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