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Oncological emergencies

Most oncological emergencies can be classified as metabolic, haematological, structural (as seen in Table 26.1), or side‐effects from chemotherapy agents (Higdon and Higdon [108]). Some oncological emergencies are insidious and may take months to develop, whereas others can manifest in hours and are potentially life threatening (Higdon and Higdon [108]). If patients with potentially serious symptoms do not present in a timely manner, optimum management might not be possible. The National Confidential Enquiry into Patient Outcome and Death audit into deaths within 30 days of receiving systemic anticancer therapy (Mort et al. [189]) confirmed that substantial numbers of patients did not recognize toxic effects or seek advice appropriately or did not want to bother health professionals. Therefore, before any cancer treatment, including supportive therapies, is delivered, patients and carers must be educated about the optimum management of potentially life‐threatening effects and their role in recognizing and reporting side‐effects. An assessment at every clinical meeting of the symptoms being experienced by the patient is essential, along with reiteration of the information.
Table 26.1  Examples of oncological emergencies, cancer of origin, signs and symptoms
Oncological emergencyCancer or treatment causesCommon presenting symptomsRare presenting symptoms
Neutropenic sepsisAll cancers where the disease or treatment causes bone marrow suppression
  • Temperature > 38°C (101°F)
  • Temperature > 37.5°C and feeling generally unwell and associated coryzal symptoms
  • Coryzal symptoms (cough, runny nose, etc.)
  • Absolute neutrophil count less than 500/mm3 (0.5  ×  109/L)
  • Rash
  • Mouth ulcers and feeling unwell
Metastatic spinal cord compression (MSCC)Lung, breast, prostate, multiple myeloma, renal, lymphoma
  • Back pain – increased by straining or laying flat
  • Limb weakness
  • Difficulty walking
  • Sensory loss
  • Altered bowel or bladder sensation or incontinence
  • Neurological signs
  • Nocturnal spinal pain
  • Crush fracture
  • Impotence
  • Saddle anaesthesia
Hypercalcaemia of malignant originLung (particularly squamous cell), breast, kidney, myeloma, leukaemias
  • Nausea
  • Vomiting
  • Constipation
  • Fatigue
  • Weakness
  • Cardiac arrhythmias
  • Polydipsia
  • Polyuria
  • Cognitive dysfunction
  • Incidental
  • Depression
  • Pancreatitis
  • Renal calculi
Superior vena cava obstruction (SVCO)Lung (particularly squamous origin), mediastinal metastases, lymphoma (particularly non‐Hodgkin), central venous access devices
  • Facial oedema
  • Superficial venous dilatation (neck and upper thorax)
  • Dyspnoea
  • Headache
  • Dizziness
  • Nasal congestion
  • Hoarseness
  • Cough
  • Stridor
  • Alteration of consciousness
 
Tumour lysis syndrome (TLS)Any advanced cancer, beginning of antineoplastic treatment (particularly for lymphomas, leukaemias, metastatic germ cell)Signs of:
  • Hyperuricaemia
  • Hyperkalaemia – cardiac arrhythmias
  • Hyperphosphataemia – muscle cramps, tetany
  • Hypocalcaemia – memory loss, confusion, muscle cramps
  • Acute kidney injury
 
Acute kidney injury (AKI)Any cancer or its treatment (particularly nephrotoxic drugs)
  • Dehydration
  • Oliguria
  • Sepsis
  • Swelling in legs, ankles, and around the eyes
  • Fatigue or tiredness
  • Shortness of breath
  • Confusion
  • Nausea
  • Chest pain or pressure
  • Seizures or coma in severe cases
Source: Adapted from Cassidy et al. ([32]), Higdon and Higdon ([108]), McCurdy and Shanholtz ([173]).
In many areas across the UK cancer patients have access to 24‐hour patient advice lines. The UK has led the way in the development of these services, with the UK Oncology Nursing Society (UKONS) establishing a validated telephone triage tool (Figure 26.1) and toxicity grading guide (Figure 26.2).
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Figure 26.1  UKONS telephone triage tool. Source: UKONS ([293]). Reproduced with permission of UKONS.
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Figure 26.2  UKONS toxicity grading guide. Source: UKONS ([293]). Reproduced with permission of UKONS.
These tools provide nurses with a framework for improving patient safety and empowering them to make the correct patient management decision (UKONS [293]). The initial assessment undertaken at telephone triage provides evidence either that the patient requires further assessment or supports the nurse to provide advice, avoiding unnecessary admissions or visits to emergency settings. Optimal management of oncological emergencies requires the nurse to:
  • promptly recognize signs of deterioration in the patient
  • have a good knowledge of the clinical symptoms of the more common acute oncology presentations
  • understand cancer's natural history and have an appreciation of the purpose of the treatment
  • be aware of the side‐effects of the main treatment modalities
  • prioritize patients and their management and know when to escalate.
When caring for a cancer patient who presents as or becomes acutely unwell there are some simple questions to ask that will aid clinical reasoning:
  1. Is there a previous diagnosis of malignancy?
  2. Are symptoms due to tumour or complications of treatment?
  3. What treatment is the patient having (or has had)?
  4. How quickly are symptoms progressing?
  5. What is the interval between treatment and onset of symptoms?
  6. Should treatment be directed at treating the malignancy or the complication?
  7. What are the patient's other existing medical conditions?
The oncological emergencies described in this chapter have been ordered according to the Higdon and Higdon ([108]) classification:
  • Haematological:
    • central venous access device complications
    • major artery vessel rupture
    • superior vena cava obstruction.
  • Metabolic:
    • hypercalcaemia of malignancy
    • hypomagnesaemia.
  • Side‐effects from chemotherapy agents:
    • diarrhoea
    • nausea and vomiting
    • neutropenic sepsis
    • pneumonitis.
  • Structural:
    • ascites (malignant)
    • bowel obstruction (malignant)
    • metastatic spinal cord compression
    • pericardial effusion (malignant)
    • raised intracranial pressure due to malignant disease.
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