The incidence of cancer is increasing as the general population ages and individual longevity grows. More patients with active malignancy are likely to come to the ED for care because of this increase, coupled with more intensive and varied treatments being applied in the outpatient setting.1 Many conditions that prompt these patients to come to the ED will not be due to cancer.2,3 Conversely, there are disorders often or uniquely related to malignancy that collectively are termed oncologic emergencies.4-7 These malignancy-related emergencies are broadly categorized as: (1) those due to local tumor effects, (2) those secondary to biochemical derangement, (3) those that are the result of hematologic derangement, and (4) those related to therapy (Table 240-1).
TABLE 240-1Emergency Complications of Malignancy |Favorite Table|Download (.pdf) TABLE 240-1 Emergency Complications of Malignancy
|Related to local tumor effects || |
Malignant airway obstruction
Bone metastases and pathologic fractures
Malignant spinal cord compression
Malignant pericardial effusion with tamponade
Superior vena cava syndrome
|Related to biochemical derangement || |
Hyponatremia due to inappropriate antidiuretic hormone secretion
Tumor lysis syndrome
|Related to hematologic derangement || |
Febrile neutropenia and infection
|Related to therapy || |
Chemotherapy-induced nausea and vomiting
Chemotherapeutic drug extravasation
Complications due to biologic therapy
EMERGENCIES RELATED TO LOCAL TUMOR EFFECTS
MALIGNANT AIRWAY OBSTRUCTION
Malignancy-related airway compromise is usually an insidious process that results from a mass originating in the oropharynx, neck, or superior mediastinum progressively obstructing airflow.5,8 Acute compromise may occur with supervening infection, hemorrhage, or loss of protective mechanisms, such as muscle tone. Iatrogenic factors, such as radiation therapy, may create additional difficulties by producing local inflammation with tissue breakdown. It is helpful to classify airway impairment due to malignant tumor obstruction in two manners, as to location—from the lips and nares to the vocal cords (upper airway) versus those from the vocal cords to the carina (central airway)—and as to nature of the obstruction—endoluminal, extraluminal, or mixed. Almost regardless of the cause, airway obstruction usually presents with symptoms of shortness of breath and signs of tachypnea and stridor. The physical examination may show evidence of a mass in the pharynx, neck, or supraclavicular area.
Patients with airway obstruction due to a malignant tumor are evaluated with a combination of plain radiographs, CT, and endoscopic visualization.5,8 Direct laryngoscopy is discouraged because injudicious manipulation of the upper airway may convert a partial obstruction into a complete one by provoking bleeding or edema.9
Emergency management includes the administration of supplemental humidified oxygen and maintenance of the best airway possible through patient positioning. Heliox—typically a 50:50 mixture of helium and oxygen—may provide symptomatic improvement in upper airway obstruction due to cancer when combined with other therapy.10...