Cancer Emergencies

  1. Leukostasis occurs with WBC count greater than 50,000 with symptoms (usually 100,000), predominantly pulmonary and neurologic symptoms.80% of patients will have fever, so treat for infection concurrently. Chemotherapy is the only treatment that decreases mortality, but if not available, leukopheresis is the next step.
  2. Neutropenic fever is defined as a single oral temperature greater than 38.3 oC or temperature >38.0 oC for one hour, with absolute neutrophil count (ANC) of < 1500 cells/microL, with severe defined as an ANC less than 500 cells/microL or an expected drop to < 500 over 48 hours. 30% of fevers are due to infection, with gram positives accounting for 60% of infections. Broad coverage targeting gram positives and pseudomonas is needed.
  3. Venous Thromboembolism (VTE) (DVT, Pulmonary Embolism (PE))is common in cancer, with 15% of patients with malignancy experiencing DVT/PE. Khorana score is validated for VTE risk stratification in this patient population. CT PE and DVT US are the best tests. Anticoagulation with heparin has the best literature support for treatment.

EM Don’ts

  1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
  2. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.
  3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis.
  4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.
  5. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones.