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13.02.20 Haematological emergencies

Neutropenic sepsis
  • Definition:
    • Neutrophils <1 E9/L
    • Fever >38
  • Nadir of blood cells is 7-10 days post-chemo
  • Algorithm:
    • H istory
    • E xamine for a focus
      • Shivering
      • BO >3/day
      • Mouth ulcer
      • Lines
      • UTI
      • Chicken pox/shingles
      • Chest pain/DIB
      • Vomiting
    • A ction
    • T reat
  • Late-stage (can come on within 3 hrs)
    • SIRS
      • Temp >38 or <36
      • Pulse >90
      • RR >20
      • WCC is already <4
    • Restless
    • Reduced consciousness
    • Cold/clammy
    • Hypotension
  • Treatment
    • Straight to majors / Don't wait for bloods!
    • IV ABx within an hour
      • Amikacin / Tazocin immediately
      • Consider Meropenam / Vanc / Antifungals if not responding after 48 hrs
    • Macrolide (clarithromycin) for CAP atypicals
    • Vanc for line infections (MRSA)
    • Aciclovir for herpetic lesions
  • Prevention
    • Protective isolation
    • Reverse barrier nursing
    • Clean diet
    • Damp dusting


Metastatic cord compression

  • Found in 5-10% of advanced cancer patients
  • Causes
    • Breast, thyroid, lung, prostate, renal
    • Myeloma, lymphoma
  • Symptoms
    • Intractable back pain
      • Wakes at night
      • Progressive
      • Aggravated by straining (stool, coughing, sneezing)
    • Sensory level
    • Urinary/faecal symptoms
    • Reduced anal tone
  • Management
    • MRI spine
    • Dexamethasone 4 mg QDS
    • Urgent surgery
    • Urgent radiotherapy


Lethal triad

  • Coagulopathy / Metabolic acidosis / Hypothermia
    • => Hypothermia => Reduced clotting
    • => Coagulopathy => Blood loss
    • => Metabolic acidosis => Reduced myocardial performance


Blood times

  • ABO blood within 10 mins
  • Full cross-match takes 30-40 mins
    • Requires full antibody screen


Notes

  • European trauma guidelines 2007
  • CABC vs ABC
  • 1:1:1 PRBC:FFP:Platelets ?
  • Stat tranexamic acid
  • Novoseven
    • Recombinant factor VIIa
    • Very expensive!
    • Requires 2 consultant signatures
  • Fibrin sealants
  • Costs
    • RBC £123
    • FFP £38
    • Platelets £240

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