Foreword
Preface
Contents
Editors
Associate Editors
Contributors
Part I: Systems
1: Epidemiology
Overview
Distribution of ED Visits Among Oncologic Patients
Data Sources
Estimates
Determinants of ED Use Among Cancer Patients
Predisposing Factors
Enabling Factors
Need Factors
International Perspective on Determinants of ED Use
Preventability of ED Visits Among Cancer Patients
International Perspective on Preventable ED Use
Conclusion
References
2: Models of Care
Introduction/Background
The University of Texas MD Anderson Cancer Center
Memorial Sloan Kettering Cancer Center
The Ohio State University Comprehensive Cancer Center: Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
Current and Future Considerations for the Cancer Emergency Department
References
3: Informatics
Introduction
Workflow Process Redesign and Quality Improvement
Workflow Analysis
Workflow Redesign
Quality Improvement
Conclusion
Clinical Decision Support
Information Technology Systems
Telehealth
Case Study 1
Security
Case Study 2
Communication
Order Sets
Transition of Care Tools
Research and Registries
Cancer Registries
Cancer Surveillance Programs
References
4: Quality Measures
Case Study: Addressing Unmet Palliative Care Needs in the ED
Introduction/Background
History and Current State of Health Policy for Quality in Oncologic Emergency Care
The No-Duty-to-Treat Principle and the Emergency Medical Treatment and Active Labor Act (EMTALA)
Known Quality Issues
Late-Stage Cancers Presenting to the ED
Overutilization of ED Services
Overcrowding, Boarding, and Ambulance Diversion
High Costs at the End of Life
Patient Dissatisfaction with Emergency Care
Caregiver Burden
Specific Issues for Dedicated Oncologic EDs
Upstream Drivers
Poor Care Coordination
Underutilized Advance Care Planning
Inadequate Access to Palliative Care
Delayed Hospice Referral and the Hospice Reimbursement Model
Limited Availability of Immediate and After-Hours Outpatient Care
Unrealistic Patient/Caregiver Expectations Regarding Prognosis and Treatment
Role of Quality Measures
History of Quality Measurement in Emergency Medicine
Limitations of Existing Quality Measures for Emergency Departments
Gaps in Existing ED Measures
Fragmented Measure Development
Difficulty Defining an Episode of Oncologic Emergency Care
Measurement Without a Clear Mechanism for Improving Care
Challenges in Obtaining ED Quality of Care Data
Desired State of National Quality Measurement for Oncologic Emergency Care
Vision for National Quality Measurement in Oncologic Emergency Care
Recommendation 8: Quality Measurement
Health Policy for Measuring Quality in Oncologic Emergency Care
HIT Support Through the Learning Healthcare System for Cancer
Role of Targeted Quality Measures in Driving Practice Change
Conclusion
References
5: Patient Navigation
Introduction
Case Study
Background
Management
Oncologic Nurse Navigator
Oncologic Social Worker
Lay Navigator
Patient-Centered Medical Home
Health Services/Resource Utilization
Future Needs/Vision
Conclusion
References
6: Nursing
Emergency Nursing and Oncologic Emergencies
Triage and General Assessment of Oncologic Emergencies
Triage
General Assessment
Chief Complaint: Chest Pain and Shortness of Breath
Chief Complaint: Altered Mental Status
Chief Complaint: Back Pain
Chief Complaint: Abdominal Symptoms
Chief Complaint: Infection
Chief Complaint: Newly Diagnosed Cancer in the Emergency Department
Chief Complaint: Malignancy Progression, Antineoplastic Treatments, and General Medical Emergencies
Chief Complaint: End of Life in Advanced-Stage Cancer
Pandemic Response: SARS CoV 2 – Novel Coronavirus
COVID 19: An Enhanced Threat to Cancer Patients
Preventing Cancer Patients from COVID-19 Exposure from ED to Disposition
Screening for COVID-19 and Safety Measures
Considerations for ED Staff
Post Patient Screening and Treatment Room Assignment
Regulatory Standards for Oncologic Emergency Departments: Brief Introduction
Interdisciplinary Collaboration
References
7: Palliative Social Work
Introduction
The Role of the ED Social Worker
Crisis Intervention
Complex Case Management
ED Social Work Role with Oncologic Patients
Psychosocial Issues for Cancer Patients in the ED
Diagnosis of Cancer in the ED
Case Discussion 1
Emergency Department Social Worker
Communication in the ED
ED as Primary Healthcare Site
Language/Cultural Barriers
Caregiver Distress
The Role of the Outpatient Oncologic Social Worker
Clinical Interventions
Cognitive Behavioral Interventions
Relaxation Techniques
Supportive Counseling
Crisis Intervention
Psychoeducation
Case Discussion 2
Oncologic Social Worker Interventions to Prevent an ED Visit
The Role of the Palliative Social Worker
Palliative Social Work Initiative in the ED
Goals of Care Conversations in the ED at End of Life
Social Work Initiatives to Prevent ED Visits
Case Discussion 3
OSW Connecting an Oncologic Patient’s Caregiver to Community Resources
Psychiatry
Health Home Initiative
Suggestions for Future Research
Conclusion
References
Part II: Prevention
8: Tobacco Control
Background
Diagnosis of Tobacco Use
Diagnosis of Tobacco-Related Illness
Illnesses Associated with Tobacco Use
Emergency Department Treatment of Tobacco Dependence
Cost
Conclusion
References
9: Problem Drinking
Case Study
Background
ED Encounters for Alcohol-Related Disease and Injury
Acute Conditions Related to Alcohol Use
Chronic Conditions Related to Alcohol Use
Special Considerations for Health Disparities
Identification and Diagnosis of Alcohol Use Disorder
Alcohol-Related Conditions
Diagnosis of Alcohol Use Disorder
ED Approach to Prevention of Alcohol Use Disorder
Potential Value of ED-Based Alcohol SBIRT for Alcohol-Related Cancers
Conclusion
References
10: Ionizing Radiation
Case Study
Introduction
CT Is a Transformative Tool in Medicine
The Explosion in CT Utilization
CT Contribution to Cumulative Radiation
Reasons for Increased CT Utilization
Patterns of Repeat/Multiple CT Imaging in the ED
Radiation and Its Effects
Deterministic Versus Stochastic Effects of Ionizing Radiation
The Link Between Low-Dose Ionizing Radiation and Cancer
Who Is Most at Risk?
Measures of Radiation
Dose Estimates
Efforts to Reduce Radiation and Optimize Imaging
Technological Improvements
Provider and Patient Awareness
Clinical Decision Support
Appropriateness Criteria
Clinical Decision Rules
Computerized Interventions
Shared Decision-Making with Patients
Quality Metrics and Regulatory Efforts
Summary
References
11: Cervical Cancer Screening
Case Study
Background
Human Papillomavirus (HPV)
Cervical Intraepithelial Neoplasia (CIN)
Risk Factors
Prevention
Schedule and Doses
Secondary Prevention: Cervical Cancer Screening
Cervical Cancer Prevention in Low- and Middle-Income Countries (LMICs)
Cervical Cancer Prevention in the Emergency Department
HPV Vaccination
Screening
Conclusion
References
12: Lung Cancer Screening
Introduction
Case Studies
Background
Epidemiology and High-Risk Populations
Pathology, Prognosis, and Treatment
Lung Cancer in the Emergency Department
ED Imaging and Lung Cancer
Lung Cancer Prevention
Lung Cancer Screening with Chest X-Ray and the Problem of Overdiagnosis
Computed Tomography (CT) for Lung Cancer Screening
National Lung Screening Trial
Barriers to LDCT Screening
Proposed Solutions to LCS Barriers
The Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) Trial
Future of Lung Cancer Screening
Health Economics
Cancer Prevention and Screening in the ED
Lung Cancer Screening in the ED: What Is Our Role?
Shared Decision-Making
Conclusion (Table 12.2)
References
13: Colorectal Cancer Screening
Case Study
Background
Diagnosis of CRC
CRC Diagnosis in the ED
Oncologic Emergencies Associated with CRC
Bowel Obstruction
Perforation
Rectal Bleeding
Complications Secondary to Chemotherapy and Radiation
Conclusion
References
14: Melanoma Screening
Case Study
Introduction
Epidemiology
Pathophysiology
Clinical Manifestations
Teledermatology
Investigation and Diagnosis
Treatment
The Future of Diagnosis
Primary Prevention
Secondary Screening
References
Part III: Evaluation and Treatment
15: Acute Airway Obstruction
Case Study
Introduction
Epidemiology
Classification
Presentation
Evaluation
Management Overview
Therapeutic Bronchoscopy: Tools
Mechanical Debulking
Rigid Bronchoscopy
Microdebrider
Dilators
Thermal Tools
Laser
Electrocautery
Argon Plasma Coagulation
Cold Tools
Cryotherapy: Cryoprobe and Cryospray
Airway Stents
Conclusion
References
16: Central Nervous System
Introduction
Approach to the Patient with Altered Mental Status
Frequency and Importance
Causes
Diagnosis
Assessment and Management
Brain Herniation
Principles
Causes
Assessment
Management and Prognosis
Status Epilepticus (SE)
Definition and Classification
Causes
Assessment
Management and Prognosis
Intracranial Hemorrhage (ICH)
Importance and Causes
Presentation
Diagnosis
Treatment and Prognosis (Fig. 16.11)
Acute Ischemic Stroke
Importance and Causes
Diagnosis
Assessment, Treatment, and Prognosis
Cerebral Venous Sinus Thrombosis
Frequency
Presentation
Diagnosis
Treatment and Prognosis
Case Studies
Case Study 1: Pembrolizumab-Associated Myopathy
Case Study 2: Atezolizumab-Associated Meningoencephalitis [50]
Case Study 3: CAR T-Cell Neurotoxicity
References
17: Pituitary Apoplexy
Case Study
Definition
Anatomy and Physiology Review
Clinical Presentation
Headache
Visual Disturbance
Pituitary Dysfunction
Incidence and Predisposing Factors
Pituitary Apoplexy Workup
Differential Diagnosis
Diagnostic Imaging
Laboratory Investigations
Emergency Department Management
Neurosurgical Management
Outcomes and Follow-Up
Summary
References
18: Spinal Cord Compression
Case Study
Introduction
Epidemiology
Pathophysiology
Clinical Presentation
History
Physical Examination
Imaging
Management
Nursing Efforts
Medical Therapy
Surgical Therapy
Radiotherapy
Special Considerations
Prevention
Prognosis
Conclusion
References
19: Head and Neck
Introduction
Case Discussion
Airway Management
Unsecured Airway
Secured Airway
Considerations During the SARS-CoV-2 (COVID-19) Pandemic
Bleeding Management
Acute Arterial Bleeding
Carotid Blowout
Internal Jugular Vein Bleeding
Tracheoinnominate Fistula
Epistaxis
Management of Treatment Complications
Surgical Complications
Radiation Therapy Complications
Chemotherapy Complications
Common Pitfalls
Neck Abscess Versus Occult SCCHN Cystic Cervical Lymph Node Metastasis
Sinusitis Versus Occult Sinonasal Malignancy
Ear Infection Versus Occult SCCHN of the Oropharynx
Summary
References
20: Ophthalmic Emergencies in Cancer Patients
Introduction
Acute Visual Loss
Diplopia
Red Eye
Epiphora
Proptosis
Ptosis
Flashes and Floaters
Conclusion
References
21: Cardiovascular Oncologic Emergencies
Introduction
Ischemic Cardiovascular Manifestations
Case Study
Case Discussion
Arterial Thrombosis
Secondary to Cancer
Secondary to Cancer Therapy
Premature Coronary Artery Disease
Secondary to Pharmacologic Therapy
Secondary to Radiation Therapy
Coronary Artery Vasospasm
Vasculitis
Peripheral Artery Disease
Secondary to Pharmacologic Therapy
Secondary to Radiation Therapy
Non-ischemic Vascular Conditions
Hypertension
Diagnosis
Treatment
Venous Thromboembolism
Diagnosis
Prevention
Treatment
Pericardial Diseases
Pericarditis
Acute Pericarditis
Immunotherapy-Induced Pericarditis
Pericardial Effusion
Cardiomyopathies
Systolic Cardiomyopathy
Stress Cardiomyopathy
Immune Checkpoint Inhibitor-Induced Cardiomyopathy
Diastolic and Restrictive Cardiomyopathy
Radiation Therapy
Anthracyclines and Monoclonal Antibodies
Cardiomyopathy Diagnosis
Cardiomyopathy Treatment
Myocarditis
Presentation
Diagnosis
Treatment
Conduction Disturbances
Valvular Heart Disease
Pathophysiology
Management of Valvular Heart Disease
Modern Techniques
Cardiovascular Imaging
Echocardiogram
Cardiac Magnetic Resonance Imaging
Cardiac Computed Tomography
Cardio-Oncologic in the COVID-19 Era
References
22: Superior Vena Cava Syndrome
Case Study
Etiology/Epidemiology
Anatomy
Clinical Features (Signs/Symptoms)
Radiographic Evaluation
Histologic Diagnosis
Treatment
Supportive Therapy
Treatment of Malignant Causes of SVCS
Chemotherapy
Radiotherapy
Intravascular Therapy (Stents)
Treatment of Benign (Nonmalignant Causes) of SVCS
Thrombolytics
Prognosis
Recurrence (Durability of Treatment)
Palliative Care Discussions
References
23: Pulmonary
Case Study
Introduction
Respiratory Failure, ARDS, and Ventilator Management
Respiratory Failure
Acute Respiratory Distress Syndrome (ARDS)
Ventilator Management
Summary
Pneumothorax and Pleural Effusion
Pneumothorax
Definitions, Etiologies, and Diagnostic Modalities
Clinical Scenarios in Cancer Patients
Treatment
Pleural Effusion
Drainage
Amount of Drainage
Chest Tube Size
Summary
Hemoptysis
Etiologies
Massive Hemoptysis
Summary
Chemotherapy and Radiation-Related Pulmonary Toxicities
Chemotherapy-Related Pulmonary Toxicity
Acute Complications
Conclusion
Conventional Chemotherapy-Related Pulmonary Toxicity
Late Complications
Summary
Nonthrombotic Pulmonary Embolism (NTPE)
Summary
References
24: Venous Thromboembolism
Case Study
Pathophysiology of Thromboembolism in Cancer
Thrombogenic Cancers
What Does VTE Mean for the Cancer Patient?
Special Considerations for Diagnosis
Risk Stratification and Management
Treatment
Thromboembolism Prophylaxis
Incidental Diagnosis and Thrombophilia Workup
Catheter-Associated Thrombosis
Advanced Treatment
Patients with Absolute Contraindications to Anticoagulation
Discontinuation of Treatment
VTE as First Manifestation of Cancer
Follow-Up
References
25: Gastroenterology
Case Study
Introduction
Gastrointestinal Hemorrhage
Bleeding Related to Tumors
Bleeding as a Consequence of Treatment
Luminal Obstruction
Acute Pancreatitis
Biliary Obstruction
Hepatic Decompensation
Fulminant Hepatic Failure
Ascites
Urgent Issues Related to Enteral Feeding Devices
Summary
References
26: The Acute Abdomen
Case Study
Small Bowel Obstruction
Clinical Presentation and Initial Assessment
Diagnostic Workup
Treatment and Operative Intervention
Clinical Presentation and Initial Assessment
Diagnostic Evaluation
Treatment and Operative Intervention
Gastric Outlet Obstruction
Clinical Presentation and Initial Assessment
Diagnostic Evaluation
Treatment and Operative Intervention
Gastrointestinal Bleeding
Clinical Presentation and Initial Assessment
Diagnostic Evaluation
Treatment and Operative Intervention
Neutropenic Enterocolitis
Clinical Presentation and Initial Assessment
Diagnostic Workup
Treatment and Operative Intervention
Radiation Enteritis
Clinical Presentation and Initial Assessment
Diagnostic Evaluation
Treatment and Operative Intervention
Conclusion
References
27: Diarrhea
Case Study
Introduction
Causes
Paraneoplastic Syndromes
Treatment-Induced Diarrhea
Symptoms
Diagnosis
Management
Diet
Medication Adjustment
Correction of Dehydration and Electrolyte Imbalances
Pharmacologic Therapy
Management of Specific Clinical Scenarios
Treatment-Induced Diarrhea
“Complicated” Chemotherapy-Induced Diarrhea
Targeted Therapy
Neutropenic Enterocolitis
Immune-Mediated Colitis
GVHD
Paraneoplastic Diarrhea
References
28: Constipation
Case Study
Introduction
The Rome Diagnostic Criteria
Pathophysiology
Clinical Presentation
Examination
Differential Diagnosis
Diagnosis
Treatment
Pharmacological Agents in the Treatment of Constipation
Bulk-Forming Laxatives
Stool Softeners and Lubricants
Osmotic Laxatives
Stimulant Laxatives
Enemas
Newer Agents
Disposition
Prevention and Patient Education
Conclusion
References
29: Endocrinology and Metabolism
Introduction
Case Study
Metabolic Emergencies
Hypernatremia
Hyponatremia
Hyperkalemia
Hypokalemia
Hypermagnesemia
Hypomagnesemia
Hypercalcemia
Hypocalcemia
Hyperphosphatemia
Hypophosphatemia
Hyperglycemia
Hypoglycemia
Tumor Lysis Syndrome
Endocrine Emergencies
Cushing Syndrome
Adrenal Crisis
Hyperthyroidism
Myxedema Coma
References
30: Nephrology
Case Study
Chapter Overview
Introduction
Acute Kidney Injury in Cancer Patients
AKI and Conventional Chemotherapy
AKI and Immunotherapy
AKI and Anti-VEGF Therapy
Chronic Kidney Disease in Cancer Patients
Multiple Myeloma and AKI
Hematopoietic Stem Cell Transplantation (HSCT) and AKI
Electrolyte Abnormalities
Tumor Lysis Syndrome (TLS)
Hyponatremia
Hyperkalemia
Hypercalcemia
Key Practice Points
References
31: Urology
Case Study
Hematuria
Microhematuria
Gross Hematuria
Renal Mass
Ureteral Mass
Bladder Mass
Urethral Pathology
Urinary Retention
Hydronephrosis
Testicular Cancer
Retroperitoneal Mass with Venous Involvement
Penile Cancer
Prostate Cancer
Postoperative Issues
Prostatectomy
Radical Cystectomy
Fever
Hydronephrosis
Urinary Tract Infection
Dehydration
Leg Swelling
Diarrhea
Acute Abdomen
Stomal Complications
Continent Diversion Problems
Nephrectomy
Hematuria
Abdominal Collections
Pulmonary Symptoms
Conclusion
References
32: Gynecology
Case Study 1
Case Study 2
Introduction
Acute Blood Loss
Management
Summary: Management of Hemorrhagic Cystitis (Fig. 32.1) [7]
Pelvic Infections
Management
Gastrointestinal Emergencies in Gynecologic Cancer Patients
Malignant Bowel Obstruction
Gastrointestinal Perforation and Fistula
Genitourinary Emergencies in Gynecologic Cancer Patients
Vaginal Cuff Dehiscence
Urinary Tract Obstruction
Pain
Conclusion
References
33: Orthopedics
Case Study
Introduction
Trauma
Pathologic Fractures
Impending Pathologic Fractures
Open Fractures
Compartment Syndrome
Infection
Cellulitis
Necrotizing Fasciitis
Other Soft Tissue Infections (Abscess, Bursitis, Tenosynovitis)
Septic Arthritis
Osteomyelitis
Arthroplasty
Periprosthetic Fractures
Prosthetic Dislocation
Pelvis
References
34: Dermatology
Case Study
Introduction
Maculopapular Eruptions
Drug Eruptions
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)/DIHS (Drug-Induced Hypersensitivity Syndromes)
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Immune-Related Maculopapular Rash
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Viral Exanthems
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Graft-Versus-Host Disease (GVHD)
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Localized Erythema
Cellulitis
Clinical Manifestations
Pathophysiology
Diagnosis
Treatment
Toxic Erythema of Chemotherapy
Leukemia Cutis
Angioedema
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Erythroderma
Toxic Shock Syndrome
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Mycosis Fungoides and Sézary Syndrome
Clinical
Etiology
Diagnosis
Treatment
Vesicles and Pustules
Drug-Induced Autoimmune Blistering Disease
Immune-Related Bullous Pemphigoid-Like Eruption
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Viral Infections
Varicella-Zoster Virus
Clinical Presentation
Pathophysiology/Etiology
Diagnosis
Treatment
Eczema Herpeticum (Kaposi’s Varicelliform Eruption)
Clinical Presentation
Pathophysiology/Etiology
Diagnosis
Treatment
Bacterial Infections
Ecthyma
Clinical Presentation
Pathophysiology/Etiology
Diagnosis
Treatment
Fungal Infections
Disseminated Candidiasis
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Blistering Diseases
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
Clinical Manifestations
Pathophysiology
Diagnosis
Treatment
Paraneoplastic Pemphigus
Clinical Manifestations
Pathophysiology
Diagnosis
Treatment
Purpuric (Non-blanching) Eruptions
Macular Purpura
Palpable Purpura
Retiform Purpura
Acute Meningococcemia
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Opportunistic Fungal Infections
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
Anticoagulant-Induced Skin Necrosis
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
DIC/Purpura Fulminans
Clinical Manifestations
Pathophysiology/Etiology
Diagnosis
Treatment
References
35: Pediatrics
Introduction
Case Study
History and Background
Anatomy
Pathophysiology
New Onset
Undergoing Therapy
Epidemiology
Health Economics
Presentation/Diagnosis
New Onset
Undergoing Therapy
Evaluation
New Onset
Undergoing Therapy
Management
New Onset
Undergoing Therapy
Disposition/Follow-Up
New Onset
Undergoing Therapy
Prognosis/Treatment
Complications
Common Pitfalls
New Onset
Undergoing Therapy
Prevention/Upstream Drivers
Future Needs/Vision
Health Services/Resource Utilization
Policy/Legislative
Medicolegal
Documentation/Quality Indicators
Key Points/Pearls
References
36: Hyperleukocytosis and Leukostasis
Case Study
Physical Exam
Laboratory Values
Imaging
Management
Introduction
Epidemiology
Health Economics
Pathophysiology of Leukemia and Leukostasis
Presentation
ED Evaluation
ED Management
Circulation
Airway/Breathing
Other Treatment Considerations
Definitive Treatment
Disposition and Prognosis
Future Research
Conclusion
Pearls
References
37: Bleeding and Thrombosis
Case Study
Introduction
Bleeding
Bleeding Related to Coagulation Factors
Bleeding Related to Platelet Number and Function
Specific Hematological Cancers Associated with Bleeding
Acute Promyelocytic Leukemia (APL)
Myeloproliferative Neoplasms
Dysproteinemia
Coagulation Defect Due to Therapy
Cancer and Thrombosis
Epidemiology
Treatment
Specific Situations
Myeloproliferative Neoplasms
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Venous Catheter Thrombosis
Antineoplastic Therapy
Use of Anticoagulants in Thrombocytopenic Patients
References
38: Infectious Disease
Introduction
Risk Factors and Immune Compromise
Antimicrobial Prophylaxis for Cancer Patients
Hematopoietic Stem Cell Transplantation (HSCT)
Chemotherapy-Induced Neutropenia
Chemotherapy and Immunotherapy Against Solid Organ Tumors
Evaluation of the Oncologic Patient with Infection
Febrile Neutropenia: An Oncologic Emergency
History and Physical Examination
Initial Diagnostic Workup
Treatment and Management
Case Study 1: An Oncologic Patient with Fever and Neutropenia
Special Considerations
Syndromic Approaches
Case Study 2: A Thorough Examination Uncovers the Source of Fever in an Ill Oncologic Patient
Future Issues and Considerations
Summary and Key Points
References
39: Febrile Neutropenia
Case Study
Introduction
Definition
Pathophysiology
Assessment
Management
Risk Stratification
Antibiotic Therapy
Antifungal Therapy
Antiviral Therapy
Granulocyte Colony-Stimulating Factor (GCSF)
Future Considerations
Biomarkers
Conclusion
References
40: Neutropenic Enterocolitis
Case Study
Introduction
Background and State of the Evidence
Clinical Presentation
Diagnostic Criteria
Risk Factors
Pathophysiology
Pediatric Considerations
Workup
The Role of Diagnostic Imaging: CT and Ultrasound
Treatment
Medical Versus Surgical
Surgical Intervention
Additional Therapy
Summary
References
41: Sickle Cell Disease
Case Study
Introduction
Pathophysiology
Epidemiology
Clinical Presentations in the ED
Pain in Sickle Cell Disease
Acute Chest Syndrome
Fever and Infection
Pulmonary Hypertension
Cerebrovascular Accident
Pulmonary Embolism
Acute Coronary Syndrome
Renal Complications
Ocular Complications
Splenic Sequestration
Priapism
Hepatobiliary
Avascular Necrosis (AVN)
Aplastic Crises
Controversies in the Management of Sickle Cell Disease
Acute Pain
Opioid Crisis and Implications for the Care of Patients with SCD
Intravenous Fluids
Blood Transfusion
Hydroxyurea (Hydroxycarbamide)
Looking Ahead
Summary
References
42: Radiological and Nuclear Terrorism
Introduction
Radiological and Nuclear Scenarios of Concern
Radiological Exposure Device (RED)
Radiological Dispersal Device (RDD)
Improvised Nuclear Device (IND) and Nuclear Weapon Detonation (NWD)
Nuclear Power Plant (NPP) Incidents
Radiation-Induced Injuries and Illnesses
Internal Contamination
Acute Radiation Syndrome
Clinical Evaluation of Acute Radiation Injury
Clinical History and Laboratory
Clinical Prodrome
Cytogenetic Biodosimetry
Acute Radiation Syndrome (ARS)
Hematopoietic Syndrome (HS)
National Network for Management of Mass Radiation Casualties
Cutaneous Subsyndrome (CS)
Gastrointestinal Subsyndrome (GS)
Neurovascular Subsyndrome (NS)
Other Considerations
Summary
References
43: Delirium
Case Study
Introduction
Definitions
Epidemiology
Etiology and Pathophysiology
Clinical Personation and Diagnosis
Patient Evaluation
Screening Tools
Differential Diagnosis
Management
Step 1. Assessing the Patient
Step 2. Reviewing the Environment
Step 3. Treating the Symptoms of Delirium
Step 4. Treating the Underlying Cause
Step 5. Counseling the Patient’s Family and Healthcare Professionals
Palliative Sedation
Prognosis
References
44: Suicide
Introduction
Case Study: Refractory Hodgkin Lymphoma
Theories of Suicide
Biopsychosocial Model of Suicide
Predisposing Factors: Genetic Makeup
Serotonin
Hypothalamus-Pituitary-Adrenal Axis
Childhood Trauma
Anger and Impulsive Behavior
Precipitating Factors
Mood Disorders
Chronic Illness
Challenges Faced by Military Veterans
Financial Crisis/Loss of Job
Environmental Factors
Perpetuating Factors
Suicide Risk Factors Specific to Cancer Patients
Management of Suicidal Cancer Patients
Management of Suicidal Oncology Patients in the Emergency Department
Management of Suicidal Patients in the Oncology Clinic
Antidepressants for the Treatment of Depression in Cancer Patients
Future Research
Conclusion
References
45: Substance Abuse
Introduction
Scope of the Problem
Substance Use Disorder
Prescription Drug Abuse
Alcohol
Diagnostic and Treatment Issues
Defining Substance Use Disorder and Addiction in the Medically Ill
Pseudoaddiction
Aberrant Drug-Taking Behaviors
Disease-Related Variables
Risks in Patients with Current or Remote Histories of Drug Abuse
Clinical Management of Substance use Disorders in Oncologic
General Recommendations
Multidisciplinary Approach
Assessment of Substance Use History
Use of Risk Assessment Tools
Setting Realistic Goals for Therapy
Evaluation and Treatment of Comorbid Psychiatric Disorders
Preventing and Minimizing Withdrawal Symptoms
Alcohol Withdrawal Syndrome
Medical Treatment of Alcohol Withdrawal
Considering the Therapeutic Impact of Tolerance
Psychopharmacology Approaches
Methadone Maintenance
Buprenorphine and Naltrexone
Selecting Appropriate Drugs and Route of Administration for the Symptom and Setting
Recognizing Specific Drug Abuse Behaviors
Using Nondrug Approaches as Appropriate
Developing the Treatment Plan
Inpatient Management Plan
Outpatient Management Plan
Case Study
Recommendations for Prescribing
Twelve-Step Programs
Urine Drug Testing and Prescription Drug Monitoring Programs
Family Sessions and Meetings
Conclusion
References
46: Radiology
Introduction
Imaging Modalities
Radiologic Evaluation of Oncologic Emergencies
Neurologic Emergencies
Chest Emergencies
Abdominopelvic Emergencies
Musculoskeletal Emergencies
Case Study
References
47: Ultrasound
Introduction
Basic Ultrasound Functionality
Ultrasound Transducer Selection
Adjusting the Ultrasound Image
Safety of Bedside Ultrasound
Emergency Cardiac Ultrasound
Basic Approach
Pericardial Effusion and Cardiac Tamponade
Left Ventricular Function
Right Ventricular Strain
Measurement of the Inferior Vena Cava
Thoracic and Pulmonary Oncologic Emergencies
Zones of the Lung
Lung Artifacts (A-Lines and B-Lines)
Diffuse Interstitial Syndrome
Consolidation
Pleural Effusions
Pleural Disease
Pneumothorax
Abdominal Oncologic Emergencies
Malignant Bowel Obstruction
Ascites and Perforation
Colitis
Genitourinary Oncologic Emergencies
Obstructive Urinary Pathologies
Pelvic Pathologies
Ovarian Torsion
Deep Venous Thrombosis
Lymphadenopathy
Basic Approach
Superficial Lymph Nodes: Benign Versus Malignant
Size and Shape
Hilar Appearance
Margins
Structural Characteristics
Color Flow
POCUS Use in Pediatric Neck Masses
Rapid Ultrasound in Shock and Hypotension (RUSH)
Case Study
HI MAP ED Approach
References
Part IV: Toxicities
48: Chemotherapy Toxicities
Introduction
Case Study
Central Nervous System (CNS) Toxicities
Chemotherapy Agents Implicated
Methotrexate
Cytarabine
Ifosfamide
Busulfan
Platinum-Based Compounds (Cisplatin, Carboplatin, Oxaliplatin)
Diagnosis and Treatment
Peripheral Neuropathy
Pathophysiology
Epidemiology
Presentation/Diagnosis
Prevention
Management
Hypertensive Crisis
Pathophysiology
Clinical Features
Chemotherapy and Targeted Agents Implicated
Treatment
Nausea and Vomiting
Pathophysiology
Clinical Features
Chemotherapy Agents Implicated
Treatment
Nephrotoxicity
Risk Factors
Chemotherapy Agents Implicated
Platinum-Based Compounds
Alkylating Agents
Antitumor Antibiotic
Antimetabolites
Targeted Therapy
Electrolyte Disorders
Pathophysiology
Chemotherapy Agents Implicated
Platinum-Based Chemotherapy
Cyclophosphamide
Vinca Alkaloids
Ifosfamide
Cetuximab
Treatment
Anaphylaxis
Pathophysiology
Clinical Features
Chemotherapy and Targeted Agents Implicated
Treatment
Extravasation
Clinical Features
Chemotherapy Agents Implicated
Treatment: Pharmacologic and Non-pharmacologic
DNA-Binding Agents
Dexrazoxane
DMSO
Sodium Thiosulfate
Non-DNA-Binding Agents
Hyaluronidase
Surgical Intervention
References
49: Treatment Toxicity: Radiation
Introduction
Acute Radiation Toxicity: Unintended Exposure
Normal Tissue Toxicity
Normal Tissue Effects of Radiation Therapy
Management of Acute Effects of Radiation Therapy
Skin
Hematopoietic System
Gastrointestinal Tract
Subacute and Late (Delayed) Effects of Treatment
Skin
Bone Marrow
Gastrointestinal Tract
Liver
Kidney
Lung
Case Study
Heart and Peripheral Vessel
Central and Peripheral Nervous System
Reproductive Organs, Genitalia, and Endocrine
Pediatrics
Conclusion
References
50: Mucositis
Introduction
Case Study
History/Background
Anatomy
Pathophysiology
Epidemiology
Health Economics
Presentation
Diagnosis
Prophylaxis and Management of Oral Mucositis
Anti-inflammatory Agents
Oral Cryotherapy
Palifermin
Photobiomodulation
Opioid Analgesics
Gabapentin
Doxepin
Nutritional Supplements
Natural Agents
Oral Care
Prophylaxis and Management of Gastrointestinal Mucositis
Amifostine
Octreotide
Sucralfate
Antimicrobials
Antihistamines
Nutritional Supplements and Dietary Modifications
Formalin
Palifermin
Hyperbaric Oxygen Therapy
Disposition/Follow-Up
Prognosis/Treatment Complications
Common Pitfalls
Future Needs/Vision
Health Services/Resource Use
Documentation
Key Points/Pearls
References
51: Stoma Complications
Introduction
Case Study
Classification
Health Economics
Diarrhea
Skin Irritation
Hernia
Retraction
Stenosis
Prolapse
Bleeding
Urostomy Complications
Future Needs
References
52: Hematopoietic Cell Transplant
Introduction
Complications of High-Dose G-CSF Administration
Splenic Rupture
Ischemic Complications
DMSO Toxicity
Case Study
Oral Complications of HCT
Gastrointestinal Complications of HCT
Engraftment Syndrome
Autologous GVHD
Transfusion-Associated GVHD
Acute Complications After Allogeneic HCT
Acute Infectious Complications After Allogeneic HCT
Veno-Occlusive Disease (VOD) (Previously Termed Sinusoidal Obstruction Syndrome)
Acute Pulmonary Complications After Allogeneic HCT
Acute Renal Complications After Allogeneic HCT
Acute Neurologic Complications After Allogeneic HCT
Acute GVHD
Graft Failure
References
53: Toxicities of Novel Antineoplastic Therapies
Introduction
Case Study
General Approach
“Familiar Scenes with New Actors”
Differentiation Syndrome
Infusion-Related Reactions
QT Prolongation
Sinusoidal Occlusion Syndrome
Tumor Lysis Syndrome from Venetoclax-Based Therapy
Novel Adverse Effects of New Immunotherapy for Cancer
Immune-Related Adverse Events (irAEs)
Chimeric Antigen Receptor (CAR)-T-Cell Therapy
Conclusion
References
54: Fluorouracil or Capecitabine Overdose
Case Study
History and Epidemiology
Pharmacodynamics
Pharmacokinetics
Toxicokinetics
Pathophysiology
Clinical Presentation
Evaluation and Diagnostic Testing
Management
Antidotal Therapy: Uridine Triacetate
References
Part V: Palliative Care
55: Emergency Department Use at End of Life
Introduction
Case Study
Rationale for Investigating ED Use at EOL
Indicator of Poor-Quality Care
Patients and Families’ Perspective on ED Visits at EOL
Healthcare Provider Perspective on ED Visits at EOL
System Perspective on ED Visits at the EOL
Frequency of ED Visits at EOL
Reasons for ED Visits at the EOL
Factors Associated with Increased Risk of ED Visits
Evidence for Strategies to Mitigate ED Use at EOL
Future Directions
Conclusion
References
56: Pain Management
Case Study
Introduction
Classification of Pain
Pain Severity
Pain Mechanisms
Oligoanalgesia
Treatment Options
WHO Analgesic Ladder
Non-opioid Analgesics
Opioid Analgesics
Opioid Side Effects
Adjuvants (Co-analgesics)
Psychosocial Support
Opioid Safety
EPEC-EM
Rapid Titration
Palliative Sedation
Consultation
Palliative Care in the Emergency Department
Summary
References
57: Dyspnea in the Dying Patient
Case Study
Introduction
Neurophysiology
Etiology and Prevalence
Evaluation
Arrival in ED/History
Physical Exam
Laboratory Studies
EKG
Imaging
Cardiac Monitoring/Telemetry/Vital Signs
General Management
Opioids
Benzodiazepines
Corticosteroids
Supplemental Oxygen
Noninvasive Ventilation (NIV)/Mechanical Ventilation
High-Flow Nasal Cannula
Management of Specific Conditions
Pleural Effusion
Anemia
Oral Secretions
Tumor Burden
Palliative Extubation
Summary
References
58: Cardiopulmonary Resuscitation
Introduction
What Outcomes After CPR Are Acceptable to Patients?
How Should Emergency Physicians Make Recommendations Regarding CPR?
Palliative and Supportive Care Interventions
Comprehensive Cancer Centers
Family-Witnessed Resuscitation
Perspectives of Family Members
Perspectives of Healthcare Workers
Perspectives of Patients
Ethical Considerations
Guidelines
Conclusions
References
59: Palliative Surgery
Case Study
Introduction
Gastrointestinal Obstruction
Gastric Outlet Obstruction
Small Bowel Obstruction
Large Bowel Obstruction
Gastrointestinal Bleeding
Wound Problems and Infections
Obstructive Jaundice
Bowel Perforation
Anorectal Infections
Ascites
Abdominal Pain in Unique Patient Populations
Celiac Plexus Involvement
Neutropenia
Multiple Myeloma
Outcome Measures
Conclusion
References
60: Palliative Care
Integrating Emergency Palliative Care for Patients with Advanced Cancer
Generalist Versus Specialist Emergency Palliative Care [17, 40, 41]
Integrated Emergency Medicine-Palliative Care Initiatives
Demonstration Models of Integrated Emergency Palliative Care
Jump-Starting an ED Palliative Care Integration Initiative
Monitoring Integrated Palliative Care Initiatives
Health Economics
Case Studies
Case 1 Communication Skills: Delivery of Difficult or Serious News
Case 2: Rapid Goals of Care Discussion
Case 3: Symptom Management: Actively Dying Patient
Summary
References
61: Hospice
Why This Chapter Is Important
Background
When a Patient Enrolled in Hospice Presents to the Emergency Department
Time for the Talk: Introducing Hospice
Review of Emergency Department and Palliative Care Collaborations: Toward Developing Pathways for Efficient Transfer to Hospice Care
Case Studies
Case Study 1
Question: Does Mr. M Meet Criteria for Hospice Enrollment?
Pause and Consider: How Would You Explore Goals of Care with Mr. M?
Pause and Consider: What Further Information Would Be Helpful to Know for His Disposition and Management?
Consider: What Might Be Important to Sign Out to the Hospice of His Choice?
Case Study 2
Question: What Next Steps Should Be Considered?
Case Study 3
Pause and Consider: What Factors About His Presentation Make Him a Candidate for Hospice? If He Elects Hospice, Is He Ineligible for Operative Management of His Fracture?
Conclusion
References
62: Communication
Introduction
Prognosis
The Building Blocks of Effective Communication
Preparation
Capacity
Physical Space
Conversation Templates
Responding
Effective Use of Silence
Language, Diversity, and Culture
Spiritual and Religious Considerations
Case Studies: Starting with Common Dilemmas and Gradually Layering in Complexity
Case Study 1: The Rapidly/Actively Dying Patient
Case Study 2: Stable Patient with Progression of Disease
Case Study 3: Death Disclosure of Sudden and/or Unexpected Death
Case Study 4: Managing Requests to Withhold Information
Case Study 5: When There Are Disagreements Among Physicians
Case Study 6: Dying in Isolation
Case Study 7: Telephone Death Notification [36–38]
Case Study 8: Death of a Child [39, 40]
References
63: Palliative Care Research
Introduction
Descriptive Studies
General Palliative Care
Cancer
Pediatric
Coordination of Care and Access to Palliative Care
Attitudinal Studies
Provision of Palliative Care in the Emergency Department
End-of-Life Care in the Emergency Department
Educational Needs
Screening
General
Speed
P-CaRES
The Surprise Question (SQ)
Other ED Screening Projects
Outcomes Research
Traditional Model of Consultation
Basic Integration
Advanced Integration
ED-Focused Advanced Integration
End-of-Life Care
Communication
Resource Allocation
Community-Based
Within the ED
After the ED
Education for Clinicians
Death Disclosure
EPEC-EM
Training Efforts
Summary
References
Part VI: Contextual
64: Ethics
Introduction
How Bioethics Fits into Our Societal and Professional Value Systems
Case Study 1
Values in Emergency Medicine
Virtues in Emergency Medicine
Bioethics, Religion, and Law
Oaths/Codes
Mid-Level Ethical Principles
Decision-Making Capacity
Evaluating Decision-Making Capacity
Patient Consent
Advance Directives and Surrogate Decision-Makers
Methods of Applying Bioethics Principles
Prioritizing Conflicting Principles: The Bioethical Dilemma
Application to Emergency Medicine: The Rapid Decision-Making Model [18, 19]
Case Study 2
Bioethics Committees and Consultants
Other Principles and Virtues
Beneficence
Beneficence: Withholding and Withdrawing Treatment
Withholding Treatment
Withdrawing Treatment
Beneficence Versus Patient Autonomy: Refusing Lifesaving Treatment
Beneficence Versus Patient Autonomy: Refusing Analgesia
Nonmaleficence
Nonmaleficence: Demands to “Do Everything”
Case Study 3
Nonmaleficence and Autonomy: Research Protocols
System Constraints: Distributive Justice and Confidentiality
Truth Telling (Fidelity)
Truth Telling and Communitarianism: Diagnosis Notification
Case Study 4
Truth Telling: Survivor Notification
Case Study 5
Future Bioethics in EM and the Role for Emergency Physicians
References
65: Health Disparities
Introduction
Concepts and Definitions
Disparities and Cancer Care for Vulnerable Populations
Case Study 1
Case Study 2
Case Study 3
Case Study 4
Summary
References
66: Emergency Oncology in the United Kingdom
Introduction
Acute Oncologic Services
Specialist Cancer Admission Units
Case Study
Ambulatory Care
UK Role in International Emergency Oncologic Research
COVID19 and Acute Cancer in the UK
References
67: Cancer Pain Management in Low-Resource Settings
Case Study
Introduction
Etiologies of Cancer Pain
Somatic Nociceptive Pain
Visceral Nociceptive Pain
Neuropathic Pain
Challenges and Opportunities for Cancer Pain Management
Managing Cancer Pain
Non-opioid Pharmacologic Management
Opioid Pharmacologic Management
Opioid Consumption in Low- and Middle-Income Countries
Non-pharmacologic Management
Interventional Procedures
Recommendations
Conclusions
References
68: Curriculum Development
Development of an Oncologic Emergency Medicine Curriculum
Emergency Medicine Residency
Problem Identification and General Needs Assessment
Goals and Objectives
Educational Strategies
Implementation
Evaluation and Feedback
Medical School Education in Oncologic
Hematology-Oncologic Fellowship Training
Oncologic Emergency Medicine Fellowships
Continuing Medical Education
References
69: National and Institutional Research Efforts
Introduction
Limitations of Published Oncologic Emergency Research
Training Opportunities
The Comprehensive Oncologic Emergencies Research Network (CONCERN)
Program in Oncologic Emergency Medicine (POEM), Department of Emergency Medicine at MD Anderson Cancer Center
Program Goals
To Facilitate Synergistic and Collaborative Projects Focused on Oncologic Emergencies
To Develop and Train Physician Scientists and Graduate Students in Oncologic Emergency Medicine Research
To Accelerate Knowledge Generation and Synthesis by Bringing Together Clinicians and Scientists from Diverse Disciplines
To Establish Synergy with Existing Centers and Departments at MD Anderson
Future Directions
References
70: COVID-19
Introduction
Epidemiology
Health Disparities
Treatment
System Impacts
Prevention
Economic Considerations
Case Study
Workforce Mental Health
Palliative Care
Conclusions
References
71: The Physician and Cancer: In Their Own Words
Introduction
Editor’s Note
The Difference a Day Makes
Marshall T. Morgan, MD (1941–2015)
Editor’s Note
Thomas J.
Patrick J. Crocker, DO
Editor’s Note
Advice for a Physician (or Anyone Else) with Newly Diagnosed Cancer
Burton F. Dickey, MD
Editor’s Note
Excerpts from The Healer Speaks
Sherry-Ann Brown, MD, PhD, FACC, FAHA
References
Multiple-Choice Questions
Answers
Index