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