Oncologic Emergencies

In depth

The one-page summary above is what the PDF prints. These sections go further.

Neutropenic fever: risk, work-up and the first hours

Neutrophils guard mucosa that chemotherapy has damaged. Below 500/µL, and most of all below 100/µL, infection spreads without pus, infiltrates or urinary white cells, so fever may be the only sign and shock can follow within hours. Gram-negative rods, Pseudomonas above all, kill fastest, hence an antipseudomonal β-lactam; IDSA 2010 advises against routine vancomycin.

In 307 febrile neutropenia episodes, each hour to the first antibiotic raised the risk of death within 28 days by 18%, and mortality was 3.0% with antibiotics within 30 min vs 18.1% at 31–60 min (Rosa 2014). ASCO/IDSA 2018 sets the first dose within 1 h of triage.

Work-up (IDSA 2010): two or more blood culture sets, one per catheter lumen plus a peripheral vein; CBC with differential, creatinine, electrolytes, liver tests; chest x-ray for respiratory signs. A catheter culture turning positive over 2 h before the peripheral one points to the line. Cefepime is labeled at 2 g IV every 8 h here (CrCl over 60). Cover known resistant colonizers, stop vancomycin at 2 days if no gram-positive infection appears, and treat unexplained fever until the ANC passes 500.

Fever lasting 4–7 days with neutropenia expected beyond 7 days calls for a fungal work-up (chest CT, fungal markers) and an empiric antifungal (IDSA 2010). Typhlitis (neutropenic enterocolitis: fever, abdominal pain, right lower quadrant tenderness) needs anaerobic cover too, bowel rest and a surgeon for perforation or bleeding.

Tumor lysis syndrome: mechanism, prevention and rescue

When cells die faster than the kidneys clear their contents, potassium, phosphate and nucleic acids flood the blood. Purines become hypoxanthine and xanthine, which xanthine oxidase turns into uric acid; it crystallizes in acidic tubular urine. Phosphate binds calcium, lowering it and depositing calcium phosphate in the kidneys and heart. AKI then traps all three, so potassium can climb within hours. Burkitt lymphoma and leukemias with very high counts can lyse before treatment starts.

Allopurinol blocks xanthine oxidase: it stops new uric acid but removes none, xanthine can crystallize, and the dose falls with kidney function (100 mg/m² every 8 h, maximum 800 mg/day, from 24–48 h before therapy; StatPearls 2024). Rasburicase turns uric acid into soluble allantoin plus hydrogen peroxide, which causes hemolysis and methemoglobinemia in G6PD deficiency; the label screens patients of African or Mediterranean ancestry. In its randomized adult study (275 patients), uric acid control was 87% vs 66% with allopurinol, but clinical TLS was similar (3% vs 4%). Draw uric acid into prechilled heparin tubes on ice and run it within 4 h.

Urine alkalinization is abandoned: it adds little once rasburicase exists and favors calcium phosphate precipitation (Howard 2011). Treat potassium early and dialyze sooner than in other AKI, because release continues. Leave asymptomatic hypocalcemia alone; give calcium gluconate for tetany, seizures or arrhythmia at the lowest effective dose. Dialysis: severe oliguria, overload, persistent hyperkalemia, symptomatic hypocalcemia from high phosphate, or a calcium-phosphate product of 70 or more (StatPearls 2024; Howard 2011 warns from 60).

Hypercalcemia of malignancy

Parathyroid hormone–related peptide from squamous, breast and renal cancers causes about 80%, osteolytic metastases and myeloma about 20%, and calcitriol from lymphoma under 1% (Electrolytes sheet). Calcium blocks urine concentration and constricts renal arterioles, so patients arrive dry, and dehydration cuts calcium excretion further; fluid breaks the loop. Confusion, constipation, polyuria and a short QT follow the speed of the rise as much as the level.

Endocrine Society 2023 recommends an IV bisphosphonate or denosumab for every adult with HCM, suggests denosumab over a bisphosphonate, adds calcitonin above 14 mg/dL, uses denosumab when calcium stays high on a bisphosphonate, and adds either drug when calcitriol-driven lymphoma stays hypercalcemic on glucocorticoids; all suggestions rest on low-certainty evidence. Loop diuretics are only for overload during saline in heart or kidney failure.

Zoledronic acid: 4 mg IV over at least 15 min after rehydration, no retreatment within 7 days, and no dose cut for HCM while creatinine is under 4.5 mg/dL (Zometa 2018); the Endocrine Society adjusts below GFR 60 and infuses over 30–60 min. Denosumab is labeled for bisphosphonate-refractory HCM at 120 mg SC every 4 weeks plus days 8 and 15; the kidney does not clear it, but severe, even fatal hypocalcemia occurs, most with CrCl under 30 or dialysis (Xgeva 2026). Calcitonin acts within hours, but tachyphylaxis ends it in 48–72 h.

Check calcium (ionized when possible), creatinine, phosphate and magnesium daily; stop thiazides, calcium, vitamin D and lithium. Recurrence usually marks advanced cancer and prompts a goals-of-care talk.

Hyperviscosity, hyperleukocytosis and APL

IgM (Waldenström macroglobulinemia) is a large pentamer that stays in the vessels, so viscosity climbs steeply, sometimes from IgM as low as 3 g/dL. Symptoms rarely appear below 4 cP (normal about 1.5; ASH 2023): mucosal bleeding, blurred vision with sausage-like retinal veins, headache, confusion and heart failure. Plasma exchange comes first (ASFA 2026), then therapy for the clone; red cells given before exchange raise viscosity.

Hyperleukocytosis (WBC over 100,000/µL) harms through leukostasis, TLS and DIC (Röllig 2015). Large, stiff, sticky myeloid blasts make leukostasis mainly an AML problem: hypoxemia with infiltrates, confusion, visual loss, intracranial hemorrhage. Start chemotherapy or hydroxyurea at once with TLS prophylaxis; avoid red cell transfusion and diuretics. Leukapheresis did not lower early mortality in 1,743 AML patients (RR 0.88, 95% CI 0.69–1.13; Bewersdorf 2020 meta-analysis) and is avoided in APL.

Acute promyelocytic leukemia (APL, PML-RARA) blasts express tissue factor and annexin II, which speeds plasmin generation, so bleeding comes from consumption plus hyperfibrinolysis; up to a quarter of patients die within 30 days, mostly of hemorrhage (Hermsen 2023). ELN 2019: start ATRA on suspicion, before genetic confirmation; keep fibrinogen above 100–150 mg/dL and platelets above 30,000–50,000/µL, and give plasma for an INR above 1.5; avoid central lines, lumbar puncture and other procedures early; no routine heparin or antifibrinolytics.

Differentiation syndrome followed arsenic trioxide in 16–23% of trial patients: fever, dyspnea, hypoxemia, infiltrates, effusions, weight gain over 5 kg, hypotension, AKI. Give dexamethasone 10 mg IV every 12 h at first suspicion, for at least 3 days and until resolved, and hold arsenic (and ATRA if severe); prednisone 0.5 mg/kg/day is induction prophylaxis. Arsenic prolongs QT: keep K above 4 mEq/L and Mg above 1.8 mg/dL, check the ECG weekly, and hold it for QTc above 450 ms in men or 460 ms in women (Trisenox label). IDH and menin inhibitors also carry boxed warnings for differentiation syndrome.

CAR-T cells and bispecific antibodies

CAR T cells meet their antigen, expand and release interferon-γ and GM-CSF, which drive macrophages to make IL-6 and IL-1; activated endothelium leaks, causing fever, hypotension and hypoxemia. ICANS reflects endothelial activation and a leaky blood–brain barrier and can come with, after or without CRS. Tocilizumab blocks the IL-6 receptor in blood but barely reaches the brain, so it treats CRS, not isolated ICANS.

Axicabtagene ciloleucel: CRS in 90% (grade 3 or more 9%), median onset 2–3 days; neurologic toxicity in 78% (grade 3 or more 25%), median 4–5 days (Yescarta label). Ciltacabtagene autoleucel for myeloma starts later (CRS median day 7) and adds delayed cranial nerve palsies (median day 21) and parkinsonism (median day 56, rarely reversible; Carvykti label). Bispecific T-cell engagers (teclistamab, glofitamab) cause CRS mostly at step-up doses.

FDA removed the REMS for the six autologous CAR-T products on June 26, 2025: monitor at least daily for a week, keep patients near a healthcare facility for 2 weeks (formerly 4), no driving for 2 weeks (formerly 8). Grade 2 or higher events need telemetry and continuous oximetry (Yescarta label). Score ICE on schedule and with any change, keep seizure, fall and aspiration precautions, and treat fever as infection until proven otherwise. Rising ferritin with new cytopenias, low fibrinogen or liver injury as CRS settles suggests the HLH-like IEC-HS (ASTCT 2023).

Checkpoint inhibitor toxicity in the ICU

PD-1, PD-L1 and CTLA-4 antibodies release brakes on T cells, so immune-related adverse events can strike any organ, usually within months. Exclude infection and progression, hold the drug, and treat grade 3–4 events with methylprednisolone 1–2 mg/kg/day tapered over at least 4–6 weeks (ASCO 2021, SITC 2021); most grade 4 events end the drug for good, endocrine ones excepted.

Myocarditis affects about 1% of treated patients, a median of about a month into therapy, yet kills 27–50%, often alongside myositis and myasthenia-like weakness (Mauriello 2026). ESC 2022 starts IV methylprednisolone 500–1,000 mg daily for 3–5 days, then prednisolone 1 mg/kg/day; refractory cases need second-line agents such as abatacept or mycophenolate.

Spinal cord compression: evidence and nursing

Most compression comes from vertebral body metastases (breast, prostate, lung, kidney, myeloma) growing into the epidural space: venous congestion and vasogenic edema come first, then infarction, which is why steroids help early and why function at the start of treatment predicts the outcome. Pain, often worse lying flat, coughing or straining, usually precedes weakness, sensory loss and sphincter failure by weeks.

NICE 2023: whole-spine MRI as soon as possible and within 24 h when there are neurological signs (within a week for pain alone); dexamethasone 16 mg orally or IV equivalent as soon as possible for neurological symptoms, continued daily until surgery or radiotherapy, then reduced, with glucose checks and a proton pump inhibitor; no routine steroids without neurological signs; radiotherapy within 24 h.

Dose: dexamethasone 96 mg IV, then 96 mg/day for 3 days with a taper, kept more patients walking at 6 months than no steroid (59% vs 33%) with serious side effects in 11% (Sørensen 1994); a 100 mg bolus did no better than 10 mg (Vecht 1989). Surgery: with a single compressed area, no paraplegia beyond 48 h, expected survival of 3 months or more and no radiosensitive tumor, decompression plus radiation left 84% walking vs 57% and restored walking in 62% vs 19% (Patchell 2005). Radiation: one 8 Gy fraction vs 20 Gy in 5 left 69.3% vs 72.7% walking at 8 weeks, narrowly missing noninferiority (SCORAD 2019).

Nurse possibly unstable patients supine, flat or partly raised, log roll them, and mobilize only once the spine is judged stable (NICE 2023). Recheck power, sensation and bladder (scan for retention) each shift and after moves; give VTE prophylaxis and a bowel regimen. Steroids are standard here but not recommended for traumatic cord injury (Spinal Motion Restriction sheet).

SVC syndrome and mediastinal masses

The low-pressure SVC compresses or clots easily, and collaterals through the azygos and chest wall veins take weeks to form, so slow obstruction is tolerated and sudden obstruction is not. In 78 patients (Rice 2006), cancer caused 60% (lung 46%, lymphoma 8%) and benign causes 40%, mostly intravascular devices; face or neck swelling (82%), arm swelling (68%) and dyspnea (66%) led the findings.

Grade 4 means stent first, diagnosis second; otherwise get tissue first when time allows, because steroids or radiation can hide lymphoma, and chemosensitive tumors (small cell, lymphoma, germ cell) respond to chemotherapy (Yu 2008). In a systematic review (Rowell 2002), stents relieved obstruction in 95% (11% recurred), chemotherapy or radiation relieved it in 77% with small cell and 60% with non-small cell cancer, and steroids had no proven benefit.

A large anterior mediastinal mass can collapse the airway or compress the heart when induction, paralysis and lying flat remove muscle tone (Li 2016). Orthopnea, stridor and SVC syndrome are warnings; anesthesia plans keep spontaneous breathing (awake fiberoptic intubation), test positions awake, and have rigid bronchoscopy and extracorporeal support ready.

Extravasation and hazardous drug safety

Vesicants blister and destroy tissue; anthracyclines bind DNA and keep killing cells for weeks, so a small leak can need surgery later. Give vesicant infusions centrally when possible, avoid hand and joint veins, and confirm brisk blood return before and during the dose. Burning pain and swelling come first, usually with little or no blood return.

Dexrazoxane runs IV over 1–2 h once daily for 3 days, starting within 6 h: 1,000 mg/m² on days 1 and 2 and 500 mg/m² on day 3 (maximum 2,000 and 1,000 mg), in a large vein of another limb, with cold packs off at least 15 min before; halve it if CrCl is under 40. In the label studies 1 of 57 evaluable patients needed surgery (Totect label).

NIOSH (2024) sorts hazardous drugs into two tables; Table 1 holds carcinogens and drugs with special handling instructions. For administration, ASHP 2018 and USP <800> require two pairs of chemotherapy gloves meeting ASTM D6978 (worn no longer than 30 min), a permeation-resistant gown, eye and face protection when splashing is possible, and closed-system transfer devices whenever the dosage form allows. Staff who are pregnant, breastfeeding or trying to conceive may choose alternative duty (ONS/HOPA 2025). Two clinicians independently verify order, drug, dose and patient before each dose (ASCO-ONS 2024), and vinca alkaloids go in a minibag, never a syringe, because intrathecal injection is almost always fatal (ISMP).

Exam pearls

• Neutropenic fever: 38.3 °C once or 38.0 °C for 1 h with ANC under 500; cultures, then an antipseudomonal β-lactam within 1 h; vancomycin only for a reason.
• TLS: high K, phosphate and uric acid with low Ca 12–72 h after chemotherapy; fluids, rasburicase or allopurinol; calcium only for symptoms.
• Hypercalcemia of malignancy: saline first, then calcitonin plus zoledronic acid or denosumab; short QT.
• New back pain with cancer: whole-spine MRI within 24 h, dexamethasone for deficits; walking at diagnosis predicts walking after.
• SVC syndrome: face and arm swelling, chest wall veins; stridor or confusion means a stent now.
• APL: DIC with hyperfibrinolysis; ATRA on suspicion; differentiation syndrome gets dexamethasone 10 mg every 12 h.
• CRS: fever, then hypotension and hypoxemia set the grade; tocilizumab 8 mg/kg, max 800 mg. ICANS: ICE score and steroids.
• Vesicant leak: stop and aspirate; anthracyclines get cold and dexrazoxane, vinca alkaloids warm and hyaluronidase.