Sunday, February 26, 2017

Cancer in the ED

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Author: Nicholas Pettit, DO, PhD
Indiana University 

Next up on the board, a 55-year-old male with a temperature of 102.3, heart rate of 119, and blood pressure of 89/50. Sick versus not sick? Clearly sick.

After that, 45-year-old male, with a temperature of 100.1, heart rate of 110, and blood pressure of 120/80, and who is also a cancer patient. Sick versus not sick? Hard to tell, right?

Cancer is a frequent comorbid condition that presents to the emergency department (ED), and researchers are just now starting to demonstrate the association between emergency medicine and the outcomes for cancer patients. The most common symptoms that are brought through our doors are shortness of breath (23%), pain (18%), fever (14%), and nausea/vomiting (14%).[1] From the same study, the investigators found out that approximately 60% of the patients were admitted, 47% of patients subsequently died after admission to the ED, and the 1-year overall survival of all patients seen in the ED was 7.3 months.

What does the aforementioned data suggest? Cancer patients that present to the ED have a high mortality rate and should be considered sick until proven otherwise. Treat the symptoms and have a low threshold to admit.

Cancer is the second leading cause of death after cardiovascular disease, and because of the improvement of novel therapies these patients are living longer.[2] Lung (32.5%), gastrointestinal (25%), and breast (9%) were the most common malignancies presenting in the ED. It was then determined that progressive disease (42%), chemotherapy side effects (21%), and infections (17%) were the most common causes for presentation to the ED.[1]  Important recognition of these symptoms and determining the cause is crucial for helping these potentially critically-ill patients extend their lives.

Fever and infections were found to be the most life threatening and a common cause of hospitalization and death among chemotherapy patients.[3] Furthermore, so much of chemotherapy is done as an outpatient-patient basis, it is not uncommon for these patients to present to the ED after hours due to their oncologist’s office being closed.

The moral of this post, cancer patients are sick until proven otherwise. They may present with any host of symptoms, such as shortness of breath, fever, and pain. Due to the high morbidity and mortality associated with cancer-associated illnesses it is on us as emergency providers to treat these patients as we would any other critically ill patient.

References


1. Sadik M, Ozlem K, Huseyin M, AliAyberk B, Ahmet S, Ozgur O. Attributes of cancer patients admitted to the emergency department in one year. World Journal of Emergency Medicine. 2014;5(2):85-90. doi:10.5847/wjem.j.issn.1920-8642.2014.02.001.

2. Swenson K, Rose M, Ritz L, Murray C, Adlis S. Recognition and evaluation of oncology-related symptoms in the emergency department. Annals of Emergency Medicine. 1995;26(1):12-17. Doi:http://dx.doi.org/10.1016/s0196—0644(95)70231-8


3. Escalante C, Weiser M, Manzullo E, et al. Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients. Support Care Cancer2004;12(9):657-662 doi:10.1007/s00520-004-0613-6

Thursday, February 23, 2017

Acute Limb Ischemia: A Literal Case of Cold Feet

Image Credit: Wikipedia
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Author: Jennifer Reink, MSIV
Ohio University Heritage College of Osteopathic Medicine

Case
A 58-year-old Caucasian male was brought into a community emergency department via ambulance for evaluation of sudden onset left leg pain and right leg numbness. He stated that about five hours earlier, he had begun to experience severe sharp pains shooting down the entire length of his left leg. His right leg had initially felt like pins and needles, but prior to arrival had gone completely numb, to the point that he was unable to lift it. He denied recent trauma, back or abdominal pain, or urinary or stool incontinence. Upon further review, we learned that he had a history of stroke, abdominal aortic aneurysm with graft repair, hypertension, and diabetes. He was taking the associated medications for these conditions, which did not include an anticoagulant. He had no prior history of tobacco, alcohol, or drug use.