Oncologic emergencies arise from the underlying malignancy or as complications of radiation and chemotherapy.
Patients with tumors of the upper and lower respiratory tract may experience acutely worsening airway compromise due to edema, bleeding, infection, or loss of protective mechanisms. Presenting symptoms and signs include dyspnea, tachypnea, wheezing and stridor. Imaging involves plain radiographs, CT scan, and/or endoscopic visualization. Emergency measures include supplemental humidified oxygen, maintenance of airway through optimal patient positioning, and, possibly, administration of a helium-oxygen mixture. If intubation is required, an "awake look" with a fiber optic bronchoscope with a 5-0 or 6-0 endotracheal tube is preferred. An emergency surgical airway, such as cricothyroidotomy, transtracheal jet ventilation, or tracheotomy may be needed. Consult with an oncologist or surgeon for definitive management.
Patient with solid tumors, most commonly breast, lung, and prostate, may present with pain, pathologic fracture, or spinal cord compression caused by bony metastases. Patients with spinal cord compression may also exhibit muscular weakness, radicular pain, and bowel or bladder dysfunction. Plain radiographs are obtained initially to assess for fracture or bony involvement, followed by CAT scan or MRI to further delineate lesions. Treatment priorities include pain control with opioid analgesia and restoration or salvage of function. Most pathologic fractures require surgical intervention. Painful bone metastases are treated with radiotherapy. The presentation, evaluation, and management of malignant spinal cord compromise are described in Table 139-1.
Table 139-1 Malignant Spinal Cord Compression |Favorite Table|Download (.pdf)
Table 139-1 Malignant Spinal Cord Compression
Patient with known cancer: especially lung, breast, prostate.
Thoracic location: 70%.
Progressive pain and worse when supine.
Motor weakness: proximal legs.
Sensory changes and bladder or bowel dysfunction: late findings.
Plain radiographs: may detect vertebral body metastases but less sensitive and specific for malignant spinal cord compression.
MRI: modality of choice, image entire vertebral column.
CT myelography: used when MRI not available or accessible.
Dexamethasone, 10 milligrams IV followed by 4 milligrams PO or IV every 6 h.
Consider starting in ED if imaging is delayed.
Standard approach, beneficial in approximately 70%.
No specific radiotherapy regimen proven superior.
Prognosis highly dependent on pretreatment neurologic function.
Consider in highly selected cases, such as:
Patient in good general condition and able to undergo extensive surgery
Appropriate prognostic life expectancy
Rapidly progressive symptoms
Clinical worsening during radiotherapy
Unstable vertebral column
Malignant pericardial effusions are usually asymptomatic but can progress to life-threatening cardiac tamponade. Symptoms depend on the rate of accumulation and distensibility of the pericardial sac (see Chapter 24 "The Cardiomyopathies, Myocarditis, and Pericardial Disease"). Patients with symptomatic effusion may present with chest heaviness, dyspnea, cough, and syncope. Physical examination findings include tachycardia, narrowed pulse pressure, hypotension, distended neck veins, muffled heart tones, and pulsus paradoxus.
Echocardiography is the test of choice as it demonstrates the size of the effusion and the presence of tamponade. Chest radiograph ...