Chest Tube Management - How to give Intrapleural tPA & Domase - Instructions:
There is evidence to support the administration of tPA+DNAse simultaneously. (https://www.atsjoumals.org/doi/pdf/10.1513/AnnalsATS.201602-127OC )
However, you should give it separately if the pulmonary team states otherwise.
Step-by-step instructions:
1. tPA will arrive at bedside {it is only usable -30 mins after it arrives at bedside)
2. Tum off suction on chest tube
3. Tum the stopcock towards the PleurEvac {C) {the direction that the stopcock is pointing to= direction that it's blocking).
4. Administer the tPA {and Domase), observing usual sterile technique {dosage may vary based on pulmonary team recommendations)
5. Flush chest tube with 30cc sterile saline flush
6. Tum the stopcock towards the patient {A) to trap the tPA and domase in the patient's pleura
7. Wait 1 hour to allow the medication to work
- If you are asked to administer tPA & Domase separately, you can repeat Steps 3-7 with Dornase.
8. Tum the stop cock to the tPA port (B) & allow drainage from the lungs to the PleurEvac
9. Restart chest tube to suction -20
Anticipatory planning:
- STOP administering if patient has pleural hemorrhage (frank blood)
- Having some blood-tinged pleural fluid is common, if it continues to become more bloody, ask pulmonary consult team to assess
- When in doubt, OK to hold a treatment and talk to pulmonary consult team
#Chest #ChestTube #Tube #Thoracic #TPA #Dornase #Instructions #Administration
Summary of Oncologic Emergencies
Neutropenic fever:
- Fever + ANC < 500 → start cefepime ± vancomycin (if SSTI or port infection suspected)
- CT chest; CT abdomen if abdominal pain; full infectious work-up
- If febrile > 4 days → add fungal work-up + empiric antifungal
- 70 % of patients will have no identifiable source
- When afebrile 24-48 h and ANC rising > 500 → may stop antibiotics
TLS (tumor-lysis syndrome):
- Hematologic malignancies, “rapid-turnover” SCLC
- Lab changes: high K, high Phos, high uric acid, high LDH, low Ca
- q8 h TLS labs, aggressive fluids, allopurinol 300 mg BID, sevelamer PRN
- Consider rasburicase if uric acid > 8 mg/dL or > 25 % rise from last lab (check G6PD first)
DIC (disseminated intravascular coagulation):
- Simultaneous clotting and bleeding; high d-dimer, low fibrinogen
- Treat underlying cause
- Give cryoprecipitate if fibrinogen < 100
- Consider TEG to guide replacement
Cord compression:
- Lower-extremity weakness, urinary retention, bowel incontinence
- High-dose steroids + urgent neurosurgery consult for decompression
SVC syndrome:
- Facial swelling, dyspnea, upper-extremity swelling
- Consult pulmonology / interventional radiology for possible stenting
- Consider anticoagulation
Leukostasis:
- Usually myeloid leukemias; “big & sticky” cells; WBC often > 100 000 (can be lower)
- Symptoms: CNS changes, headache, dizziness, shortness of breath
- Asymptomatic: hydroxyurea
- Symptomatic: hydroxyurea + leukapheresis
Hyperviscosity syndrome:
- Seen in MM and Waldenström macroglobulinemia (incidence up to 30 %)
- Symptoms: CNS changes, headache, dizziness, shortness of breath
- Treatment: plasmapheresis
Hypercalcemia of malignancy:
- Calcium > 14 mg/dL → treat
- Calcium > 12 mg/dL with symptoms → treat
- Calcium > 10 mg/dL without symptoms → no immediate treatment
1. Aggressive IV fluids (200–300 mL/h)
2. Calcitonin (rapid onset; tachyphylaxis after ~48 h)
3. IV bisphosphonates (onset ~48 h, duration 3–4 weeks)
4. Adjuncts: loop diuretics, denosumab, steroids, dialysis
Cytokine-release syndrome (CRS) / ICANS:
- Occurs after CAR-T, bispecifics, or HSCT
- CRS: fever, rash, hypoxia, hypotension (hours-to-days post-infusion)
- ICANS: altered level of consciousness, seizures, speech changes (CAR-T day 3–10; 2–4 days after CRS)
- Treatment: corticosteroids ± tocilizumab; call oncology early
Differentiation syndrome:
- Seen with AML (~20 %) and APL (~25 %) during therapy
- Symptoms: fever, weight gain, hypotension, renal failure, pulmonary opacities, SOB, pleural effusions
- Treatment: continue differentiating agent, add steroids, supportive care
#Oncologic #Emergencies #Oncology #HemeOnc #Diagnosis
The Neurological Evaluation of a Comatose Patient
Definition:
• Coma: a state of unresponsiveness; the absence of consciousness
Differential Diagnosis:
• Unresponsive wakefulness syndrome
• Locked-in syndrome
• Mutism
Pathophysiology:
• Severe injury/dysfunction to the bilateral cortex → Awareness
• Injury to brainstem (to the ascending reticular activating system/ARAS) → Arousal
How to Examine a Comatose Patient
1. Ensure the patient is off sedation, if safe to stop
2. Track response to voice or noxious stimulation
3. Test downward eye movement (i.e., is the patient locked in?)
4. Test if patient blinks to threat
Cranial Nerves:
Brainstem Reflexes:
• Pupillary light reflex
• Corneal reflex
• Oculocephalic reflex
• Vestibulo-ocular reflex
• Gag reflex
• Cough reflex
Pupils:
• Anisocoria + Coma → high concern for structural etiology of coma
Abnormal Eye Movements:
• Bobbing: Rapid downward movement followed by slower return to previous gaze position; indicates pontine lesion
• Dipping: Slow downward movement followed by rapid return to previous gaze position; indicates pontine lesion
• Roving eye movements: Slow horizontal movements; also normal in sleep; indicators of cortical etiology for the coma
• Forced gaze deviation: Not reversed by oculocephalic reflex; indicates ipsilateral hemispheric lesion; usually of frontal eye fields or brainstem
Motor/Sensory:
• Tone: check for asymmetry and hypotonia/flaccid limbs vs hypertonia (spasticity, rigidity, paratonia)
• Apply a noxious stimulation to all four limbs and document response (tests motor and sensation)
- Possible painful stimuli:
1. Supraorbital pressure
2. Sternal rub
3. Nail bed pressure
4. Trapezius squeeze
• Possible responses to pain: localizes, flexion withdrawal, abnormal flexor response (decortication), abnormal extensor response (decerebration), no response
• Document presence of spontaneous movements (i.e. myoclonic movements, tremors)
Reflexes:
• Deep tendon reflexes
• Plantar responses
• Check for presence of clonus
• Carefully note any asymmetry
Extra Tests:
• Examine for signs of meningoism (may not be present in coma)
• If ok with ICU team, place patient on pressure support ventilation and observe breathing
Localizing Posturing:
• Decorticate posturing: Arms flexed at the elbow in direction to the body; wrists clenched; legs extended; lesion above the red nucleus
• Decerebrate posturing: Arms extended; wrists flexed back, away from the body; wrists clenched; legs extended; lesion below the red nucleus
Glasgow Coma Scale (GCS):
• Eye opening
• Verbal response
• Motor response
Full Outline of UnResponsiveness (FOUR Score):
• Eye response
• Motor response
• Brainstem reflexes
• Respiration
By Dr. Gabriela Figueiredo Pucci @neudrawlogy and Dr. Casey Albin MD @caseyalbin
#PhysicalExam #neurology #comatose #diagnosis
