Pediatric Oncology Emergency Recap.pdf

- Oncological emergencies can have various presentations and may be the first presentation of underlying malignancy that develop acutely and progress rapidly - So a high index of suspicion and accurate clinical assessment are vital to the prevention, early recognition and management of these emergen...

- Oncological emergencies can have various presentations and may be the first presentation of underlying malignancy that develop acutely and progress rapidly - So a high index of suspicion and accurate clinical assessment are vital to the prevention, early recognition and management of these emergencies - The most common etiologies for pediatric oncologic emergency are 1- Metabolic 2- Hematologic 3- Space occupying Lesion “Pressure” 4- Infectious & Inflammatory A) Tumor Lysis $yndrome - It is a rapid breakdown of malignant cells which releases large amounts of Nucleic acid, phosphorus and potassium into the circulation - Happens mostly: After chemotherapy: Highly sensitive tumorscan also be fragile to radiotherapy Spontaneously: Rapid growing tumor as Burkitt lymphoma size doubles every 18h - Nucleic acid is rapidly broken down to uric acid which is not water soluble and precipitates in the kidney, joints and cardiac conducting system - This can cause Hyperkalemia due to release of intracellular potassium or Hypocalcemia as a result of calcium joining with phosphate and precipitation or Urate nephropathy due to accumulation of DNA breakdown byproduct or Ca-Phos nephropathy due to their precipitation Lab Investigations “The Cairo and Bishop classification” 2 or more of the following within 3 days before or 7 days after initiation of chemotherapy = Tumor Lysis $yndrome - Uric acid > 8 mg/dl - Potassium > 6 mmol/dl - Phosphorus > 6.5 mg/dl (more than 10 = nephropathy) - Corrected calcium < 7 mg/dl - Ionized calcium < 1,12 mg/dl #In this case TLS is still asymptomatic #If ABG, CBC, and electrolytes are normal then discharge if not then further investigate with renal functions and ECG Symptoms - Acute kidney injury because of Ca-Phos or urate nephorpathy - Cardiac arrhythmia because of hyperkalemia - Seizures and tetany because of hypocalcemia - Paresthesias and laryngeospasm because of hypocalcemia - Sudden death because all of the above Risk Factors “High index suspension” - Large tumor burden hyper leukocytosis - Rapidly growing malignancies - Intravascular volume depletion - Renal insufficiency #Most TLS occurs 6-72 hours after chemotherapy Management - Admit to PICU - Establish good venous access (CVC) - Lab monitoring of: Na, K, CL, PO4, HCO3, Ca, Uric acid , S.Cr, Urea, LDH - Consult nephrology services - Treat the electrolyte imbalance IF Hyperurecimia - Hydration with IV fluids 3 liters per m2 - Allopurinol inhibits xanthine oxidase from converting hypoxanthine to uric acid hence lowering it - Rasburicase converts uric acid by oxidization to allantoin a byproduct excreted in urine #Alkalinization of urine was a treatment that is now obsolete because even though it has positive effects on hyperurecimia, it can worsen the situation of Ca-Phos precipitation IF Hyperkalemia - Calcium gluoconate - Sodium Bicarbonate - Insulin & Glucose - Salbutamol - Cation exchange resins - Dialysis in desperate cases IF Hyperphosphatemia - Avoid oral phosphate - Oral phosphate binder (aluminium hydroxide) or Magnesium hydroxide as Mucogel0 (oral) #The hypocalcemia caused by hyperhosphatemia should NOT be treated with giving calcium because it can worsen the situation B) Hyponatremia Etiology - SIADH Increased ADH => Retention of water + less sodium reabsorption - Fluids “dilutional hyponatremia” - Sodium loss in vomiting Manifestation - Seizures - Lethargy #May be a symptomatic Associated Malignancy: - Leukemia - CNS tumor Treatment: - Restrict free water for SIADH - Replace sodium if depleted C) Hypercalcemia Etiology - Bone resorption - Ectopic parathormone - Vitamin D - Prostaglandins #Pray Palestine Manifestation - Anorexia, nausea and polyuria‫جت سؤال‬mcq ‫في نظري الباطنة‬ - PRolonged PR, shortened QT interval - Pancreatitis and gastric ulcers Associated Malignancy: - Leukemia - Rhabdomyosarcoma - Bone mets by resorption Treatment: - Hydration and furosemide diuresis - Corticosteroids - Calcitonin - Bisphosphonates ‫فلش باك للندو‬ A) Hyperleukocytosis Defined as peripheral WBC > 100,000 cells/UL - It is present at the initial presentation of: ALL 9-13% AML 5-22% CML 100% Pathophysiology - Leukocyte increase in leukemia causes an increase in the viscosity of the blood leading to stasis “leukostasis” - This can occlude small vessels leading to impaired transfer of glucose and O2 in tissue causing tissue injury Manifestations - Hypoxia and tachypnea ‫الجسم بيحاول يعوض نقص الكسجين بأنه يتنفس اكتر‬ Chest X-ray: shows diffuse interstitial infiltrate ‫ده عبارة عن اليا لوكيميا بتترسب‬ - CNS manifestations as Altered mental status, Blurred vision, Headache, Dizziness, Seizures and coma Management - Hydration especially in low hemoglobin - Chemotherapy - Blood Transfusion should be avoided but you can do Leukapheresis & Exchange transfusion - Hydroxyurea - Platelet should be given for bleeding or platlets < 10000 #If blood is irradiated then it can be used for transfusion B) Neutropenia Defined as absolute neutrophil counts < 0.5 × 109/L - It is associated with increased risk of infection - It is the most common toxic result of myelo-suppressive chemotherapy - If persisting longer than 2 weeks it is associated with increased risk of systemic fungal infection - TTT: GM-CSF C) Graft vs Host Disease Defined as a hostile immune reaction made by the immune cells of the graft (donated part) against the body of the recipient Etiology Immunosuppression Non irradiated blood products Bone marrow transplantation Manifestations - Dermatitis - Diarrhea - Hepatitis Management - Corticosteroid - Cyclosporine - Tarcolimus - Antithymocyte Globulin D) Disseminated intravascular coagulation Defined as a abnormal excessive formation of fibrin and thrombin in blood Etiology - Sepsis, hypotension and tumor factors #Common with promylocytic leukemia Manifestations - Shock and Hemorrhage Management - Fresh Frozen Plasma - Platelets - Cryoprecipitate - TTT of underlying cause E) Hemorrhagic Cystitis Defined as hematuria that results from an inflammation of the bladder Etiology Chemotherapy especially Cyclophosphamide and Ifosfamide Primary Prophylaxis - Hyperhydration - Continuous bladder irrigation - Administration of Mesna F) Extravasation Defined as leakage of something “In this case chemotherapy products” from blood to nearby tissue - May cause severe irreversible local injury - Irritant drugs cause pain at injection site with local inflammation - Vesicant drugs cause local tissue necrosis or induce blister formation Management - Stop injection of the chemotherapy immediately - Aspirate of residual drug ‫عشان لو فضل جوا الجسم احتمال انه يتسرب هيزيد‬ - Antidote ‫علي حسب نوع الكيمو‬ - Avoid applying pressure to site of swelling - Rare but associated with significant morbidity and mortality - Large masses can result in life threatening events such as upper airway obstruction and compression of great vessels (SVC syndrome) #Children with stridor are often croup if younger than 6 but if around the age of 12/13 then order chest X-ray You may find a tumor Anterior mediastinum: 4Ts - Teratoma (Germ-cell tumors) - T-Cell-Lymphoma - Thymic tumor or cyst - Thyroid or neoplasm (Retrosternal) Middle mediastinum: - Lymphoma Posterior mediastinum: / TeachMe Anatomy - Neuroblastoma Manifestations - Related to site of involvement and size of tumor - Symptoms of chronic illness (Chronic cough, fever , weight loss, back pain) - Respiratory distress (50% decrease in lumen) - Tachypnea, wheezing and stridor - Superior vena cava syndrome (high risk for respiratory arrest) #SVC$ is characterized by swelling of face and neck1, prominence of neck and chest veins2, Cyanosis or Plethora3, Stridor4, Dyspnea5, neck Hyperextension6, chest pain7 and sudden respiratory arrest8 Manifestations 1) Initial stablization - Continuous cardio-respiratory monitoring - Give oxygen if there is respiratory distress - Adequate hydration - Spontaneous breathing should be maintained as possible - Patient poisoning (45o) because tumor compresses the airway against the pressure of lying flat causing orthopnea #General anesthesia can worsen the airway obstruction leading to cardiovascular collapse #The patient is at high risk of TLS 2) In severely symptomatic patients empiric treatment may be necessary 3)Avoid muscle paralysis with mechanical ventilation before tissue diagnosis giving steroid #The least invasive diagnostic procedures are done under local anesthesia B) Spinal Cord Compression Etiology Metastasis to vertebra and extramedullary space Associated Malignancy - Neuroblastoma - Medulloblastoma Manifestation - Back Pain - Cord above T10 symptoms - Conus Medullaris (T10 - L2) - Cauda Equina Syndrome (L2 - all way below) Cord above T10: Symmetric weakness, increased deep tendon reflex, sensory level present and toes up Conus Medullaris: Symmetric weakness, Increased knee reflex, Decreased ankle reflex, Saddle sensory loss and Toes up or down Cauda Equina $yndrome Asymmetric weakness, Loss of deep tendon reflex, Sensory deficit and Toes down Investigations is the best diagnostic test to localize the disease and distinguish tumor, abscess, hematoma, and disk herniation. #Spinal cord compression requires rapid intervention to minimize irreversible dysfunction. Treatment - A combination of analgesia, corticosteroids, radiation therapy, and surgery ( Decompressive laminectomy) C) Increased ICP ‫مفيش جديد‬ Etiology - Primary or metastatic brain tumor - Neuroblastoma, astrocytoma and glioma Manifestation - Headache - Projectile vomiting - Blurring of vision and Papilledema - Seizure - Confusion and Coma - Hypertension and Bradycardia - Hydrocephalus - Cranial nerve III& V Ipalsies TTT - CT or MRI for diagnosis - Drugs as: Phenytoin and Corticosteroids - Ventriculostomy tube - Radiotherapy and Chemotherapy ‫زود بقي المانيتول و الهيابرتونك سالين و الحاجات اللي ادانها قبل كده‬#