CHEST fellow course 2024 Heme Onc Emergencies

  • concerning finding for anemia
  • cytopenia

  • C

Acute Leukemia

  • don’t need to know Cairo scale

  • releasing purine metabolite
  • down stream leads to tubular necrosis and AKI
  • allopurinol: first line to prevent consequence of TLS
    • can cause hypersensitivity reaction: use febuxostat instead
  • higher risk of TLS or already have AKI: use rasburicase
    • reduces concentration of uric acid
    • can actually reverse renal tubular effects from uric acid
    • have to check G6PD level

Multiple Myeloma

  • high Ca

  • ingestion, sun exposure, bone osteoclast
  • PTHrP: sqCC lung
  • bony mets will cause osteolysis such as in MM
  • Lymphoma such as Hodgekin’s: peripheral conversion like sarcoid, results in unregulated increase in 1-25 hydroxy vit D

  • long PR, QRS, short QT
  • end QRS notching like J point for Osborn wave
  • pseudo epsilon wave like in Brugada syndrome
  • replace phos and mag levels

  • steroids is good for peripheral conversion of vitamin D
  • most of time can get away without dialysis

APML

  • happens often

  • hypotension

  • variety of highly active cancer therapy with side effects
  • sinusoid occlusion syndrome: venous occlusive disease (VOD). Most common complication
  • angiogenesis related: bleeding
  • small molecule inhibitors (kinase inhibitors): QT prolongation and arrythmias
  • CAR-T: myleosuppression, cytokine release syndrome

Immune checkpoint inhibitor Pneumonitis

  • combination therapy
  • concern about deep seated infection
  • progressive GGO on L side

  • steroids

  • immune checkpoint inhibitor promotes inflammatory response within first weeks to months
  • progressive skin rash: early sign of ICI toxicity

Others

  • increase frequency of nonmalignant causes
  • histoplasmosis causing fibrosing mediastinitis

  • extrinsic compression and internal involvement of SVC, either tumor/clot
  • anticoagulate if no contraindication. Often will rely on venous collaterals flow back to heart (low flow and small diameter, easy to thrombose)

  • compression from either fracture or from tumor invasion itself

  • medical emergency
  • rad onc vs NSY

  • MRI better than contrast CT
  • 4th ventricle disease (cerebellum and brainstem) have different treatment options

  • steroids can buy time for a few days while you look for primary cancer
  • infratentorial lesions/cerebellum: smaller space and more poor prognosis => NSY more likely intervention

  • sickle cell
  • acute chest syndrome

  • sludge, thrombosis, release inflammatory mediators, compromise blood flow, in situ pulmonary thrombosis, infarction, inflammation of lung
  • bad sickle crisis: bony infarction in ribs. Can’t breath

  • target encapsulated organisms from functional asplenia
  • exchange transfusion. If not, then normal blood for simple volume expansion
  • hydroxyurea for chronic for reducing Hgb-F
  • steroids used to be used but not anymore: not effective

  • abruptly cyanotic
  • encephalopathy: more worrisome
  • most classic: caine and dapsone
  • leukopheresis vs apheresis
    • no clear mortality benefit of leukopheresis over cytoreduction