Hematology/Oncology Emergencies

Contents

Foreword: Hematology/Oncology Emergencies xv

Amal Mattu

Preface: Hematology/Oncology Emergencies xvii

John C. Perkins and Jonathan E. Davis

Oncologic Mechanical Emergencies 495

Umar A. Khan, Carl B. Shanholtz, and Michael T. McCurdy
Prevalence of cancer and its various related complications continues
to rise. Increasingly these life-threatening complications are initially man-
aged in the emergency department, making a prompt and accurate diag-
nosis crucial to effectively institute the proper treatment and establish
goals of care. The following oncologic emergencies are reviewed in this
article: pericardial tamponade, superior vena cava syndrome, brain metas-
tasis, malignant spinal cord compression, and hyperviscosity syndrome.
Oncologic Metabolic Emergencies 509
Jonathan Wagner and Sanjay Arora
Cancer and its therapies may lead to several metabolic emergencies that
emergency providers (EPs) should be well-versed in identifying and man-
aging. With prompt recognition and treatment initiation in the emergency
department, lives can be saved and quality of life maintained. Most onco-
logic metabolic emergencies occur in advanced cancer states, but some
follow initiation of treatment or may be the presenting syndrome that leads
to the cancer diagnosis. This article reviews the 2 most emergent oncologic
metabolic diagnoses: tumor lysis syndrome and hypercalcemia of malig-
nancy. A discussion on associated cancers and conditions, pathogenesis
and pathophysiology, and management recommendations is included.
Pediatric Oncologic Emergencies 527
Melanie K. Prusakowski and Daniel Cannone
The overall prognosis for most pediatric cancers is good. Mortality for all
childhood cancers combined is approximately half what it was in 1975,
and the survival rates of many malignancies continue to improve. How-
ever, the incidence of childhood cancer is significant and the related
emergencies that develop acutely carry significant morbidity and mortality.
Emergency providers who can identify and manage oncologic emergen-
cies can contribute significantly to an improved prognosis. Effective
care of pediatric malignancies requires an age-appropriate approach to
patients and compassionate understanding of family dynamics.
Neutropenic Fever 549
Lindsey White and Michael Ybarra
Fever is a common presenting complaint among adult or pediatric patients
in the emergency department setting. Although fever in healthy individuals
does not necessarily indicate severe illness, fever in patients with
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neutropenia may herald a life-threatening infection. Therefore, prompt

recognition of patients with neutropenic fever is imperative. Serious bacte-
rial illness is a significant cause of morbidity and mortality for neutropenic
patients. Neutropenic fever should trigger the initiation of a rapid work-up
and the administration of empiric systemic antibiotic therapy to attenuate
or avoid the progression along the spectrum of sepsis, severe sepsis, sep-
tic shock syndrome, and death.
Chemotherapeutic Medications and Their Emergent Complications 563
Janet S. Young and Jennifer W. Simmons
Patients with complications of chemotherapy, either acute or chronic, are
frequently encountered in the emergency department (ED). Some patients
present with complaints immediately after chemotherapy administration,
whereas others may show subtle, secondary signs or may have no signs
or symptoms of chemotoxicity. An increased index of suspicion prompts
early recognition, diagnosis, and prevention of further iatrogenic injury.
This article reviews characteristic hypersensitivity reactions, typical organ
system dysfunction, and treatment strategies for adult patients who pre-
sent to the ED with complications after chemotherapy.
Acute Leukemia 579
Hayley Rose-Inman and Damon Kuehl
Although great progress has been made in the understanding and treat-
ment of acute leukemia, this disease has not been conquered. For emer-
gency providers (EPs), the presentation of these patients to an emergency
department presents a host of challenges. A patient may present with a
new diagnosis of leukemia or with complications of the disease process
or associated chemotherapy. It is incumbent on EPs to be familiar with
the manifestations of leukemia in its various stages and maintain some
suspicion for this diagnosis, given the nebulous and insidious manner in
which leukemia can present.
Myeloproliferative Disorders 597
Brian Meier and John H. Burton
The emergency providers generally encounters myeloproliferative disor-
ders (MPNs) in 1 of 2 ways: as striking laboratory abnormalities of seeming
unknown consequence, or in previously diagnosed patients presenting
with complications. The course of patients with MPNs is highly variable,
but major complications can arise. Emergent conditions related to hyper-
viscosity need to be recognized early and treated aggressively. Rapid hy-
dration, transfusion, cytoreduction, and early hematology consultation can
be lifesaving. Likewise, although management is not altered, a high index
of suspicion for thrombotic complications is required in patients with
known MPNs as these are a significant cause of morbidity and mortality.
Anemia 613
Julie T. Vieth and David R. Lane
Patients with anemia are frequently encountered in the emergency depart-
ment (ED); emergency physicians (EPs) often play an important role in the
evaluation and management of anemia. Although many patients have
findings consistent with anemia on routine laboratory tests, only a small
 Contents ix

percentage will require acute intervention. An understanding of the

broader types of anemia and how to manage such patients is important
in the practice of an EP, as the presence of anemia will impact treatment
plans for a variety of other disorders. This article reviews the evaluation
and management of adult patients presenting to the ED with anemia.
Sickle Cell Disease in the Emergency Department 629
Paris B. Lovett, Harsh P. Sule, and Bernard L. Lopez
Acute painful episodes are the most common reason for emergency depart-
ment visits among patients with sickle cell disease (SCD). Early and aggres-
sive pain management is a priority. Emergency providers (EPs) must also
diagnose other emergent diagnoses in patients with SCD and differentiate
them from vaso-occlusive crisis. EPs should be aware of cognitive biases
that may misdirect the diagnostic process. Administration of intravenous
fluids should be used judiciously. Blood transfusion may be considered. Co-
ordination of care with hematology is an important part of the effective emer-
gency department and long-term management of patients with SCD.
Thrombotic Microangiopathies (TTP, HUS, HELLP) 649
Shane Kappler, Sarah Ronan-Bentle, and Autumn Graham
Thrombocytopenia, strictly defined as a platelet count less than 150,000, is
common in the emergency department. Recognition, diagnostic investiga-
tion, and proper disposition of a thrombocytopenic patient are imperative.
One group of disorders leading to thrombocytopenia is the thrombotic
microangiopathies, hallmarked by platelet destruction. These thrombotic
microangiopathies include thrombotic thrombocytopenic purpura (TTP),
hemolytic uremic syndrome (HUS) and hemolysis, elevated liver enzyme
levels, low platelet count (HELLP), which should be distinguished from
similar disease processes such as immune thrombocytopenia (ITP),
disseminated intravascular coagulation (DIC) and heparin induced throm-
bocytopenia (HIT). In this article, clinical presentations, pathophysiology,
diagnostic workup, management plans, complications, and dispositions
are addressed for this complex group of platelet disorders.
Evaluation and Management of Congenital Bleeding Disorders 673
Rahul Bhat and Whitney Cabey
Patients presenting to the emergency department with acute bleeding and
a history of clotting or platelet disorder present a unique challenge to the
emergency physician. The severity of bleeding presentation is based on
mechanism as well as factor levels: patients with factor levels greater
than 5% can respond to most minor hemostatic challenges, whereas
those with factor levels less than 1% bleed with minor trauma or even
spontaneously. Treatment should be initiated in consultation with the pa-
tient’s hematologist using medications and specific factor replacement,
except in rare, life-threatening, resource-poor situations, when cryopreci-
pitate or activated prothrombin complex may be considerations.
Acquired Bleeding Disorders 691
Alisheba Hurwitz, Richard Massone, and Bernard L. Lopez
Emergency medicine practitioners treat bleeding patients on a regular
basis. Disorders of hemostasis are an additional challenge in these
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patients but can be assessed and managed in a systematic fashion. Of

particular importance to the emergency clinician are the iatrogenic causes
of abnormal hemostasis. Other acquired causes of abnormal hemostasis
include renal disease, immune thrombocytopenia, thrombotic thrombocy-
topenic purpura, hemolytic uremic syndrome, acquired coagulation factor
inhibitors, acute traumatic coagulopathy, liver disease, and disseminated
intravascular coagulopathy.

Antithrombotic Reversal Agents 715

Matthew D. Wilson and Jonathan E. Davis
The actively bleeding anticoagulated patient presenting to the emergency
department requires rapid evaluation and treatment, which is made
increasingly complicated by the ever-evolving antithrombotic treatment
options used in medicine. Even with excellent supportive care, the timeli-
ness with which reversal decisions need to be made continues to demand
of the emergency practitioner a familiarity with the properties and general
characteristics of a variety of antithrombotic agents. Reversal options vary
and may include vitamin K, FFP, PCC, rFVIIa, platelets, and desmopressin,
among others.

Blood Product Transfusions and Reactions 727

Jessica L. Osterman and Sanjay Arora
Blood product transfusions are an essential component of the practice of
emergency medicine. From acute traumatic hemorrhage to chronic blood
loss necessitating transfusion for symptomatic anemia, familiarity with in-
dividual blood products and their indications for transfusion is an essential
tool for every emergency physician (EP). Although the focus of this article is
primarily on the transfusion of red blood cells, many of the concepts are
applicable to the transfusion of all blood products. EPs must be fully
familiar with both the individual blood components and the potential reac-
tions and complications of these transfusions.

Index 739