Cancer is a diagnosis that nobody wants - but, unfortunately for a multitude of reasons, some potentially environmental -- most forms of cancers continue to rise year over year. Because of this, the amount of cancer related patient encounters who have in the field is also higher.
This blog doesn't aim to make you an expert on oncological emergencies, but it will hopefully expand your neurons as well as your potential list of differential diagnosis, when the alarms summons you to respond to their emergent needs.
Many cancer patients are seeking advanced treatments in an outpatient setting which allows them to recover at home. The advent of chemotherapy, radiation and even immunotherapy have come a long way to target the rapid dividing neoplasms. These new growths could be solid tumors, or they can be coming from the bone marrow in the form of a leukemia. As you know treating cancers aggressively come with risk. The most know risk likely related to immunosuppression and the high likelihood of infections. However, aside from those ones we are most familiar with, today, I'll introduce another one called Tumor Lysis Syndrome. The causation behind this very common oncological + metabolic emergency is centered around the fact that when tumor cells succumb to the specified treatment - they release the contents of their intracellular environment. On other rarer occasions, mainly when the cancer burden is large (think of a palpable mass), the same phenomenon can happen spontaneously even in the absence of treatment.
Keep in mind that the cancer cells are dying in rapid succession and in very high numbers. It is a good thing if the abnormal cells are sensitive to the chemotherapy/radiation. Chemo is cytotoxic but its very nature. Therefore, once the cells are dead, they spill their cellular contents into the bloodstream, The patients are then at risk for electrolyte abnormalities and acute kidney injury. These can be fatal. I'll highlight some of them here:
Hyperkalemia - life threatening dysrhythmias and other EKG changes -
Phosphorus also climbs as it is a major intracellular anion
Hypocalcemia - tetany, seizures, parathesias/numbness
Increased uric acid - crystal formation and deposition in the kidneys, which causes acute injury
Lactic acidosis - from the breakdown of nuclear/genetic materials
You may find that these patients may be suffering from generalized malaise, nausea, vomiting and diarrhea. Additionally, those patients with leukemia and/or lymphoma are most likely to present with this syndrome.
Patients who become dehydrated or those who already have some underlying renal compromises are more at risk. So, keeping them hydrated can be a great prophylaxis. This can go a long way in helping the kidneys "moving" so that their compensatory mechanisms don't fail. Urine production and excretion is key as urine represents a metabolic end point. As you can imagine urinary retention is bad and usually sets off a cascade of events that lead to clinical deterioration. It all leads back to impairment in the function of target organs like the brain, heart, and kidneys.
Physicians focus is around identifying patients at highest risk and start prophylactic treatment before the condition develops. They will also try to avoid substances that cause vasoconstriction. You may not be able to diagnosis this in the pre-hospital arena but keeping it, a part of your differential diagnosis is important. Correcting fluid and volume status as well as pharmacological interventions for nausea and vomiting are certainly in your scope and could go a long way.
October 28, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
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