.... Imaging

Several imaging modalities can aid in the diagnosis of

severe sequela of vasoocclusive crises. When fever or res piratory signs or symptoms are present, a c hest x-ray should

be obtained to assess for signs of infection or infarction.

Should pulmonary embolus be suspected, a helical con ­

trast computed tomography (CT) can be performed.

Patients with significant abdominal pain should undergo

abdominal imaging to search for evidence of gallbladder or

liver infarction or infection. Patients with new neurologic

symptoms or signs should have a CT scan of the brain to

assess for possible CVA.

PROCEDURES

An exchange transfusion is used to reduce vasoocclusion;

the abnormal Hb is removed and replaced with normal

donor blood. It is used during certain crises s uch as stroke

and priapism when the hematocrit is greater than 35%. The

procedure involves removing 500 mL (adult) through one

intravenous (IV) line while simultaneously infusing 500 mL

of normal saline (NS) through a second. After blood is

removed the patient is given one unit of donor blood.

MEDICAL DECISION MAKING

The differential diagnosis associated with sickle cell vasaocclusive crisis is broad. It includes acute chest, pneumonia,

pulmonary embolism (PE), myocardial infarction (MI),

cellulitis, osteomyelitis, and septic arthritis. The clinician

must differentiate a simple pain crisis from one of these

potential life threats. A high level of suspicion must be

maintained in each case.

Bone and joint pain during a pain crisis does not usually

present with limited range of motion. When joint range of

motion deficits are present, the physician should be prompted

to search for osteomyelitis or septic arthritis. Although an

elevated WBC may be typical of a sickle cell pain crisis, a left

shift would be more concerning for infection and necessitates

a closer evaluation for an infectious process. A high index of

suspicion for infection is always warranted. Localized left

upper quadrant pain could indicate splenic infarction,

whereas right upper quadrant pain may indicate cholecysti ­

tis. Electrocardiogram (ECG) findings consistent with acute

MI or ischemia (ST-segment elevation, hyperacute T waves,

T-wave inversions, ST-segment depression) should prompt

further cardiac evaluation. Patients whose chest pain is

atypical for their pain crisis and who also exhibit vital sign

abnormalities or signs of right heart strain on the ECG

should be evaluated for PE. Patients with altered mental status should be evaluated for severe anemia due to splenic

sequestration, meningitis, CVA/transient ischemic attack

(TIA), or seizure disorder (Figure 71-1).

TREATMENT

Any identifiable preCipitants of pain crisis should be

treated. Even if the patient does not appear dehydrated,

fluids should be replaced. If unable to tolerate oral fluids,

5% dextrose with 0.45% NS is the fluid of choice for fluid

replacement. NS boluses are reserved for the hypovolemic

patient. A simple blood transfusion is indicated in patients

with symptomatic anemia, sequestration crisis, hemolysis,

or aplastic crisis. Exchange transfusion should be considered in severe vaso-occlusive crises such as acute chest

syndrome, stroke, or priapism, where the Hgb level is > 10.

..... Pain Crises

Treatment should begin with prompt analgesic administration. Supplemental oxygen is needed only for patients with

low oxygen saturations or those with oxygen saturations

lower than baseline. Mild pain should be treated with 1 g of

acetaminophen by mouth (PO) every 4 hours (children: 15

mg/kg/dose PO), codeine 0.5-1 mg/kg/dose PO, or ibuprofen 800 mg (children: 5-10 mg/kg/dose) PO every 8 hours.

IV or intramuscular ketorolac has been shown to be effective with limitations in dosing frequency. Opiates are firstline therapy for a moderate to severe pain crisis. Morphine

(0.1-0.15 mg/kg/dose) and hydromorphone (0.0 1-0.02

mg/kg/dose) are appropriate opiates to consider.

Diphenhydramine is often required to blunt histamineinduced pruritus resulting from opiate administration .

.... Infection

Antibiotics should be used for patients with suspected

infection ( eg, those with suspected meningitis, urinary

tract infection, acute chest syndrome, or osteomyelitis).

.... Anemia

Transfusion should be considered for symptomatic anemia

and is generally indicated in cases in which the hemoglobin

CHAPTER 71

CT head: CVA?

Figure 71-1. Sickle cell emergencies diagnostic algorithm. CP, chest pain;

CT, computed tomography; CTA, computed tomography angiography; CVA,

cerebrovascular accident; CXR, chest x-ray; ECG, electrocardiogram.

is <6 gldL with an inappropriately low reticulocyte count.

An acute crisis (acute chest, stroke, liver/gall bladder

infarction, priapism) with hemoglobin <10 g/dL also merits transfusion. With regard to aplastic crisis, simple transfusion is often sufficient. Splenic sequestration is best

treated with adequate hydration, analgesia, and simple

transfusion. Refractory cases are treated with exchange

transfusion.

..... Acute Chest Syndrome

Control pain, hydrate, and start oxygen therapy. Give

empiric antibiotics consisting of a third-generation cephalosporin and a macrolide (eg, ceftriaxone and azithromycin). Triggers for transfusion should include a Pa02 <70

mmHg or an oxygen saturation that falls > 10% from their

baseline.

..... Stroke

Patients with stroke related to SCD are not considered

candidates for thrombolysis. Correction of hypovolemia,

hypoxia, hypoglycemia, and fever are necessary. Exchange

transfusion should be performed in an effort to reduce the

percent of HbS to <30%. Hemorrhagic strokes warrant

neurosurgical consultation.

..... Priapism

Hydrate, treat pain, and transfuse (refractory cases). After

4-6 hours of priapism and failure of ice packing, drainage

may be necessary. Drainage should be done in conjunction

with urologic consultation .

DISPOSITION

..... Admission

Criteria for admission include refractory pain, acute chest

syndrome, CVA or TIA, unexplained fever >38.3°C or focal

infection, aplastic crisis, splenic sequestration, or refractory priapism .

..... Discharge

If the patient's pain is well controlled and good outpatient

follow-up is available, he or she may be discharged.

SICKLE CELL EMERGENCIES

SUGGESTED READING

Baker M, Hafner JW. What is the best pharmacologic treatment

for sickle cell disease in pain crises? Ann Emerg Med.

201 2;59:515-5 16.

Claudius I. Sickle cell disease. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1: 1 480-1 488.

Gladwin MT, Vichinsky E. Pulmonary complications of sickle

cell disease. N Engl ] Med. 2008;359, 2254-2265.

Kavanagh PL, Sprinz PG, Vinci SR, et a!. Management of children with sickle cell disease: A comprehensive review of the

literature. Pediatrics 20 11;128:1 552.

Rees DC, Williams TN, Gladwin MT. Sickle-cell disease. Lancet

201 2;376, 201 8-203 1.

Roberts JR, Hedges JR. Clinical Procedures in Emergency

Medicine. 5th ed. Philadelphia, PA: Saunders, 2009.

Transfusion Reactions

Christopher Reverte, MD

jorge Fernandez, MD

Key Points

• Obtain consent when possible before admin istering

blood transfusions and properly inform patients

regarding the risk of developing complications.

• Always transfuse leukocyte-reduced blood products to

recipients who are immunocompromised to prevent

graft versus host disease.

• It may be difficult to clinically distinguish between

benign (urticaria, simple febrile reactions) and more

INTRODUCTION

Emergency transfusion of blood products is often necessary

in the emergency department (ED) for life-threatening

illness or injuries. Commonly transfused blood products

include packed red blood cells (PRBCs), platelets, freshfrozen plasma (FFP), and cryoprecipitate. In the United

States, approximately 30 million units of blood components

are transfused annually. Approximately 1% of patients

receiving transfusions will develop a transfusion-related

reaction, the most common being a simple febrile reaction.

Transfusion reactions must be rapidly identified to prevent

morbidity and mortality.

Acute intravascular hemolysis is due to ABO blood

group incompatibility between the donor and recipient.

Preformed antibodies in the patient's serum react with

antigens on the transfused PRBCs, resulting in complement-mediated intravascular RBC lysis. Patients present

with chest pain, shortness of breath, back pain, fever,

tachycardia, or shock. Complications include acute renal

failure, disseminated intravascular coagulopathy (DIC),

cardiovascular collapse, and death.

Delayed extravascular hemolysis is due to non-ABO blood

group incompatibility between the donor and recipient.

serious transfusion reactions (acute hemolysis,

anaphylaxis, transfusion-associated acute lung injury,

sepsis).

• Whenever a transfusion reaction is suspected,

immediately stop the transfusion, confirm that the

correct blood product was administered to the correct

recipient, and send samples of the transfused product

and the recipient's serum to the blood bank for further

ana lysis.

This type of hemolysis is the result of splenic removal of

RBCs, which may present days to weeks after the transfusion

and in general is not life-threatening.

Simple febrile reaction is the most common type of

transfusion-related reaction, occurring in about 1-7% of

all transfusions. It is caused by recipient antibodies to

donor leukocytes. The risk is minimized by leukoreduction.

Patients present with fever without urticaria, bronchospasm,

or shock.

Type I hypersensitivity reactions include urticaria and

anaphylaxis. Urticaria is the result of a mild reaction due to

recipient antibodies to donor blood. Patients present with

hives and pruritus without fever, bronchospasm, or shock.

Anaphylaxis is a life-threatening reaction seen most com ­

manly in immunoglobulin A (IgA)-deficient individuals who

are transfused IgA-containing blood. Patients rapidly develop

fever, airway obstruction, bronchospasm, urticaria, and/or

shock.

Transfusion-associated acute lung injury (TRALI)

may result in a life-threatening noncardiogenic pulmonary

edema. It is associated with anti-HLA antibodies (higher

rates in pregnant donors). It most commonly occurs after

plasma transfusion but can occur from transfusion of any

type of plasma-containing blood product (including

304

TRANSFUSION REACTIONS

PRBC, platelets, cryoprecipitate, etc). Signs and symptoms

include fever, severe respiratory distress, noncardiogenic

pulmonary edema and cardiovascular collapse.

 

..... Infection

Patients with SCD are at increased risk of infection as a

result of the loss of splenic function secondary to recurrent

splenic infarcts. Children as young as 6 months of age may

be functionally asplenic, and most patients with SCD are

by the age of 5 or 6 years. This makes them more vulnera ­

ble to infections with encapsulated organisms such as S.

pneumoniae and H. influenzae.S. aureus, Escherichia coli,

and Salmonella typhimurium are also common pathogens.

Bone, pulmonary, and central nervous system (CNS)

infections are common and must be considered in any

febrile patient with SCD.

..... Neurologic

Patients with SCD are at increased risk for cerebrovascular

accident (CVA), ischemic and hemorrhagic, as well as s ubarachnoid hemorrhage. Approximately 10% of patients

will have a CVA by the age of 20 years. Vasoocclusion, as

well as endothelial damage, are believed to play a role in

development of CVA.

..... Splenic Sequestration

The abnormal sickled cells become trapped in the spleen

(splenic sequestration), leading to a rapid decrease in

steady state hemoglobin and an enlarged spleen. A rapid

decrease in hemoglobin can lead to hemodynamic instability and altered mental status. Splenic sequestration is a

serious complication seen more commonly in children

than adults and carries a significant morbidity and mortality potential.

..... Aplastic Crisis

Aplastic crisis arises when bone marrow production of

RBCs stops or falls below the rate of destruction. Aplastic

crisis is also associated with reticulocytopenia. Aplastic

crisis in patients with SCD has been linked to infection

with parvovirus as well as folic acid deficiency.

..... Hemolytic Anemia

Chronic hemolysis is a problem for all patients with

SCD due to the deformed RBC. Hemoglobin levels

range from 6-9 g/dL. Patients will also have an increased

reticulocyte count due to increase RBC destruction.

Under stress (eg, infection), hemolysis rates may

increase and patients my have a decrease in hemoglobin

from their baseline.

..... Priapism

Priapism, a painful failure of penile detumescence secondary to corpus cavernosum obstruction by sickled cells, has

a bimodal peak (5-13 years and 2 1-29 years of age).

Prolonged priapism can lead to impotence due to fibrosis

and vascular damage.

CLINICAL PRESENTATION

..... History

Patients will present with pain that is usually moderate to

severe and most commonly involves the extremities, back,

chest, and abdomen. Important historical considerations

include possible precipitants, previous complications,

home analgesic regimen, and routine medical care.

Common precipitants of a pain crisis include infection,

cold, and dehydration. Determine whether the patient's

pain is typical or atypical in relation to previous episodes in

an effort to determine whether more than a simple vasoocclusive pain crisis is occurring. The presence of fever, chest

pain, shortness of breath, joint swelling, or redness should

prompt the clinician to look beyond a simple pain crisis.

..... Physical Examination

Note the presence of abnormal vital signs (VS), particu ­

larly fever, tachycardia, tachypnea, hypoxia and hypotension, which may indicate complications of SCD or another

acute process. Although most patients with an acute vaseocclusive crisis will have a low-grade temperature, a fever

greater than 38.3°C (100.9 F) should prompt a search for

an infectious precipitant. In addition, acute chest syn ­

drome should be suspected in patients with chest pain,

shortness of breath, fever, and cough. Determination of

hydration status is critical. Rehydrating the patient in crisis

not only reduces sickling of the cells, but also increases the

intravascular volume, thereby helping to relieve vasoocclusion. In addition to rapid and accurate VS measurements

and determination of hydration status, several key organ

systems must be assessed .

The general appearance of the patient should be noted

for signs of respiratory distress, physical pain, and lethargy.

Because of the increased rate of hemolysis, patients with

SCD may have j aundice or scleral icterus. Pallor may indicate a significant drop in hemoglobin. The skin should be

examined for signs of infection. Pallor, left upper quadrant

pain, and splenomegaly are all concerning for splenic

sequestration. Chest auscultation should be done to note

any rales, rhonchi, or wheezing. The abdominal exam

should note the presence of focal tenderness, especially the

right or left upper quadrants. The presence of splenomeg ­

aly or hepatomegaly, or the presence of guarding or

rebound tenderness, should alert the practitioner to an

intra-abdominal process beyond that associated with pain

crisis. Extremities and joints should be examined for focal

tenderness, joint erythema, or swelling, all of which may

indicate osteomyelitis or septic arthritis and not simply

bone pain associated with a crisis. Patients with SCD

require a thorough examination of the extremities, and it

should be performed on an undressed patient to rule out

these serious complications. A full neurologic exam including cranial nerves and cerebellar signs should be per ­

formed to assess for any new neurologic deficits in a

patient with acute complaints.

SICKLE CELL EMERGENCIES

DIAGNOSTIC STUDIES

..... Laboratory

Initial laboratory studies in patients s uspected of having vasaocclusive crisis include complete blood count and reticulocyte

count. The Hb level is usually between 6 and 9 g!dL, but

should be compared with previous levels for any acute

decreases that would be consistent with rapid hemolysis,

splenic sequestration, or aplastic crisis. The r eticulocyte count

should be elevated during a typical acute vasoocclusive pain

crisis to compensate for increased RBC turnover. A reticulocyte count less than 2% would be concerning for aplastic crisis. Leukocytosis (12-20 K/mm) is common and does not

necessarily indicate infection. Infection should not be

excluded solely on the basis of white blood c ell (WBC) count.

Liver function tests are indicated in patients with abdominal

pain or jaundice to further evaluate evidence of hemolysis,

gall bladder, or liver end-organ damage. Urinalysis is needed

to assess for infection as a precipitant for the acute pain crisis.

Blood and urine cultures are only needed in patients in whom

infection is suspected.

 

is initiated. Loop diuretics (furosemide) can also be given

in a dose of 40-80 mg IV. Bisphosphonates may also be

used, but their maximum effect does not occur for

2-4 days. Hemodialysis may be indicated in severe cases.

Cancer patient in ED

Identify signs, symptoms, risk factors for

specific cancer-related complications

PE, malignant

effusion

Hypercalcemia, tumor Wea kness, arrhythmia, lysis syndrome, CNS �+----� f infection or metastasis AMS, ever

svc syndrome Upper trunk, facial

edema

Consider non-cancer-related illness

or complication

.A. Figure 70-1. Oncologic emergencies diag nostic algorithm. AMS,

altered mental status; CNS, central nervous system; ED, emergency

depa rtment; PE, pulmonary embol ism; SVC, superior vena cava.

CHAPTER 70

Tumor lysis syndrome is treated with IV hydration (NS),

loop diuretics, and allopurinol. Hyperkalemia remains the

most dangerous component of tumor lysis syndrome,

causing life-threatening dysrhythrnias. Hemodialysis may

be needed in patients with renal failure, severe electrolyte

abnormalities, or fluid overload.

If not treated in the first 48 hours, the mortality for

neutropenic sepsis approaches 50%. The prompt administration of empiric antibiotic therapy has resulted in a

decrease in mortality to 1 0%. Neutropenic fever should be

treated expeditiously with ceftazidirne 2 g IV. Vancomycin

should be added for patients with sepsis, known methicillin-resistant Staphylococcus aureus, or indwelling venous

catheters.

DISPOSITION

..... Admission

Patients with acute spinal cord compression will often

require intensive care unit (ICU) admission for frequent

neurologic evaluation. Neutropenic patients may also

require an ICU if they have signs of sepsis or septic shock.

If admitted to the floor, they should have reverse isolation

precautions to protect them from hospital acquired infections. Patients with renal failure or severe electrolyte

abnormalities will require an ICU or telemetry monitored bed.

..... Discharge

Cancer patients with a febrile illness who are not neutropenic may be considered for discharge depending on the

source of the fever. Patients with mild dehydration and

correctable electrolyte abnormalities may also be considered for discharge.

SUGGESTED READING

Blackburn P. Emergency complications of malignancy. In: Tintinalli

JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergeno/ Medicine: A Comprehensive Study Guide.

7th ed.New York, NY: McGraw-Hill, 2011, pp. 1 508-1516.

McCurdy MT, Shanholtz CB. Oncologic emergencies. Grit Care

Med. 201 2;40:22 12-2222.

Sickle Cell Emergencies

Brian R. Sellers, MD

Amy V. Kontrick, MD

Key Points

• Control pain aggressively.

• Search for and treat the precipita nts of

pain crisis.

INTRODUCTION

Sickle cell disease (SCD) is an inherited chronic disease

found primarily in those of African, Middle Eastern,

Indian, or Mediterranean ancestry. SCD is characterized by

a defect in the hemoglobin molecule, which normally consists of two pairs of a and p globin. A single amino acid

substitution (valine for glutamine) on the P-globin gene

results in sickle hemoglobin (Hb S). The mutation that

causes the amino acid substitution is inherited as an auto ­

somal recessive trait. Patients with sickle cell trait have one

abnormal P-globin gene (heterozygous HbAS), whereas

those with SCD have 2 abnormal P-globin genes (homozygous HbSS). During states of biologic stress (eg, low 02

state, infection, dehydration, pregnancy, cold exposure,

trauma) the Hb S polymerizes, resulting in deformation

(sickling) of the red blood cell (RBC). This sickled RBC has

reduced ability to pass through small blood vessels, resulting in vasoocclusion, hemolysis, and end-organ damage.

Premature destruction of the sickled RBC results in a

shorter than normal life span of the cell.

Two million people in the United States have sickle c ell

trait, and 70,000 have sickle cell disease. Although survival

has improved dramatically recently, life expectancy of

patients with SCD is shorter than average, now just greater

than 50 years.

Most patients with SCD present to the emergency

department (ED) with either a painful vase occlusive crisis

• Complications of sickle cell disease, both typical and

atypical, must be aggressively sought after and treated.

• Have a low threshold for admission when patients may

have an occult infection.

or sequela from vase-occlusion, some of which may be lifethreatening. It is the role of the emergency physician to not

only control pain but also diagnose and treat potential life

threats. Acute sickle cell emergencies can be divided into

several classifications: acute pain crisis, acute chest syn ­

drome, infection, neurologic, splenic sequestration, aplastic crisis, hemolytic anemia, and priapism.

..... Acute Pain Crisis

Vase-occlusive pain crises account for approximately 90% of

ED visits. Severe back and extremity pain results from microinfarction of the bones and joints. Abdominal pain crises

result from ischemia to the mesentery, spleen, and liver.

..... Acute Chest Syndrome

Acute chest syndrome is the most common cause of death

in patients with SCD. Although it is more common in

children, it is more severe in adults. Acute chest syndrome

is characterized by fever, chest pain, respiratory symptoms, hypoxia, and an infiltrate seen on chest x-ray

(CJCR). It is a result of pulmonary ischemia and infarction. Acute chest is frequently a complication of pneumonia. Chlamydia and Mycoplasma are the 2 most common

organisms, but viruses, Streptococcus pneumoniae,

Staphylococcus aureus, and Haemophilus influenzae are all

potential causes.

299

CHAPTER 71

may demonstrate a spectrum from peaked T waves, PR and QRS prolongation, loss of P-wave and T-wave flattening, and finally a sine wave. Hypocalcemia causes a prolonged QT

 

CHAPTER 70

hypocalcemia. These electrolyte and metabolic disturbances

can progress to clinical toxic effects, including renal insufficiency, cardiac arrhythmias, seizures, and death due to organ

failure. It is most common in cancers with high cell turnover

(leukemia and lymphoma).

One of the most common hematologic emergencies is

neutropenic fever, which is the presence of a fever >38°C

with an absolute neutrophil count of <500/!lL. Febrile neutropenia is a result of bone marrow suppression, a common

side effect of chemotherapy. Patients with neutropenia are

susceptible to life-threatening bacterial infections. Older

age has been shown to be an independent risk factor for the

development of neutropenia and febrile neutropenia. A history of previous chemotherapy-induced neutropenia predicts recurrent neutropenia and neutropenic fever.

CLINICAL PRESENTATION

..... History

Pain is the presenting symptom of spinal cord compression

in 90-95% of patients. The pain is usually constant and

close to the site of the lesion. Patients complain of a band

or girdle of pain/tightness radiating from back to front,

exacerbated by recumbency, movement, coughing and

sneezing. Symptoms may include numbness and tingling,

which usually precedes weakness. Weakness often presents

with "stiffness," dragging of a limb, or unsteadiness.

Facial edema is the most common symptom of SVC

syndrome with patients often describing feeling bloated.

Other symptoms include dyspnea, cough, chest and shoulder pain, and hoarseness. Dyspnea may be worse when

leaning forward or lying down. Arm swelling and lymphedema are other common symptoms of SVC syndrome.

In both acute and chronic hypercalcemia of malignancy, the major manifestations affect gastrointestinal,

renal, and neuromuscular function. Patients with acute

hypercalcemia commonly present with anorexia, nausea,

vomiting, polyuria, polydipsia, dehydration, weakness, and

confusion. Patients with tumor lysis syndrome may have

similar symptoms often related to acute renal failure.

Neutropenic patients, usually on chemotherapy, often

present to the ED with fever and no clear source of infection. Tachycardia and hypotension may accompany fever

and may indicate severe sepsis or septic shock. Weakness

and dehydration are usually present.

..... Physical Examination

Patients with cancer who present to the ED require a thorough physical examination to identify potential life threats

associated with malignancy. Vital signs and general assessment including mental status will often reveal whether an

acute medical emergency such as neutropenic sepsis or

arrhythmia exists. A thorough head-to-toe examination

should follow. Head, eyes, ears, nose, and throat examination should assess for a patent airway, oropharyngeal

infection, facial plethora, and cranial neuropathies. Neck

examination should assess for cervical spine tenderness and

dilated neck veins. Cardiovascular and respiratory exams

should assess breath sounds and cardiac rhythm. Decreased

breath sounds or distant heart sounds may indicate pleural

or pericardia! effusions. Abdominal exam should assess for

masses and possible source of occult infection. Back exam

should assess for any localized tenderness or masses, and

neurologic exam should identify any focal neurologic deficits. Extremities and skin should be assessed for hydration

status and edema, possibly related to acute renal failure.

DIAGNOSTIC STUDIES

..... Electrocardiogram

An electrocardiogram should be performed in all patients

with suspected electrolyte abnormalities. Patients with hypercalcemia may have a shortened QT interval due to the

increased rate of cardiac repolarization. Arrhythmias such as

bradycardia and first -degree atrioventricular b lock may occur.

Tumor lysis syndrome may result in multiple electrolyte

abnormalities that may manifest as arrhythmias. Hyperkalemia

may demonstrate a spectrum from peaked T waves, PR and

QRS prolongation, loss of P-wave and T-wave flattening, and

finally a sine wave. Hypocalcemia causes a prolonged QT

and may result in ventricular arrhythmias.

..... Laboratory

Serum basic metabolic panel (BMP) with calcium, magne ­

sium, and phosphorous should be assessed on all patients

with vague complaints, vomiting, or dehydration. BMP

should also be ordered for those at risk for hypercalcemia

(bony metastasis) and tumor lysis syndrome (recent cancer

treatment). Patients with tumor lysis syndrome present

with acute renal failure in the presence of hyperuricemia

(> 15 mg/dL), hyperphosphatemia (>8 mg/dL), hyperkale ­

mia, and hypocalcemia. A complete blood count should be

obtained on all patients to assess for neutropenia (absolute

neutrophil count <500/!lL), anemia, and thrombocytopenia. The absolute neutrophil count is determined by mul ­

tiplying the total white blood cell count times the

percentage of neutrophils plus bands. Multiple sets of

blood cultures and a urine culture should be collected in

all febrile neutropenic patients in the ED.

..... Imaging

Patients with signs or symptoms suggestive of spinal cord

metastasis should have their spine imaged. Plain radiographs may identify bony metastasis or pathologic fractures

but are not sufficiently sensitive to rule out the presence of

spinal disease. Computed tomography ( CT) scan of the

spine is more sensitive than plain films; however, magnetic

resonance imaging of the spine is the test of choice to

assess for spinal metastasis and cord involvement. Similarly,

chest radiograph may be used as an initial test for patients

with suspected SVC syndrome, but CT chest with contrast

is the test of choice for identification.

ONCOLOGIC EMERGENCIES

MEDICAL DECISION MAKING

Identification of common emergencies associated with

malignant disease is key to the expeditious ED care of the

cancer patient. Patients with acute shortness of breath

should be assessed for malignant pleural or pericardia! effusions or pulmonary embolus. Generalized weakness may be

from dehydration, electrolyte abnormalities associated with

tumor lysis syndrome or renal failure, or an occult infection

owing to immunosuppression from chemotherapy. Brain

or spinal cord metastasis should be considered for any focal

neurologic sign or symptom, and appropriate imaging

should be performed in the ED (Figure 70-1).

TREATMENT

For patients with acute spinal cord compression from spinal

metastasis, IV corticosteroids relieve pain, reduce edema,

and may improve neurologic function. They may also ternporarily prevent the onset of cord ischemia. Radiation

therapy provides more definitive treatment in most patients.

Indications for radiation therapy include known radiosensitive tumor with no spinal instability and palliative therapy

in patients who present with paraplegia.

SVC syndrome is treated in the ED with IV steroids

(dexamethasone 10 mg IV) and furosemide IV in an

attempt to reduce venous pressures. Patients with cardiac

or respiratory compromise or central nervous system

dysfunction may require emergent endotracheal intubation or radiation therapy. Vascular surgery should be consulted for possible SVC stenting.

Hypercalcemia is treated in the ED with IV fluid

administration. Levels > 13 mg/ dL usually require

treatment. An initial bolus of 1-2 L of normal saline (NS)