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Ok. Hello everyone. Um My name is Ria. I work for medical support team. Um I'm a penultimate year medical student at Imperial and it gives me great pleasure to introduce our speaker for the management of oncological emergencies. So it's doctors Malavi. She is a consultant, clinical oncologist and has been for almost 10 years and she's also a lecturer at Plymouth University. Um So I'm very glad to introduce her. Um And I'd like to encourage you all to please ask questions where possible. She's very lovely and quite happy to answer any questions. So please take it away. Thank you, Riah. Good morning, everyone. Um Those who join this part of the world and good afternoon for those who join from the eastern part of the world. And it's um talking about oncological emergencies, uh which is an utmost important topic because I understand as health professionals when you do your on calls, when you work at acute emergency section or critical care units, either if it's in surgical or medical region, almost, you may come across more than 50% percent of the emergencies related to oncology or related complications. So, what we are going to discuss within the next 30 to 40 minutes is um all the common oncological emergencies including spinal cord compression, called equina syndrome. And maybe you raise intracranial pressure or come to a similar group and then SSS VC obstruction or thoracic blood syndrome and then hyperviscosity syndrome and related other hematological malignancy complications, tumor lysis syndrome, malignant hypercalcemia. Oh in inappropriate ADH secretion and neutropenic sepsis. So, what I will do um after each and every section, I will make this as a discussion. As I understand. When you work in an emergency setting, you may have a lot of other questions because we are covering such a broad topic within 42 60 minutes. I encourage you to ask questions. You can switch on your mute, unmute your microphone and switch on your video and ask questions. So from one topic to the other, we'll have a small incision of questions and answers that way you will be able to absorb most of the important um aspects of each topic. And again, I advise you to like concentrate mostly about this topic rather than getting notes because this will be recorded and you will have to like uh to um listen again. So I want you to think while I'm talking and try and record your experience regarding same topics so that it will be very interactive. And most importantly, when you do your postgraduates and when it comes to exit exams and assessments, these um discussions will be very important as uh memory. The retain and retrieval ability is high when you interact and when you actively participate. So I encourage you to ask questions after each topic when the time is given. So um as you can see in the um slide, I want you to pick up co compression. What's the location, try and think of? So it's cervical spine 23456. So at the level of cervical 56, there's an obvious cord compression. And in this setting, you can see it's the T 12. So how do you recognize? Because if, if you are in a remote setting where you don't have facilities to do MRI even X ray, lateral spinal view, you can count upwards or downwards where you can easily recognize as you can see, this is S 1 L5. So count upwards and this is T 12 and this is uh an obvious spinal cord compression at the level of corna, right? So then uh try and recall how would they present when you are in an emergency setting or acute admission unit? Uh How do you suspect spinal cord compression? So it's a bit of um you need to recall your anatomy knowledge including like how would they present when there's an external compression? Depend on the location of compressions. Usually more than 90% of the patients, they start feeling heaviness of their limbs, that's the initial um symptom and then they start feeling loss of sensation, altered sensation, we call it paresthesia. And then um some patients, if it's called equina, they get sudden paresthesia or sudden numbness. And then further, if, if the t if we ignore the sensory symptoms, then start um compressing the motor. Uh like usually most anterior, they've been malignant deposits come um occur in the body. So when start compressing first, the get sensory loss and then if it's further and if it no sensory symptoms, they might experience more symptoms, like depend on the location. And sometimes with Equina syndrome, they start autonomic symptoms first, like bladder and bowel incontinence and it fits in the C 345 level. What's the nerve supply to diaphragm or breathing the CRE now and they might present as breathing difficulty. So when patients presenting symptom, you need to have the suspicion of spinal cord compression and this is to recap your knowledge or memory of symptoms related to Coquina Syndrome. Uh sudden numbness, loss of feeling between legs, numbness around the back passage and inability to feel toilet tissues when they wipe. Mm. And when it's upper motor neurons symptoms, usually they get con constipation first and then develop diarrhea if it's if the compression of autonomic nerves affecting the sphincters, and if uh usually the pain comes later after numbness, paresthesia. So they might sometimes present with uh complaining sexual issues like inability to um achieve an erection or it accumulation. So, whenever patients have this background symptoms and signs. First thing that you need to exclude during an acute setting is spinal cord compression. Imagine that you found all these symptoms and you clinically sure more than 80% that this patient might have a spinal cord compression. Then you investigate accordingly while you're organizing your investigations, it's mandatory to start steroids to reduce perilesional edema that can prevent further irreversible complications. So what's the dose of steroids? You start usually if obvious before we uh with, with clinical suspicion, you can start IV DEXAmet 16 mg teds. But then meantime, you have to advise being a leader in in a medical professional setting with an acute admission unit, you may lead to um or delegate your work to your subordinating staff, including you have to advise them about questioning about pain management in like get involved, the palliative care team earlier that uh and your physio team to advise on positioning, alert them about your suspicion, then ask radiotherapy radiation oncology team to have look and organize urgent treatment. Once um we confirm with MRI MRI is the investigation of choice to recognize exact lesion, which in a minute we'll discuss how important when it comes to radiation therapy. I need to discuss with neurosurgical team about the possibilities of uh resection. If it's solitary cord compression. If it's multiple, usually surgical team would not proceed with surgery. However, it's mandatory to discuss with all multidisciplinary teams related to spinal cord compression. And once you handle emergency or urgent management. Then think of adding bisphosphonates. So we are going to discuss about bisphosphonates in detail about do what you should do, what kind of a bisphosphonate ate. But for time being, bisphosphonates will prevent skeletal related events secondary to malignant spinal cord compression. So which prevents pathological fractures. So, bisphosphonates is an essential factor in managing spinal cord compression and then targeted therapy including denosumab. Again, we are going to discuss in detail with another topic like me and hypercalcemia uh about dose and proper inject um regimes. And um another option is injecting bone cement when patients uh when you think or suspect lesions where the crash injury or fracture risk is high. And then we need to think of definitive treatment for that particular malignancy. If it's breast cancer, malignant deposits in spine or prostate or thy thyroid, we can start hormonal treatment. And if it's other solid malignancies, we need to start definitive chemotherapy in order to prevent progression of the disease. So this is how we deliver radiation therapy. I if we if we can organize radiation therapy within 40 24 hours after the uh evidence of copious spinal cord compression, as you can see in this uh slide that we organize, we call them like dose volume histogram. The it's the uh dose range and isodose lines where we can exactly organize the required dose to the compressing lesion and can prevent further progression of the disease. So it work. The radiation goes as a straight line where we can organize to deliver exact required dose to the tumor where we suspect tumor deposits and avoiding surrounding normal structures. So, patient positioning could be either supine or prone, depending on patient's comfort. Without aggravating the existing pain and treatment, it can right rotate right around the patient's body and deliver required dose and gradients accordingly. So, uh radiation therapy, if we can organize within 24 hours, 48 hours of obvious um diagnosis of spinal cord compression, that will relieve pain, 40 to 80% of patients and gain sphincter control if they already lost sphincter control, 45 to 90% and prevent patient getting like walking disabilities. 90% if we administer radiation therapy before they get motor dysfunctions and those who got walking disabilities can gain ambulation 30% if it is uh earlier than later. So, it's really important to discuss with radiotherapy department if you suspect over confirmed spinal cord compression. So um like once you handle acute management and by the time when it comes for patient's discharge, you need to think of all the complications related to spinal cord compression. So the even we start a definitive treatment, they may have further complications that related to less mobility including thrombosis. So make sure that we prescribe thromb prophylactics and to prevent pressure, pressure. So as we need to contact community nurses and uh organize patient handling, prevent bed. So organize um proper. Yeah, at home to prevent, um, orthostatic or prevent positional pneumonia mean, um, prophylactic antibiotics if you suspect any infection and need to organize bladder and bowel problems when we discharge patient who treated for spinal cord compression. So, before we move into the other topic, um, let's open this for a discussion. I'm happy to answer if you have any questions related to spinal cord compression, cord equina syndrome or raised intracranial pressure. It's the same even though these are broad topic, topics we are going to discuss today. So I'm not going to address one by one brain again. If you suspect brain metastasis, patient comes with severe headache, confusion, seizures and de consciousness depending on the level or the location of brain metastasis. The same principle applies high dose steroids to reduce per edema. Usually depending on the severity we can give it. So 100 mg divided doses day one and rapid tail off is recommended to prevent steroid induced complications including altered sugar, controls, gas distress and of motoneuron dysfunctions which related to long term steroids. Any questions related to spinal cord compression, you can switch on your camera, uh microphone and ask questions. Yes. If um do you have any questions? Ok. If you don't have any questions, let's move to the next oncological emergency, which is S VC obstruction. So now try and recall your memory of um uh now it's time to recall your anatomy of uh thoracic inlet where if there's a tumor compressing the venous return. What will happen that will uh lead to form collaterals where you would see dilated collaterals and swollen upper torso, discoloration, plethoric upper torso and swollen upper limbs. So, appearance of collateralized, dilated chest veins, scient abusing the skin, extreme like extremities of um swollen upper torso and you can see in the neck area, the patient's discomfort, swollen neck. So it's, it's the typical picture which is not very hard to recognize even it may appear in your osteo diagnosis in your six months and it's in patient. Um When you see a patient with symptoms and signs of S3 C obstruction, then you have to think of the possible primary or the cause for obstruction. Usually it's um more than 80% of SVC obstructions are malignin. Uh you may need, if you can't find any malignant cause, then you have to think of other benign causes like large lymph node. We call uh the cholester nodes where tuberculosis or syphilis or other conditions that can cause generalized lymphadenopathy can cause obstruction to the venous return and any other mediastinal conditions related to cardiovascular or trauma. And then um when it comes to malignant tumors, um the common malignancies which can cause S VC obstruction is mediastinal tumors including lung cancers which can cause upper mediastinal problems. The lymphoma which again can see large mediastinal masses and uh uh patients with sarcoma, they get um thoracic uh sarcoma related to mediastinum and metastatic disease, especially with germ cell tumor and leiomyosarcoma. We can see mediastinal tumors compressing the venous return and uh commonly plasmocytoma, even patient does not diagnose with multiple myeloma or any other myelodysplastic disease. We can see it could be the initial presentation of uh plasmacytoma. So when it comes to uh your investigations with your clinical suspicion, you may need to do CT head, neck and chest, preferably if you're in a setting where you don't have all these sophisticated investigations, even chest X ray would show mediastinal widening and you may easily recognize causes for S VC syndrome. So when patient comes with S VC syndrome, you have to start your ABCD management. It's uh another talk of ABCDE. But anyone in this audience would know airway breathing, circulation, disabilities and uh alertness. But uh you have to think of the environmental causes. So ABC you know, disabilities including if patient comes with very low GCSF and seizures have to think of meningeal or intracranial lesions and exposure, which is maybe history related to hyperthermia or hypothermia. And then think of other mm less malignant nonmalignant causes. Again, same principle applies when it comes to management of SPC syndrome. If you suspect clinically before you organize all the images and confirmation, if there's no contraindications, starting steroids will prevent lifethreatening complications. Sometimes patients do present with severe shortness of breath and the arrest. You may have experienced patients have um severe airway compromising with VA syndrome. So after confirmation with radiological images, radiotherapy gives a magical response when it comes to well responding tumors, especially lymphoma, uh plasmacytoma, any hematological malignancies are very radiosensitive. So then before we start proper treatment, uh within 48 hours, if we can offer radiation therapy with the steroid cover, we can prevent patients, ended up being life threatening events. So when you, when you organize radiation therapy to media ta tumor, again, it's essential that we have the images to volume primary tumor. And then we can uh organize exact dose uh uh deliver to the required tumor while preventing other critical structures around like mediastinum has heart. And then for if it's a young patient, then we have to think of the thymic activities and while avoiding critical structures, we can easily deliver radiation to the tumor compressing the so vena cava which relieve patients from. Yeah, we um and then um if you think of the critically ill patients, you meet at um emergency settings with the obstructions. So the recall management that you have to give steroids in relation to reduced peril and edema that will give you give the patient immediate symptomatic relief and then need to organize pro exact treatment for disease. Like if it's um lymphoma a after we established patients airway breathing circulation, and if it's a brain related uh complications presenting with the obstruction, um we can deliver the specific treatment depending on the tumor. If it's ger tumor again, well responded to chemotherapy, even if it's lymphoma, very highly sensitive to chemotherapy. So one other complication related to SVC obstruction is thrombosis. So we need to think of all the other complications related to SV obstruction and think of starting prophylaxis dose of thrombolytics. Usually in our setting, we start enoxaparin. But if there are con uh contraindications, you have to analyze things are the risks and benefit and balancing the dose adjustments. If none of these works, the stent replacement is life life saving treatment option for severe S VC obstruction. So, before we step into the next oncological emergency, I'm happy to answer if you have any questions related to SVC syndrome. So feel free to ask questions if you have any questions or if you can recall patients you managed in emergency setting with S VC syndrome. Do you have any questions? So, um I'm happy to have interactive sessions um rather than me talking all alone. However, we can keep these questions to address at the end. But when you switch from one topic to the other, it will be very useful for you to absorb the important factors in each um setting of emergency management. So that's why I encourage you to ask questions if you have managed any patients with SVC syndrome, right? So um next oncological emergency is hyperviscosity syndrome where you would come across patients commonly with hematological malignancies. They have a lot of blood cells like abnormal blood cells. When you take a acute myeloid leukemia, acute lymphoblastic leukemia. Sometimes you may have seen patients with WBC BC like count 1000 more than 2 100s. And then um you may have seen patients with um multiple myeloma where they are circulating proteins including light chains very high. So then the circulation is sluggish. So the hyperviscosity syndrome always related to vascular stasis, all these symptoms and signs related to vascular stasis. Like you can see in this picture. So it could be malignant or nonmalignant hypercellular conditions like polycythemia rubra, vera. Yeah, if patient comes to an emergency setting with headache, dizziness, and history of stroke and if you find any of these features like Erythromycin, try and see the new score and if the BP is high, then your suspicion is higher, especially when you look at a patient with polycythemia vera, they are plethoric and you you could diagnose by looking at their face, they have a lot of visual changes and their hemoglobin level and hematocrit is more than 45. So hemoglobin level usually more than fif 150 or 15 g per deciliter and hematocrit level is above 45. So then, so similarly, in multiple myeloma, they get older, but because of sluggish circulation leading to thrombosis. So if you think of vasculopathy, nephropathy, cerebropathy, so all the m peripheral vessels can block with sluggish sluggish circulation which lead to form thrombosis when it comes to the hyperviscosity syndrome. Hydration is the uh first treatment. But if it's severe and when patients having severe syndromes, like patients uh level of consciousness low and if you found evidence for severe hyperviscosity syndrome, starting antithrombotics mandatory. But if it's mild, you can start aspirin to prevent patient worsening and causing symptoms related to thrombosis. If you think that patient can't reverse or you can't reverse symptoms using thrombolytics hydration and then you have to think of dialysis. Um if it's um polycythemia or grave, you can do flat toy or encourage patient to go for. If it's hyper macroglobulinemia, we do plasmapheresis and then uh we have to find the course, exact cause and treat for course. So when you treat mm malignant conditions of special hematological malignancies, there are a lot of other c precautions that you need to think of like tumor lysis syndrome and malignant hypercalcemia related to treatment which we will discuss in a minute, right. So this is where we commonly use flat toy for patients with polycythemia rubra vera or hyperviscosity syndrome. In order to if it's hypercellular condition, polycythemia, rubra, vera, we do, we do venous section and this is just a dichromia in 19 seventies or in, in 17th century. So, nine how they treated patients with polycythemia or grave. So whenever we treat malignant conditions, especially hematological malignancies or solid tumors with high tumor burden. The when tumor catabolize tumor breakdown, the the release of electrolytes causing a lot of abnormalities. We call tumor lysis syndrome. When you work in an emergency setting or acute admission, if patient comes with hyperkalemia, you may have come across a lot of patients with hypercalcemia. And then if patient is having hyperphosphatemia and uric acid level is high, the suspicion of tumor lysis syndrome, or you need to exclude tumor lysis syndrome, which is life saving. So always, if patient is having hyperuricemia, hyperkalemia, hyperphosphatemia suspect tumors syndrome, why I didn't highlight hypocalcemia because if you go by hypocalcemia, a lot of patients with solid malignancies, especially with bone metastasis, the develop hypercalcemia because of tumor um osteoclastic activity. So in tumor lysis, you get hypocalcemia because of the body homeostasis, response to hyperphosphatemia. When the phosphate level is high, the kidney balancing the level of calcium. However, if the patient is having other causes, which cause hypercalcemia, we can go by this feature solely for diagnosis of tumors. Usually we go by uric acid level. If patients having hyperuricemia, the suspicion is high and it's lifethreatening if we do not attend tumor lysis syndrome early. So think of all the symptoms related to tumor lysis. If patients having lethargy, fainting, frequent faintish attacks and presented with seizures and then patients whenever you monitor patients having dysrhythmias. And if the history suggestive of previous solid malignancies or any ongoing malignancies, the number one you need to suspect tumor lysis syndrome. So, further inquiry, you may find patients anorexic nausea, vomiting, patients having diarrhea, and if patients having muscle cramps, muscle weakness, copper, needle spasm and pleuritis. So that confirms your clinical suspicion of tumors syndrome. And then immediately you need to think of correcting electrolytes. So it's mandatory to correctly abnormalities when you suspect lysis and number two hydration. If it's mild, if it's not developed or severe up to the seizures, then we can manage with correction of electrolytes and hydration. Make sure that we need to monitor input output at least 100 cc, uh vigorous hydration to prevent ending up with laser toxicity. Light, it can cause sudden death with hyperkalemia. So if you suspect severe tumor lysis syndrome, which confirms with hyperuricemia. IV Respi utica is the treatment of choice. As you can see when DNA S break down. So the purine nucleic acid in DNA breakdown to S hypoanthine and then hypoanthine break down to xanthine by xanthine oxidase. And then Xanthine break down to all alloin, which is the ultimate product. After increasing uric acid level, if you diagnose or if you suspect them early or if you're treating for a patient who's having hematological malignancy with high tumor, high tumor burden or high cell count. Definitely, we need to take precautions and we need to prevent tumor lysis using allopurinol. But when patient developed T tumors, we can't prevent. So they already developed. So anyway, still allopurinol helps for the further breakdown of cancer cells. Still ra cases the treatment of choice once established stimulis syndrome. But if none of these medications help. Then we need to think of dialysis in order to get rid of all these electrolyte imbalances for life saving. So that's all about tumor lysis. And let's ask if anyone has any questions up to now. Yes, I had a question if that's ok. It, you know um how for hyperviscosity syndrome, there's acrogenic p pruritus. What is the mechanism that? So it, it's a, it can cause um the when it's hyperviscosity. So it, it's sluggish circulation that in induce immune responses. So that can release histamine and cause pruritis. I see. And why is it? Sorry? Yeah, a little bit aquagenic specifically. But it's because we uh hydrate and immediately releasing uh the uh there are a lot of uh tumor related um electrolytes released by uh treating cancer. So, breakdown of DNA and then we treat with um hydration knowing that it's uh lysis and that induced the immune responses and histamine release. Oh, I see. Oh, perfect. Thank you. You're welcome. That's great. So I encourage uh all the other um um members who are in the audience to ask questions like we did. So that will make you absorb this knowledge better than you just be passive participant. So be active and ask questions. Um Let's move to the next topic, malignant hypercalcemia. So malignant hypercalcemia, you may see a lot of patients coming to emergency setting with very high calcium levels. So that's why I wanted you to not to mask lysis knowing that hypocalcemia is a feature of tumor lysis. But patients with a lot of solid malignancies with metastatic deposits can cause hypercalcemia. So, what's the treatment for hypercalcemia? So, usually again, it's causes concentration of your circulation. So, hydration is the treatment of number one treatment whenever you suspect or you find evidence with hypercalcemia proper hydration and that can correct calcium level within an hour of administration. But if it's severe hypercalcemia, if the calcium level is more than um eight, and if it's definitely need um support with bisphosphonate. But if it's more than 10 and we call it malignant hypercalcemia and it's life threating. So then we need calcitonin for usually we give 4 to 8 milli um international units per kg subcutaneously or intramuscularly and it act within four hours of administration. But for long term or the address to the course, which causes hypercalcemia, that's how bisphosphonates acts where it inhibits osteo osteoclastic activity and it stops um osteoclasts, uh proliferation and go induce programmed cell death of osteoclast which prevents further releasing of calcium levels. So the action from bisphosphonates acts within 2 to 4 days after administration bisphosphonates. We have clinic acid pamidronate or ibandronate where we usually as first line use Solan acid 4 mg, which has several reasons why we select Solan acid or pamidronate or ibandronate because clinic acid can in give within 15 minutes. We are uh we need longer infusion rates for pamidronate if we rapidly infuse or give a rapidly that can cause renal impairment. So, whenever you decide to give bisphosphonate, you need to check kidney functions. And if deranged kidney functions, usually bisphosphonates um including pamidronate and ibandronate is not ideal, but we can keep zend with cautions with longer durations, more than 15 minutes. If there's severe renal impairment like a grade four, then we need, we can't, it's a contraindication to give bis bisphosphonates if um EGF are less than 30 especially definitely contraindicated to give pamidronate or ironate. But still, we can consider. So if you do not have denosumab in your settings, so, denosumab is safe as in case of kidney or deranged liver function. So we don't need to do dose adjustments. Um if you have denosumab, which act um directly through impairment of osteoclastic activity, so we can give denosumab 100 and 20 mg subcu to get the action, it'll take 2 to 4 days. So in malignant hypercalcemia, again, it's essential. And whenever you see patients with hypercalcemia, we tend to ignore in your word settings. So try and think of um solid malignancies which can cause uh metastasis in bones, especially breast cancer, prostate cancer and gi malignancies, lung cancer, very common to cause bone because it's and multiple myeloma is another cause which can cause malignant hypercalcemia. So, um when uh it comes to uh the syndrome of inappropriate ADH syndrome, um it's ADH secretion with malignancies is very common before we step into inappropriate a secretion syndrome. Uh Any questions regarding malignant hypertension or malignant hypercalcemia. So, um you may have seen patients with very low sodium levels, they can um present in the acute settings with confusion, seizures and um sometimes especially with coma. Always, unless otherwise proven, you have to think of syndrome of inappropriate age secretion because it is very common with like daily common scenarios, patients with infections, pneumonia or cerebral lapses or primary brain injuries related to meningitis or intracranial hemorrhage, any raised intracranial pressure tumors, brain tumors can increase inappropriate ADH secretion. So, and other causes including hypothyroidism, especially um paraneoplastic syndrome related to lung cancers, hepatocellular cancers, thymic cancers can cause high vasopressin levels and certain drugs like carBAMazepine and amitriptyline morphine. Again, we may see patients with morphine opioids for malignancies and it's very common to see low sodium levels. So then you have to have the suspicion of inappropriate ADH secretion. How do you treat patient patients with inappropriate ADH secretion? So if it's mild or moderate, if patients having poor concentration, nausea and then you can think of having um fluid restriction is the treatment number one modality of treatment for mild ADH secretion. So we should start monitoring them, advise them usually if they are having other problems related to fluid like kidney injuries, try and balancing uh fluid intake. Usually we advise 50 CC per hour depending on the body weight, we can adjust. So, fluid restriction, especially if patients having very low sodium. And if patients having IV fluid, um we need to stop IV fluids and encourage them to have oral fluid intake with restriction. And if it's adva patients having advanced symptoms including confusion, somnolence and hallucinations, then they are about to go into grave symptoms like coma. So then still we can start 3% saline or rectal. But when it's um severe, we need to start 3% saline with the um slow regime because if we infuse 3% saline rapidly, that can cause um cerebellar uh because uh symptoms that is related to rapid correction of um sodium. So welcome management of inappropriate ADH syndrome. Um Do you have any questions related to management of inappropriate ADH? So next topic is uh the very common scenario related to malignancies, which is neutropenic sepsis. In definition, when patients comes with the evidence of sepsis with high high new score, then you have to have the suspicion of neutropenic sepsis if patients already know on malignancy or on chemotherapy, especially if the absolute neutrophil count is less than 500 per microliter. And uh if, if the predicted decline up down to 500 within the next two days with the evidence of infection, we need to start antibiotics and usually it depending on the uh organizational institution policies, the starting antibiotic differ. However, when you suspect uh patients with severe sepsis with neutropenia, septic screen is mandatory and need to take blood cultures. Subs from all the suspicion areas including groins, axilla and throat, subs which is very important if they are not responding to um the antibiotics, we start first line, usually with neutropenic sepsis need to cover pseudomonas and um usually the first line including car or mepe and need to add acoss if there is a septic, obvious septic. So source and if fever is not settling within 48 hours, we we should, we, it's ideal or it's a luxury if we have the culture reports. But if not, it's mandatory to shift antibiotic broad spectrum cover like Vancomycin or test. And then if he was not settling by four days, need to think of adding antifungal and anti viral depending on patients. Um septic screens and clinical scenario, even blood culture or negative antifungal, it's mandatory, it's neutropenia and absolute neutrophil count less than 500 lead to an antifungal and anti virus. So, uh in summary, we discussed today, the oncological emergencies including structural complications which comes um malignant spinal cord compression cord equina syndrome, which is almost similar management when it comes to the rest, intracranial pressure related to malignant deposits. And we um briefly discussed the metabolic complications including um malignant hypercalcemia, tumor lysis syndrome and sy syndrome of inappropriate ADH secretion. And then we discussed hematological complications like f fibrile neutropenia and hyperviscosity syndrome. And what we did not discuss which could be a magnet or oncological emergency, which is treatment related toxicity which should warrant another talk, including complications of chemotherapy, radiation therapy, immune therapy and uh problems related to gi malignancies and problems related to cardiac complications like malignant pericardial effusion and cardiac tamponade. And then problems related to lung cancer which could cause um pneumothorax and malignant pleural effusions would be another day off topic. But when you, when it comes for your assessments and your exam point of academic point of view, those are the oncological emergencies which you should be able to handle or manage at acute settings, emergency settings. Uh We have a few minutes to answer questions if you have any questions. I think we are, you got questions. So anyone else sound good. Do you have any questions? Um uh II would just like to share something. I just remembered uh a patient that I saw with tumors syndrome some time back and it just reminded me uh of that particular case when you spoke a bit. Uh So it was actually um I think I saw this patient three or four years back, uh elderly gentleman with a lymphoma uh who came post chemotherapy. Uh and we were all concerned um with regard to the high white cell count that the patient had and we were treating the patient uh with uh with uh uh with this for a suspected sepsis. Uh And then uh we ignored the fact that the patient had hypocalcemia. Uh and uh eventually the patient uh went into uh ventricular fibrillation which is a uh uh complication of hypocalcemia. Uh So it's, it's a case which got it in my head. So it's something that I remembered uh kind of sharing it. So I think we should be mindful of those uh electrolyte, you know, uh abnor abnormalities that you get in uh tumors syndrome. Excellent. That's very true. Always w whenever you work in an emergency setting, we see a lot of like abnormalities, but hardly that comes to our mind. Um So we should um always think of Tully if patients have known to malignancy on treatment. Excellent, good. Any other questions? Thank you, Sanka for sharing that uh your experience that is very useful. Anyone else who has um questions? So we want to share your experience of managing oncological emergencies. Yes, we are. Did you have any experience managing oncological emergencies? If people are too shy to come onto the screen, you can still use the chat. We would love you to come on the screen. But if you want to please do use the chat and we can ask those questions or just turn on your microphone and not your camera just in case you're still in your pajamas or something. All right. Actually, I've got an experience I'd like to share from placement. I remember when I was in third year, um I was in a General medicine ward. Um and I remember a patient came in and she had um I believe she had like um, I think it was brain tumors. And what happened was they, they saw her in the emergency department and she was presenting with kind of like no bowel movements. Um, you know, that classic where you think there's spinal cord compression and it was interesting because she then went home and they said there was nothing wrong with her and then she came back and was blue lighted because she, you know, was paralyzed from the waist down. I remember kind of, II think like up until third year, I don't think I quite understood the implications of not catching these signs. And certainly, I think you think about oncological emergencies and you think they're not that common, but, um, from my impression, at least they're a lot more common than you think. Would you agree with that? Yes. Yes. Yeah. Um, yeah, definitely. I agree because in our emergency setting, if we take 100 cases, more than fifties, um, related to oncological emergency and especially as we saw in that slide, we can prevent the patient being not able to walk and we can even regain their walking if we attend or if we have this suspicion, we can prevent them getting, not having bowel or bladder incontinence, which ultimately, it's a massive support to patients quality of life and patient caregivers. So it's very important to keep that in mind and be cautious about your leg. Always think of, could this be a spinal cord compression when patient comes with constipation. We never thought of. That's very important. We are sharing that uh experience. Thank you. I think so. In chat. We don't have any questions, isn't it? No, we don't have any questions. Everyone's rather quiet. We did have something earlier on. Let me see. We did have something earlier on. I think Ria's covered her question and we did have from Melinda, a stent replacement put in the S VC to widen it. That was something that was earlier much earlier on. Yeah, stent replacement. Yeah. Very um me. Do. Your question is um uh I think relevant because it's uh the stent can widen the airway. So it's not to address or to treat the primary course, but we can buy time by inserting a stent until we address the primary course with radiation therapy, chemotherapy or uh targeted therapy. Uh If we insert a stent, we can prevent a patient going to respiratory failure. So that's the whole aim. Yes, it's widen the respiration and the airway me. Do, do you have any other questions regarding that? I I think everyone's very quiet, aren't they? They're not used to have this interaction, but I'm really happy that r and so they came up with that experience because it how it, I mean, when, when you discuss your experience, that memory goes like to a long term memory when it comes to your assessments and when actually you practice day to day, when you had emergencies. This experience, I mean, comes first. So each of every topic would be a one day talk. If we discuss with case based scenario, that would be the ideal way of discussing rather than just having this talk. I like case based discussions. Ideally, that is the best way of um understanding pathophysiology and exact treatment. So one day we should do case based discussions. That's the best. I like that. R and Sana came out with their cases. That's excellent. Well, if you're offering to do more teaching, I'm sure we would love to have you. We have this discussion. So I mean, that's the best way of learning than just having talks on one particular topic. Perfect. I'll be up for organizing those. So if anyone has any further questions, please turn your microphone on, tell us those questions. Otherwise we will be uh ending the session. Um Your feedback form will be, it's in the chat now and it will be um on in your inbox. We do have other events on medal. Uh coming up. I think there's one tomorrow evening. Is that why you, tomorrow? We've got another one. There's another one tomorrow. I've got the link, I'll paste it in the trial. Perfect. So if you want to attend that one, um we will be uploading this as catch up. So if you want to catch it again, then you can, we will upload it as catch up. Um If not, then we will see you at our next event. So thank you very much and enjoy the rest of your weekend. Thank you, just pop that link to that. Thank you very much. Thanks so much. Bye.