Day 5- Hematologic Emergencies — The Intern at Work

Other Hematologic Emergencies (not discussed elsewhere) include…

APML

If you see “blasts” on the peripheral smear- consider APML ! This is a hematologic emergency, and immediate treatment with All-trans retinoid acid should be arranged.
Classically >10% blasts on smear (but realistically if your blood smear reports any blasts this is cause for alarm and requires hematology review)

Tumor Lysis Syndrome

podcast and infographic pending!
massive and abrupt release of cellular contents (nucleic acids, proteins, phosphorus, potassium) into bloodstream after rapid lysis of malignant cells
treatment induced: classically 12-72 hours post initiation of cytotoxic treatment for hematologic malignancy (can occur rarely with solid tumours)
High: K, phosphate, uric acid
Low: calcium
AKI
Management:
cardiac monitoring for arrhythmia
lytes/Cr/uric acid monitoring q4-6hr
consider early involvement of nephrology re: dialysis
Rrasburicase 0.2mg/kg IV daily x 5-7 days (for high uric acid)
Treatment of hyperkalemia, hyperphosphatemia, hypocalcemia and AKI (discussed in other blog posts)

Febrile Neutropenia

Temperature >38.3 or >38.0 for more than 1 hour associated with ANC <0.5 cells/mm3, or <1.0 cells/mm3 if expected to decrease to less than 0.5 cells/mm3
focus of infection only found in 20-30% of patients
Obtain blood cultures from every intravenous port and at least one peripheral, urine R+M, sputum culture, CXR, AXR
In the correct context consider:
- diarrhea: stool for c.dif
- catheter appears infected: swabs for culture and sensitivity of site
- neurological changes: LP
- neutropenia >7 days: consider galactomannan

Management:

involve hematology/oncology
tazocin 4.5g IV q6hr or ceftazadime 2g IV q8hr (for pseudomonas coverage) + vancomycin 1g q12hr (if suspected MRSA infection)
Add anti fungal coverage if neutropenia > 7 days or if hemodynamically unstable/febrile 4-7 days after initiation of broad spectrum antibiotics