intracranial
pressure ,
 Visual disturbances
 Headache & altered
mental status
 Vertigo , Tinnitus ,
Fainting
DIAGNOSIS
 Chest X-ray
 CT scan

 MRI

 ECG
SURGICAL MANAGEMENT
 Windows or openings in the pericardium can be
created surgically as a palliative measure to
drain fluid into the pleural space.
 Catheters may also be placed in the pericardial
space & sclerosing agent such as tetracycline,
bleomycin, 5-fluorouracil injected to prevent fluid
from reaccumulating.
 MEDICAL MANAGEMENT

- In malignant effusions, pericardiocentesis provides only

temporary relief.
- - Radiation therapy or antineoplastic agents, depending
on how sensitive the primary tumor is to these t/m.
- - In mild effusion, prednisone & diuretic medications may
be prescribed & the pts status carefully monitored.
NURSING MANAGEMENT
- Monitor vital signs & O2 saturation frequently.
- - Assess for pulses paradoxus.
- - Monitor ECG tracings.
- - Assess heart & lung sounds, neck vein filling,
level of consciousness, respiratory status & skin
color & tempreature.
- - Monitor & record intake & output.
- - Elevate the head of the pt’s bed to ease
breathing.
 CONT…
- Minimize pt’s physical activity to reduce O2
requirements; administer supplemental O2 as prescribed.
- - Provide frequent oral hygiene.
- - Reposition & encourage the pt to cough & take deep
breaths every 2 hr.
3.SPINAL CORD COMPRESSION
SPINAL CORD COMPRESSION
DEFINITION :
 Spinal cord compression is a condition that
causes pressure on the spinal cord or its nerve.
CAUSES :
 Tumor

 Lymphoma

 Intervertebral collapse or interruption of blood

supply to the nerve tissues
 Breast cancer , lung , kidney , prostate cancer
associated with spinal cord compression.
CLINICAL MANIFESTATION
 Inflammation , edema , venous stasis & impaired
blood supply to nervous tissues
 Neck pain , pain exacerbated by movement ,
coughing , sneezing
 Neurological dysfunction , numbness , tingling ,
feeling of coldness in the affected area , weakness
 Bowel dysfunction
DIAGNOSTIC FINDINGS
 Percussion tenderness at the level of compression
 Magnetic Resonance Imaging (MRI) is the gold
standard method to SCC Diagnosis.
 Myelogram

 Spinal cord x-rays

 Bone scans

 CT scan

 Positron emission tomography (PET)

 MEDICAL MANAGEMENT

 - Give Radiation therapy to reduce tumor size to halt

progression & corticosteroid therapy to decrease
inflammation & swelling at the compression site.
 - Give chemotherapy as adjuvant to radiation therapy for
patients with lymphoma or small cell lung cancer.
 SURGICAL MANAGEMENT

- Surgery if symptoms progress despite radiation therapy,

or if vertebral fracture leads to additional nerve damage.
- - Surgery is also an option when the tumor is not
radiosensitive.
 NURSING MANAGEMENT

 - Perform ongoing assessment of neurologic function to

identify existing & progressing dysfunction.
 - Control pain with pharmacologic & non-pharmacologic
measures.
 - Prevent complications of immobility resulting from pain
& decreased function. eg. Skin breakdown, urinary stasis,
thrombophlebitis, decreased clearance of pulmonary
secretions.

 CONT…..
- Maintain muscle tone by assisting with range of motion
exercises in collaboration with physical & occupational
therapist.
- - Provide encouragement & support to patient & family
coping with pain & altered functioning, lifestyle, roles &
independence.
4. INCREASED INTRACRANIAL
PRESSURE(ICP)
INCREASED INTRACRANIAL
PRESSURE(ICP)

 Cranial metastasis affects around a quarter of

patients who die from cancer.
 Lung, breast and melanoma are the tumors that
most commonly metastasizes to the brain.
CLINICAL MANIFESTATION
 Headache  Nausea and vomiting
 Behavioural change  Seizures

 Focal neural defects  Faling level of

 Papiloedema conciousness
 Unilateral ptosis  Bradycardia

 3rd and 6th cranial

nerve palsies
DIAGNOSIS
 CT scan
 MRI

MANAGEMENT
 Hyperventilation

 Mannitol(Hyperosmotic agent)

 Dexamthasone injection (Corticosteroid)

URINARY TRACT
OBSTRUCTION(UO)
URINARY TRACT OBSTRUCTION
 Definition: It is defined as complete interruption
of urine natural flow.
 this complication may occur iatrogenically or as
a result of the underlying cancer.
 It concerns patients with primary tumors in the
pelvis (such as gynecological or urological
malignant neoplasm's) ,but may also result from
metastatic disease from any primary cancer to
the pelvic area.
MECHANISMS AND CAUSES

Low UO is due to obstruction of urine output at

the level of the urethra ,prostrate or bladder.
• It can be related to urethral strictures , BPH,
prostrate cancer, iatrogenic causes(like Foley
catheter obstruction , previous extensive pelvic
surgery or the use of cholinergics)
PRESENTATION:
• The pivotal symptom is the inability to urinate
(incontinence).
DIAGNOSIS & TREATMENT

DIAGNOSIS
 At physical examination (suprapubic tenderness)
ultrasound (to confirm the diagnosis, if not
clinically clear)
TREATMENT
 Urinary Foley catheter placement or use of a
suprapubic tube if there is a tight urethral
stricture.
HAEMOPTYSIS
HAEMOPTYSIS
 Definition : It is defined as blood expectoration coming
directllyfrom the bronchial tree.
 For assessing the risk and seriousness of the hemoptysis
there are three main prognostic factors: hemoptysisvolume
, bleeding speed and patient’s previous lung functional
capacity.
 Massive haemoptysis is defined as the loss of ≥500 ml of
the expectorated blood over a 24 hour period or a bleeding
rate of ≥ 100 ml/hr.
CAUSES
 Bronchial disease eg. Bronchitis, Tumor,Trauma
Pulmonary Disease eg. Pneumonia , Rheumatic/immune
pathology
Coagulopathy eg. Hereditary ,Anticoagulants
Pharmacological cause eg. Cocaine,Nitrogen dioxideexposure
 DIAGNOSIS
In caseof In caseof
Non-massive Haemoptysis Massive Haemoptysis
•History andPhysical examination •ABG(Arterial BloodGas)
(Tolocalize the sourceof bleeding) •CoagulationTest
•LaboratoryTests: •Bronchoscopy
 CBC •Arteriography
 RFT
 LFT
 CoagulationProfile
•Othertests:
 SputumCulture
 Specificantibodytest
•ImagingStudies:
 ChestRadiography
 ComputedTomography(CT)
• Bronchoscopy
TREATMENT OR SUPPORTIVE CARE
 Focus on the underlying causes
 Fresh Frozen Plasma( In case of elevated INR)

 Antiplatelet agents

 Platelet transfusion (in case of Thrombopaenia)

HYPERCALCEMIA
HYPERCALCEMIA
 Hypercalcaemia is an elevated serum calcium
level above 11.0 mg/dl.
 If patients with cancer , hypocalcaemia is a
potentially life-threatening metabolic
abnormality resulting when the calcium released
from the bones is more than the kidneys.
 Malignancies most commonly associated include
lung, breast, neck, kidney, lymphoma and
myeloma.
CAUSES

 Bone destruction by tumor cells & subsequent

release of calcium
 Production of prostaglandins

 Tumor that produce parathyroid

 Excessive use of vitamins & minerals

 Dehydration ,

 Renal impairment ,

 Primary hyperparathyroidism ,

 Thyrotoxicosis


CLINICAL MANIFESTATION

 Fatigue ,weakness , confusion

 Decreased level of responsiveness
 Hyporeflexia
 Nausea & Vomiting
 Constipation
 Polyuria
 Polydipsia
 Dehydration
 Dysrhythmias
 Abdominal discomfort
 Increase gastric acid secretion
HYPERCALCEMIA - CLINICAL FEATURES
“STONES, BONES, GROANS AND MOANS”
 MEDICAL MANAGEMENT :
 - Therapeutic aims in hypercalcemia include decreasing
the serum calcium level & reversing the process causing
hypercalcemia.
- Administering fluids to dilute serum calcium & promote
its excretion by the kidneys & resulting dietary calcium
intake.
 CONT…

 -Calcitonin can be used to lower the serum calcium level

& is particularly useful for pts with heart disease or renal
failure who can’t tolerance sodium loads.
- Calcitonin is administered by IM injection rather than
subcutaneously, because pts with hypercalcemia have
poor perfusion of subcutaneous tissue.
- - Corticosteroids may be used to decrease bone turnover
& tubular reabsorption for pts with sarcoidosis,
myelomas, lymphomas & leukemias.
 NURSING MANAGEMENT :

- To monitor for hypercalcemia in pts who are at risk.

- - Educate the pt about to take more fluids can help
prevent hypercalcemia, or at least minimize its severity.
- - Hospitalized pts who are at risk for hypercalcemia are
encouraged to ambulate as soon as possible; outpatients
& those cared for in their homes are informed of the
importance of frequent ambulation.
 CONT…
- Fluids containing sodium should be administered unless
contraindicated, because sodium favors calcium excretion.
- - Encourage pts to consume 2-3 lit. of fluid daily.
- - Explain the use of dietary like fiber diet &
pharmacologic interventions such as stool softener &
laxatives for constipation.
- - Give antiemetic therapy if nausea & vomiting occur.
SYNDROME OF INAPPROPRIATE
SECRETION OF ANTIDIURETIC
HORMONE (SIADH)
SYNDROME OF INAPPROPRIATE SECRETION
OF ANTIDIURETIC HORMONE (SIADH)

DEFINITION : SIADH is characterized by

excessive release of antidiuretic hormone from
the posterior pitutary gland or another source.
This result is hyponatremia.

CAUSES:
Lung cancer
CLINICAL MANIFESTATION
 Serum sodium levels lower than120 meq / l :
 Personality changes
 Irritability
 Nausea
 Anorexia Vomiting
 Fatigue
 Muscular pain
 Headache
 Confusion Lethargy
 Seizure
 Abnormal reflexes
 Papilledema
 Coma & death

 MANAGEMENT
- Fluid intake range limited to 500-1000 ml/day to
increased the serum sodium level & decrease fluid
overload.
- - If neurologic symptoms are severe, parenteral sodium
replacement & diuretic therapy are indicated.
- - Electrolyte levels are monitored carefully to detect
secondary magnesium, potassium & calcium imbalances.
 NURSING MANAGEMENT
- Maintain intake & output chart.
- - Assess level of consciousness, lung & heart sounds, vital
signs, daily weight & urine specific gravity.
- Assess for nausea,vomiting,anorexia,edema
vomiting,anorexia,edema,fatigue & lethargy.
- Monitor lab. Test results, including serum electrolyte
levels, osmolarity & blood urea nitrogen, creatinine &
urinary sodium levels.
- Minimize the pt’s activity.
- Provide appropriate oral hygiene.
- Maintain environmental safety & restrict fluid intake if
necessary.

LACTIC ACIDOSIS
LACTIC ACIDOSIS
 Lactic acidosis is a frequent cause of life- threatening metabolic
acidosis and is characterised by lactate levels >5 mmol/l and
serum pH <7.35.
• Lactic acidosis in cancer patients may be due to excessive
production(tumor derived) as well as due to impaired
elimination(hepatic metabolism and renal clearance).
 CLINICAL MANIFESTATIONS

•Nausea and vomiting •Abdominal pain

•Diarrhoea •Altered sensorium
•Loss of consciousness •Dehydration
•Hypotension •Circulatory cpllapse
Diagnosis
i. Blood lactate level ≥2mmol/L (venous plasma)
ii.Arterial pH<7.25
iii.Anion gap>22meq/L

Treatment
Chemotherapy to treat the underlying haematological
malignancy is the only effective treatment.
TUMOR LYSIS SYNDROME
TUMOR LYSIS SYNDROME
 This syndrome is due to the effects of treatment of
malignancy.
 There is a reaction to the sudden and large release of
cellular lysis products caused by tumor destruction. The
body may be unable to excrete and neutralize such toxic
products.
CAUSES
 Non- hodgkin’s lymphoma
 Acute leukemia
 Breast cancer
 Testicular cancer
 Lung cancer
 Neuroblastoma
CLINICAL MANIFESTATION
 NEUROLOGIC : Fatigue, Weakness ,Memory loss
,Altered mental status ,Seizures, Numbness & Tingling
 CARDIAC : Increased blood pressure ,Dysrhthmias,
Cardiac arrest
 GI : Anorexia ,Nausea & vomiting ,Diarrhea,
Abdominal cramps
 RENAL : Flank pain ,Oliguria ,Anuria, Renal failure
,Acidic urine PH
 MANAGEMENT :

 Medical management :
- To prevent renal failure & restore electrolyte balance.
- - Diuretic therapy, with a carbonic anhydrase inhibitor;
to alkalinize the urine.
- - Administration of a cation exchange resin, such as
sodium polystyrene sulfonate to treat hyperkalemia by
binding & eliminating potassium through the bowel.
- - Administration of hypertonic dextrose & regular insulin
temporarily shifts potassium into cells & lowers serum
potassium levels.
 NURSING MANAGEMENT :

 - Identify at risk pt, including those in whom tumor lysis

syndrome may develop up to 1 week after therapy has
been completed.
 - Assess pt for signs & symptoms of electrolyte
imbalances.
- Assess urine PH to confirm alkalization.

- - Monitor serum electrolyte & uric acid levels for

evidence of fluid volume overload secondary to aggressive
hydration.
- - Instruct pts to report symptoms indicating electrolyte
disturbances.

HAEMORRHAGIC CYSTITIS
HAEMORRHAGIC CYSTITIS
• Management of cervical cancer by external
pelvic radiation and brachytherapy may cause
haemorrhagic cystitis, particularly if radiation is
given after removal of uterus.
• It is also observed in patients receiving high
doses of chemotherapeutic agents as Ifosfamide
or cyclophosphamide for longer periods.
CLINICAL MANIFESTATION
• Dysuria
• Frequency
• Urgency
• Burning sensation
• Gross haematuria
• Incontinence
MANAGEMENT
 Oral and IV hydration
 Menesa administered with lfosfamide or high
dose cyclophosphamide
 Bladder irrigation

 Urinary diversion

 Internal iliac ligation

 Cystectomy
NEUTROPENIC FEVER
NEUTROPENIC FEVER
• Neutropenia arises mostly from treatment of
malignancy by chemotherapy and is defined by
Absolute Neutrophil Counts (ANC) less than
1500cells/ml[1000-1500:Mild; 500-
999:Moderate; <500:Severe]
• Fever: defined as a single oral temperature
measurement of ≥38.3°C or a temperature of
≥38.0°C sustained over a 1-hour period.
 CAUSES AND RISK FACTORS

Bacteria
1) Gram Positive Cocci 2) Gram Negative Cocci
S.aurues E.coli
Streptococci Klebsiella species
Staphylococci P.aeuginosa
Risk Factors
•IV devices
•High dose chemotherapy regimens
•Corticosteroid use
•Mucositis
•Bone marrow incompetence
DIAGNOSIS
• History & Physical Examination [Try to elucidate
the source of infection by avoiding invasive
procedures; like Urinary catheterization, Digital
Rectal Examination, Vaginal examination, lumber
puncture, chest tube insertion, etc.]
• CBC, RFT, LFT
• Blood culture [minimum of 2 sets] including culture
from indwelling IV catheter.
• Urinanalysis and culture
• Stool microscopy and culture
• Skin Lesion [Aspirate/Biopsy/Swab]
• Sputum microscopy and culture
• Chest radiography
MANAGEMENT
• Broad spectrum antibiotics [Cephalosporin] like
cefepime are 1st line antibiotic with other drugs
like ceftriaxone/ gentamicin/ ceftazidime or
piperacillin/ tazobactam.
• Ciprofloxacin, aztreonam and vancomycin can
be considered in patients hypersensitive to
penicillins
• Vancomycin -> In patents with suspected
central line infection.
• Removal of central line -> In case of persistent
infection.
PAIN
PAIN
 Moderate to severe pain experienced by 40% to
50% of cancer patients.
 Very severe pain experienced by 25% to 30% of
cancer patients .
 80% of terminal stage cancer experience
moderate to severe pain
OVERVIEW OF PAIN
Causes –
 – Infection

 – Tumor related

 –Nervous system, bone, visceral, mucosal

 – Treatment Related

 – surgery, radiation therapy, chemotherapy,

 interventional procedures

• Types :
 – Nociceptive : pain signals from nerve endings

 – Neuropathic : damage to nerve fibres.

WHO LADDER OF PAIN MANAGEMENT
RADIATION & PAIN RELIEF
 Effective for Nociceptive and Neuropathic pain
 • Effective for mild to moderate and severe pain

 • Pain relief starting from within 24 hrs.

 • Complete effects seen after 1 - 2 months.

 • Brings about alleviation of other associated

symptoms – tumor swelling, anxiety and
depression, appetite.
SEPSIS AND DISSEMINATED
INTRAVASCULAR COAGULATION
(DIC)
DESCRIPTION

 The client with an oncological disorder is at

increased risk for infection .
 Disseminated Intravascular Coagulation(DIC) is
caused by sepsis. DIC is a condition affecting the
blood’s inability to clot and stop bleeding .here
there is abnormal clumps of thickened blood
(clots) form inside the blood vessels which lead to
massive bleeding in other places.
MANAGEMENT

 Maintain strict aseptic technique with

immunocompromised client and monitor closely
for infection.
 Administer IV antibiotics as prescribed.

 Administer anticoagulants as prescribed during

the early phase of DIC.
 Administer cryoprecipitated clottting factors as
prescribed, when DIC progresses and
hemmorahage is the primary problem.
ROLE OF NURSES
• Patient assessment
• Patient and care giver
• Education
• Patient care
• Symptom management
• Supportive care