Oncologic Emergencies

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    Introduction

    • Here I list key hematologic emergencies that show up on the royal college exam;

     

    Tumor Lysis Syndrome

     

    Leukostasis

    • Extremely elevated blast cell count and markers of tissue malperfusion
      • Large numbers of WBCs obstruct microcirculation
    • Extremely high mortality (20-40% at 1 week), requires prompt management. 
    • Most commonly seen in AML or CML blast crisis
    • Typical Malignancies:
      • AML (most common - large non-deformable blasts)
      • ALL 
      • NOTE: CLL extremely uncommon unless WBC > 400
      • NOTE: CML extremely uncommon unless myeloid blast crisis and WBC > 250 
    • Presentation:
      • Patients with leukemia & hyperleukocytosis presents with respiratory or neurologic distress
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    • Labs:
      • Total leukemic blood count > 50 * 10^9 /L 
      • Thrombocytosis (Blast fragments mistakenly counted as plts)
      • Hyperkalemia (spurious)
      • DIC – decreased fibrinogen, increased D-Dimers
      • Spontaneous TLS – High Uric Acid, High K+, High PO4 + LOW Ca++
    • Management
      • Cytoreduction
        • Chemotherapy (i.e. hydroxyurea, but induction chemotherapy preferred)
        • Leukapheresis
      • TLS Prophylaxis
        • Hydration, Allopurinol
      • DIC Monitoring
      • Thrombocytopenia
        • Treat to maintain plts > 20,000-30,000
        • Avoid Transfusion (can increase blood viscosity)

     

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