Oncological Emergencies are the group of conditions that occur as a direct or indirect results of cancer or its treatment that are potentially life-threatening. after definition it consist of classification and descriptive explanation of each disease and in the end NURSES ROLE

1. ONCOLOGICAL
EMERGENCIES

2. DEFINITION
• Oncological Emergencies are the group
of conditions that occur as a direct or
indirect results of cancer or its treatment
that are potentially life-threatening.

3. CLASSIFICATION OF ONCOLOGICAL EMERGENCIES
Structural/
Obstructive
Emergencies
Due to Metabolic/
Hormonal
Problems
Secondary to
Complications
Arising from
Treatment Effects
•Superior Vana Cava
Syndrome (SVCS)
•Pericardial Effusion/
Temponade
•Spinal Cord
Compression (SCC)
•Increased ICP
•Urinary Tract
Obstruction
•Hemoptysis
•Airway Obstruction
•Hypercalcaemia
•Syndrome of
Inappropriate Anti-
diuretic Hormone
(SIADH)
•Lactic Acidosis
•Tumor Lysis
Syndrome
•Haemorrhagic Cystitis
•Anaphylactic
Reactions Related to
Chemotherapeutic
Agents
•Neutropenic Fever

4. SUPERIOR VANA CAVA
SYNDROME
• Superior vena cava syndrome (SVCS)
encompasses a range of signs and symptoms
resulting from external compression or
intrinsic obstruction of the superior vena cava
(SVC) or associated greater veins.

5. Principal Causes of SVCS
Lung cancer • Small-cell cancer
• Non-small-cell cancer
• Diffuse large-cell cancer
Lymphoma • Lymphoblastic
Metastatic disease to
mediastinum
• Breast cancer
• Germ cell cancer
• Gastrointestinal cancers
• Other
Primary mediastinal
tumours
• Thymoma
• Sarcomas (e.g. malignant fibrous histiocytoma)
• Melanomas
• Thymic carcinoma
Non-malignant causes • Infectious disease – syphilis, tuberculosis and
histioplasmosis
• Central line thrombus and other iatrogenic causes
• Idiopathic fibrosing mediastinitis
• Congestive heart failure
• Goitre

6. INVESTIGATIONS
OF
SVCS

7. Clinical Evaluation
Of
SVCS
Symptoms of SVCS Signs of SVCS
•Dyspnoea
•Nasal stuffiness
•Facial oedema
•Tongue
swelling
•Cough Nausea
•Headache
•Light
headedness
•Distorted vision
•Stridor
•Hoarseness
•Jugular venous
distension
•Lethargy, stupor
and coma
•Upper
extremity
swelling
•Syncope
•Facial and
upper body
plethora
•Cyanosis
•Chemosis
•Papilloedema
•Mental status
changes

8. Radiological Evaluation
• Chest X-ray
• Contrast computed tomography (CT)
• magnetic resonance imaging (MRI)

9. Management Algorithm of SVCS

10. Pericardial Effusion/
Temponade
• It is usually associated with advanced lung and
breast cancer, leukemia or lymphoma.
• The spectrum of malignant pericardial
involvement includes pericarditis, pericardial
infusion, cardiac temponade, and constructive
pericarditis.

11. • It may be due to
⁻ direct extension of disease,
⁻ from spread through mediastinal lymphatic or
blood vessels,
⁻ obstruction of lymphatic drainage, or
⁻ a direct effect of chemotherapy or
radiotherapy.

12. Clinical Manifestations
•Dyspnoea
•Orthopnoea
•Raised JVP
•Preicardial Rub
•Pulses paradoxus
• Chest discomfort/pain
•Cough
•Muffled heart sounds
•Low BP

13. Diagnosis
• Chest X-ray
• CT scan
• MRI
• ECG
Management
• Pericardiocentesis and Catheter Drainage
⁻ Allowing for the relief of the temponade and
cytologic analysis of fluid.

14. SPINAL CORD
COMPRESSION
• Lung, prostate and breast cancer are leading
causes of SCC.
• Other significant causes of SCC are non-
hodgkin’s lymphoma, renal cell carcinoma,
multiple myeloma, sarcoma.

15. Clinical Manifestations of SCC
• Pain : Localized to spine or radicular in
nature. May be aggravated by
movement ,straining and coughing.
• Muscular weakness or sensory loss.
• Numbness, paraesthesia, ataxia.
• Urinary Incontinence or Retention
• Faecal incontinence or constipation

16. Investigations of SCC
• Magnetic resonance imaging (MRI) is the gold
standard method for SCC Diagnosis.
• Myelography
• Bone scan
• Computed tomography (CT)
• Positron emission tomography (PET)

17. Management of SCC

18. INCREASED ICP
(INTRACRANIAL PRESSURE)
• Cranial metastasis affect around a quarter of
patients who die from cancer.
• Lung, breast, and melanoma are the tumors'
that most commonly metastasise to the brain.

19. Clinical Manifestations
•Headache
•Behavioural changes
•Focal neurological defects
•Papilloedema
•Unilateral ptosis or
3rd and 6th cranial nerve
palsies
•Nausea and vomiting
•Seizures
•Falling level of
consciousness
• Bradycardia

20. Diagnosis
• Computed tomography(CT)
• Magnetic resonance imaging (MRI)
Management
• Hyperventilation
• Mannitol (Hyperosmotic agent)
• Dexamethasone Injection(Corticosteroid)

21. Urinary Tract Obstruction
• Definition: Urinary tract obstruction (UO) is
defined as the complete interruption of urine
natural flow.
• This complication may occur iatrogenically, or as a
result of the underlying cancer.
• It concerns patients with primary tumours in the
pelvis (such as gynaecological or urological
malignant neoplasm's), but may also result from
metastatic disease from any primary cancer to
the pelvic area.

22. Urinary Tract Obstruction
Lower Urinary
Tract
Obstruction
Upper Urinary
Tract
Obstruction
According to
Location

23. Lower Urinary Tract Obstruction
• Mechanisms and causes:
Low UO is due to obstruction of urine output at the
level of the urethra, prostate or bladder.
It can be related to urethral strictures, BPH, prostate
cancer, iatrogenic causes (like, Foley catheter
obstruction, previous extensive pelvic surgery, or
the use of anticholinergics).
• Presentation:
The pivotal symptom is the inability to urinate
(incontinence).

24. • 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.

25. Upper Urinary Tract Obstruction
• Mechanisms and causes:
Stones and cancer growth are the two most frequent
causes of upper UO.
Ureter flow may be compromised in one or both
sides, due to neoplasm (like prostate, bladder,
cervical or colon cancer).
• Presentation: If there is bilateral upper UO or
involvement of a solitary kidney, or poor renal
function, the signs and symptoms will be those of
uraemia.

26. • Diagnosis:
Ultrasound
computed tomography (CT) without contrast
magnetic resonance imaging (MRI)
• Treatment:
If the cause is not reversible in the short term and/or
there are severe symptoms and/or renal failure,
diversion of the urinary tract is indicated.
Two methods are available:
1) Placement of percutaneous nephrostomy tubes,
2) Addition of indwelling ureteral stents through
cystoscopy.
These devices need to be changed every 3–6 months.
Reversible causes such as distal ureter stones can be
treated medically (eg. Tamsulosin 0.4 mg qd).

27. Haemoptysis
• Haemoptysis is defined as blood expectoration
coming directly from the bronchial tree.
For assessing the risk and seriousness of
haemoptysis there are three main prognostic
factors: haemoptysis volume, bleeding speed and
patients’ previous lung functional capacity.
• Massive haemoptysis is defined as the loss of
≥500 ml of expectorated blood over a 24-hour
period or a bleeding rate of ≥100 ml/h.

28. Causes of Haemoptysis
Bronchial disease  Bronchiectasis
Tumours (squamous cell lung carcinoma,
small-cell lung carcinoma, metastatic
melanoma, metastatic colorectal cancer,
metastatic breast cancer, bronchial carcinoid)
Trauma
Aorto-bronchial fistula
Pulmonary disease Pneumonia
Rheumatic/immune pathology
Coagulopathy Hereditary
Anticoagulants
Pharmacological Bevacizumab
Other antiangiogenic agents
Cocaine
Nitrogen dioxide exposure

29. Diagnosis
In case of
Non-massive Haemoptysis
In case of
Massive Haemoptysis
•History and Physical examination
(To localize the source of bleeding)
•Laboratory Tests:
CBC
RFT
LFT
Coagulation Profile
•Other tests:
Sputum Culture
Specific antibody test
•Imaging Studies:
Chest Radiography
Computed Tomography (CT)
• Bronchoscopy
•ABG (Arterial Blood Gas)
•Coagulation Test
•Bronchoscopy
•Arteriography

30. Treatment or Supportive Care
• Focused on the underlying cause
• Fresh Frozen Plasma(In case of elevated INR)
• Antiplatelet agents,
• Platelet transfusion(In case of Thrombopaenia)

31. HYPERCALCAEMIA
• Hypocalcaemia is an elevated serum calcium level
above 11.0 mg/dl.
• Malignancies most commonly associated include
lung, breast, head, neck, kidney, lymphoma, and
myeloma.

32. Clinical Manifestations
•Polydipsia
•Dehydration
•Constipation
•Drowsiness
•Nausea and vomiting
•Bradycardia
•Changes in mental
status
•Polyuria
•Abdominal discomfort
•Increased gastric acid
secretion
•Muscle weakness

33. Management
• Intensive rehydration for 12-24 hours with 4-6 litre
of normal saline.
• Loop Diuretics:- Furosemide 40-80mg, IV
• Bisphosphonate:- Pamidronate 90mg (2-4 hour
infusion); Zoledronic acid 4mg(15 minute infusion)
• Adjunctive Therapies:- Corticosteroids, calcitonin.
• Haemodialysis:- In case of refractory hypercalcemia

34. SYNDROME OF INAPPROPRIATE
ANTI-DIURETIC HORMONE
• Syndrome of Inappropriate Anti-diuretic
Hormone (SIADH) result from abnormal and
sustained production of anti-diuretic hormone
(ADH) by tumor cells with resultant water
retention and hyponatremia.

35. Causes
• Carcinoma of lung, pancrease, duodenum, brain,
oesophagus, colon, ovary, prostate, bronchus,
nasopharynx.
• Leukemia
• Hodgkin’s lymphoma
Clinical Manifestations
•Weight gain without oedema
•Anorexia
•Oliguria
•Coma
•Weakness
•Nausea and vomiting
seizures
•Decrease in reflexes

36. Management
• Correct the sodium-water imbalance, including:-
Fluid restriction
Oral salt tablets or isotonic saline administration
In severe cases, IV administration of 3% sodium
chloride solution
Furosemide

37. 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).

38. Clinical Manifestations
•Nausea and vomiting
•Diarrhoea
•Loss of consciousness
•Hypotension
•Abdominal pain
•Altered sensorium
•Dehydration
•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.

39. TUMOR LYSIS SYNDROME
• This syndrome is due to the effects of
treatment of malignancy. There is a reaction
to the sudden and large releases of cellular
lysis products caused by tumor destruction.
The body me unable to excrete and neutralize
such toxic products.

40. Clinical Manifestations and Diagnosis
• Symptoms are non specific an include:-
• Routine uric acid and electrolyte measurement are
indicated to find out the cardinal biochemical
features:-
-Nausea and vomiting
-Fatigue
-Weakness
-Myalgia
-Dark urine
-Neuromuscular irritability
-Arrhythmias
-Seizures
-Sudden death
⁻Hyperkalaemia
⁻Hyperphosphataemia
⁻Hyperuricaemia
⁻Hypocalcemia

41. Management
• IV hydration with NS 3-4Lit./24 hours, with
sodium bicarbonate
• Acetazolamide is used to alkalinise the urine
• Allopurinol is used as prophylactic for
Hyperuricaemia
• Diuresis with Furosemide/ Mannitol
• Oral Aluminium Hydroxide to treat
Hyperphosphatemia
• Dialysis; in case of refractory Hyperkalaemia
and severe acute renal failure

42. 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 Manifestations
•Dysuria
•Frequency
•Urgency
•Burning sensation
•Gross haematuria
•Incontinence

43. Management
• Oral and IV hydration:- Increase urine flow and
reduce contact of acrolein with bladder mucosa
• Mensa administered with Ifosfamide or high dose
cyclophosphamide:- To detoxify acrolein and it’s
metabolites in urine
• Bladder irritation with formalin solution for 10
minutes.
• Systemic Aminocaproic Acid as first line treatment
follower by Fulguration.
• Internal iliac ligation or embolization, urinary
diversion.
• Cystectomy

44. 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. n

45. Causes and Risk Factors
Bacteria
1) Gram Positive Cocci 2) Gram Negative Cocci
S.aurues
Streptococci
Staphylococci
E.coli
Klebsiella species
P.aeuginosa
Risk Factors
•IV devices
•High dose chemotherapy regimens
•Corticosteroid use
•Mucositis
•Bone marrow incompetence

46. 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

47. 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.

48. Role Of Oncology Nurses’
• Patient assessment
• Patient and care giver education
• Patient care
• Symptom management
• Supportive care