Level 2 of 6Must-remember

Oncological emergencies: cord compression, SVCO, hypercalcaemia and tumour lysis

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Know the three families: structural (malignant spinal cord compression, superior vena cava obstruction, raised intracranial pressure from brain metastases, malignant pericardial tamponade, airway obstruction); metabolic (hypercalcaemia of malignancy, tumour lysis syndrome, hyponatraemia from inappropriate antidiuresis, paraneoplastic hypoglycaemia); and treatment-related or haematological (neutropenic sepsis, cytokine release syndrome, immune checkpoint inhibitor toxicity, hyperleucocytosis with leucostasis, DIC in acute promyelocytic leukaemia).
Expect more than one at a time: a febrile, drowsy patient with back pain may have neutropenic sepsis, hypercalcaemia and cord compression at once, each requiring treatment in parallel rather than in sequence — and the emergency may be the *presenting* feature of an undiagnosed cancer.
Cord compression — the history that makes the diagnosis: progressive back pain, frequently a band around the trunk, characteristically worse on coughing, straining and lying flat; this recumbency-worsened pattern is the opposite of mechanical back pain and is the single most useful discriminator.
Cord compression — what follows: numbness or paraesthesiae beginning in the feet and ascending, with a sensory level typically two to three dermatomes below the anatomical level of compression; then motor weakness distal to the block; then, last and latest, sphincter disturbance — painless retention with overflow, then bowel incontinence.
Cord compression — examine for upper motor neurone signs below the lesion with focal spinal tenderness at the level, though lower motor neurone findings may predominate early or where nerve roots or the cauda equina are involved; ambulatory status at presentation is the single strongest predictor of ambulatory status afterwards.
SVCO — symptoms and their frequency: dyspnoea (63%), facial swelling and head fullness (50%), cough (24%), arm swelling (18%), chest pain (15%), dysphagia (9%); headache from cerebral venous congestion is aggravated by stooping or lying down.
SVCO — signs: venous distension of the neck (66%), an elevated non-pulsatile jugular venous pulse (66%), venous distension of the chest wall (54%), facial oedema (46%), cyanosis (20%), facial plethora (19%) and arm oedema (14%); visible chest wall collaterals indicate a subacute process.
SVCO — the features that convert urgent into immediate: stridor, hoarseness, inability to lie flat, confusion or a falling conscious level, which indicate laryngeal or cerebral oedema.
Hypercalcaemia is notoriously non-specific and mimics advanced malignancy itself — drowsiness, delirium, nausea and vomiting, constipation, polyuria, polydipsia, dehydration and oliguria — which is why it is missed: the drowsiness is attributed to opioids and the vomiting to progression. Measure the albumin-corrected calcium in all of them.Not available at your setup — Serum electrolytes.
Tumour lysis syndrome may be purely biochemical, or present with nausea, lethargy, oliguria, cramps, tetany, paraesthesiae, seizures, arrhythmias or sudden death, typically within 1–5 days of starting chemotherapy and often afebrile.
Neutropenic sepsis may present with fever, rigors and hypotension, but equally with only tachycardia, confusion, diarrhoea, a single vomit, mild abdominal pain or a relative's observation that the patient is not right; hypothermia in a neutropenic patient is a worse prognostic sign than fever.
Raised intracranial pressure from brain metastases: headache and nausea (40–50%), focal deficit (20–40%), cognitive or personality change (35%), seizures (10–20%) and papilloedema in fewer than 10% — so the absence of papilloedema excludes nothing.
The danger signs demanding immediate action: new or worsening back pain in any patient with known malignancy, especially band-like, nocturnal or worse lying flat; any leg weakness, sensory level, saddle anaesthesia or urinary retention; stridor, hoarseness or inability to lie flat with facial or neck swelling; fever or unexplained deterioration within six weeks of cytotoxic chemotherapy; systolic blood pressure below 90 mmHg or lactate above 2 mmol/L; drowsiness or confusion in a patient with bone metastases or myeloma; and any new arrhythmia or ECG change during or shortly after chemotherapy.
Neutropenic sepsis is defined (UK NICE) as a temperature above 38°C sustained for more than one hour with a neutrophil count below 0.5 × 10⁹/L, *or* a neutropenic patient with any other sign or symptom of significant sepsis — the second clause is deliberate, and fever is not required.
Correct the calcium for albumin: add approximately 0.02 mmol/L for every 1 g/L that albumin falls below 40 g/L; grade it as mild 2.60–3.00 mmol/L, moderate 3.01–3.40 mmol/L, severe above 3.40 mmol/L — but symptoms track the *rate of rise*, so a patient at 3.0 mmol/L reached over 48 hours may be more unwell than one at 3.5 mmol/L over months.Not available at your setup — Serum electrolytes.
Age and drugs change the picture: in the elderly, delirium may be the sole manifestation of hypercalcaemia or sepsis, fever is often absent or blunted, new immobility may in fact be cord compression, and a fall may be the presentation of a pathological fracture; in children, tumour lysis is proportionately commoner, a mediastinal mass causing SVCO frequently also compresses the trachea and both worsen with supine positioning and sedation, and back pain in a child is never benign; on glucocorticoids the inflammatory response is suppressed and perforation may occur silently, while abrupt withdrawal may produce an adrenal crisis indistinguishable from sepsis; and on immune checkpoint inhibitors, immune-related adrenal insufficiency is a readily missed cause of shock.

Management— do this, in order

Treat on clinical suspicion, because the therapeutic window closes before the investigation returns; correct the reversible physiology first — potassium, volume depletion, oedema, infection — before addressing the tumour; never attribute new reversible pathology to disease progression without evidence; and obtain tissue before immunosuppressing an undiagnosed mediastinal or nodal mass wherever the patient's condition permits.Doctor / Nurse
Neutropenic sepsis — broad-spectrum intravenous antibiotic within one hour of presentation, given empirically to any patient who has received cytotoxic chemotherapy within the preceding six weeks and is febrile or unwell, without waiting for the blood count; cultures are taken first, but first means within minutes, and the first dose is given at full strength with renal adjustment afterwards.Doctor / NurseNot available at your setup — Blood culture.
Neutropenic sepsis, adults: piperacillin–tazobactam 4.5 g IV every 6–8 hours; where antipseudomonal cover must be assured and this is unavailable, ceftazidime or cefepime 2 g IV 8-hourly combined with gentamicin 5–7 mg/kg IV once daily. Ceftriaxone alone is inadequate — it has no antipseudomonal activity.Doctor / Nurse
Neutropenic sepsis, escalation: for severe sepsis, shock, prior treatment failure or known resistant colonisation, meropenem 1 g IV 8-hourly (2 g 8-hourly if central nervous system infection is suspected); add a glycopeptide — vancomycin 15–20 mg/kg IV 12-hourly, target trough 15–20 mg/L, or teicoplanin — for suspected line infection, cellulitis, severe mucositis, haemodynamic instability or known MRSA.Doctor / Nurse
Neutropenic sepsis, children: piperacillin–tazobactam 90 mg/kg IV 6–8 hourly (maximum 4.5 g per dose); meropenem 20–40 mg/kg IV 8-hourly (maximum 2 g); gentamicin 7 mg/kg IV once daily; vancomycin 15 mg/kg IV 6-hourly.Doctor / Nurse
Resuscitate concurrently as for any sepsis: oxygen to maintain saturations of 94–98%, and balanced crystalloid or 0.9% sodium chloride 500 mL IV over 15 minutes in adults (10–20 mL/kg in children) repeated to a total of 30 mL/kg if hypotension or hyperlactataemia persist, with reassessment of blood pressure, perfusion, chest auscultation and urine output after each bolus; vasopressors if hypotension persists after adequate fluid.Doctor / Nurse
Cord compression — immobilise with flat bed rest, neutral alignment and log-rolling until spinal stability has been assessed, then dexamethasone 16 mg IV or orally immediately, then 8 mg twice daily orally, with proton pump inhibitor cover (omeprazole 20–40 mg daily) and capillary glucose monitoring; the steroid is given on clinical suspicion and does not wait for imaging.Doctor / Nurse
Cord compression, children: dexamethasone 1–2 mg/kg IV as a loading dose (maximum 16 mg), then 1–1.5 mg/kg/day in divided doses.Doctor / Nurse
Cord compression — analgesia: paracetamol 1 g IV or orally 6-hourly (children 15 mg/kg 6-hourly, maximum 60 mg/kg/day) with morphine titrated intravenously in 2.5–5 mg increments every 5–10 minutes in the opioid-naive adult (children 0.1 mg/kg); patients already on regular opioids need their usual dose plus a proportionate breakthrough dose; prescribe a stimulant plus softener laxative with every opioid.Doctor / Nurse
Cord compression — urgent MRI of the whole spine, then definitive treatment: direct decompressive surgery followed by radiotherapy gives superior functional and survival outcomes compared with radiotherapy alone and should be considered first in all patients; radiotherapy is used for the remainder and for radiosensitive tumours.
SVCO — sit the patient upright, give oxygen, and site venous access in the lower limbs, because infusions into an arm vein will not reach the heart reliably and worsen local oedema; avoid large-volume fluid unless genuinely hypovolaemic, avoid sedation (which may precipitate airway collapse with a large mediastinal mass), and obtain a contrast CT thorax.Doctor / Nurse
SVCO — steroids: give dexamethasone 8–16 mg IV immediately where there is airway compromise, stridor, cerebral oedema or falling conscious level, and otherwise obtain tissue first in the stable patient; where the obstruction is thrombotic, anticoagulate, weighing thrombocytopenia and bleeding risk. Endovascular stenting gives the most rapid and reliable relief in malignant extrinsic compression.Doctor / Nurse
Hypercalcaemia — volume repletion is the highest-yield intervention: 0.9% sodium chloride, beginning with 1 litre IV over 2–4 hours in adults, continuing to 2–4 litres over 24 hours, titrated against blood pressure, jugular venous pressure, chest auscultation and hourly urine output (target ≥0.5–1 mL/kg/hour), more cautiously in the elderly, cardiac failure and renal impairment; children: 0.9% sodium chloride at 2–3 times maintenance, approximately 3 L/m²/day.Doctor / Nurse
Hypercalcaemia — intravenous bisphosphonate concurrently: zoledronic acid 4 mg IV over at least 15 minutes in 100 mL of 0.9% sodium chloride, or pamidronate 60–90 mg IV over 2–4 hours; reduce the dose and prolong the infusion in renal impairment and never give either as a bolus. Children: pamidronate 0.5–1 mg/kg IV, or zoledronic acid 0.0125–0.05 mg/kg IV. Calcium falls over 2–4 days and normalises in most patients within 5 days; duration of action is up to 4 weeks and treatment may be repeated at 3–4 weekly intervals.Doctor / Nurse
Hypercalcaemia — bridge and adjuncts: salmon calcitonin 4 IU/kg subcutaneously or intramuscularly 12-hourly (adults and children) for the first 24–48 hours only in life-threatening hypercalcaemia (onset within hours, but tachyphylaxis develops rapidly); stop thiazides, calcium and vitamin D supplements, lithium and where possible nephrotoxins; denosumab initially 60 mg subcutaneously (many refractory protocols use 120 mg with repeat doses on days 8 and 15) when bisphosphonates fail or renal function precludes them; prednisolone 40–60 mg daily only for calcitriol-mediated hypercalcaemia (lymphoma, myeloma, granulomatous disease).Doctor / Nurse
Tumour lysis — prevention is the mainstay: intravenous hydration plus allopurinol 300 mg orally daily (children 10 mg/kg/day in divided doses, or 100 mg/m² 8-hourly, maximum 800 mg/day) in low- and intermediate-risk patients, and rasburicase 0.2 mg/kg IV over 30 minutes daily for 3–7 days (same dose in adults and children) in high-risk patients such as acute leukaemia with a white cell count above 100 × 10⁹/L — rasburicase is contraindicated in G6PD deficiency, and urate samples must travel on ice.Doctor / Nurse
Established tumour lysis — treat the potassium first, because it is what kills: calcium gluconate 10%, 10 mL IV over 5–10 minutes in adults (children 0.5 mL/kg, maximum 20 mL) for ECG changes, repeated until the trace improves; soluble insulin 10 units in 50 mL of 50% glucose IV over 15–30 minutes (children 0.1 units/kg with glucose 0.5 g/kg) with hourly capillary glucose for at least 6 hours; nebulised salbutamol 10–20 mg in adults (2.5–5 mg in children) — all temporising measures, with renal replacement therapy for definitive potassium removal. Aggressive hydration: 0.9% sodium chloride, typically 2.5–3 litres per 24 hours in adults or 3 L/m²/day, targeting urine output of 100 mL/hour in adults and 2–3 mL/kg/hour in children.Doctor / Nurse
Raised intracranial pressure from brain metastases: dexamethasone 4–16 mg daily in divided doses for symptomatic vasogenic oedema, titrated to the smallest effective dose (children 0.25–0.5 mg/kg/dose), with gastric protection and glucose monitoring; treat seizures with a benzodiazepine acutely then levetiracetam 40–60 mg/kg IV (maximum 4.5 g) or phenytoin 20 mg/kg IV; for impending herniation, mannitol 0.5–1 g/kg IV or hypertonic saline bridges to definitive treatment.Doctor / Nurse

Caution— what harms

Never attribute a new, reversible emergency to progression of disease without evidence — the commonest and most costly error in acute oncology.
Never wait for the neutrophil count, or for imaging, before the first dose of antibiotic in a patient unwell within six weeks of chemotherapy; the neutrophil count, not the white cell count, defines neutropenia, and in acute leukaemia a high white count frequently masks profound neutropenia because blasts predominate.
Never give ceftriaxone alone for neutropenic sepsis — it has no antipseudomonal activity, and antipseudomonal cover is essential.
Never let a normal spinal radiograph reassure you: MRI of the whole spine is the investigation of choice and the only one that reliably confirms or excludes cord compression, multi-level disease occurs in around a third, and the sensory level misleads by 2–3 segments. Myelography risks acute neurological deterioration and has no place as a first-line emergency investigation.
Never delay dexamethasone in suspected cord compression waiting for the scan — function lost before treatment is rarely regained, while function preserved at the time of decompression is usually retained.
Never cannulate the arm in SVCO — site access in the lower limbs, and give CT contrast through a lower limb vein where feasible; avoid large-volume fluid unless genuinely hypovolaemic, and avoid sedation, which may precipitate airway collapse in a patient with a large mediastinal mass.
Do not give steroids to a stable patient with an undiagnosed mediastinal or nodal mass before tissue is obtained — glucocorticoids can partially treat, and thereby obscure, a lymphoma, one of the most curable causes; the exception is airway compromise, stridor, cerebral oedema or falling conscious level, where dexamethasone 8–16 mg IV is given immediately.
Furosemide is not calcium-lowering therapy: loop diuretics are reserved for fluid overload developing during rehydration, and given to a dehydrated patient furosemide worsens hypercalcaemia.
Never give a bisphosphonate as a bolus — nephrotoxicity is dose- and rate-dependent; reduce the dose and prolong the infusion in renal impairment, and monitor for delayed hypocalcaemia after denosumab.
Be sparing with calcium in tumour lysis: the hypocalcaemia is secondary to hyperphosphataemia, and calcium given into a high-phosphate environment precipitates in tissues — treat symptomatic hypocalcaemia (tetany, seizures, arrhythmia) and hyperkalaemic ECG change, but do not treat the number.
Urinary alkalinisation is no longer recommended routinely in tumour lysis: it increases urate solubility but promotes calcium-phosphate precipitation and worsens the hypocalcaemia, and it is unnecessary when rasburicase is available; loop diuretics are used only to maintain output in the euvolaemic patient, not in hypovolaemia.
Avoid digital rectal examination, suppositories and enemas in the neutropenic patient (they translocate gut organisms) and avoid intramuscular injections in the thrombocytopenic patient; remember that neutropenic peritonitis may produce almost no guarding, and avoid NSAIDs where there is thrombocytopenia, renal impairment or concurrent steroid use.
Lumbar puncture is contraindicated where raised intracranial pressure from a mass lesion is suspected, and prophylactic anticonvulsants are not indicated in patients who have not fitted; the absence of papilloedema excludes nothing, since it is present in fewer than 10%.
Expect the harms of the treatment you give: corticosteroids, used across nearly all these conditions, cause hyperglycaemia, proximal myopathy, insomnia, psychosis, gastric ulceration, opportunistic infection and adrenal suppression on withdrawal; bisphosphonates and denosumab both risk osteonecrosis of the jaw with repeated use; stenting carries risks of migration, re-thrombosis and rarely vessel perforation.

Refer / escalate

Refer or escalate the same hour for any suspected cord compression (urgent whole-spine MRI plus surgical and oncology opinion — mobility is preserved in over 80% of patients ambulatory at presentation but established paraplegia seldom recovers), for stridor, hoarseness, inability to lie flat or falling conscious level in SVCO, for systolic blood pressure below 90 mmHg or lactate above 2 mmol/L in neutropenic sepsis, for refractory hyperkalaemia, anuria or volume overload in tumour lysis (renal replacement therapy should be anticipated early rather than instituted late), and for impending herniation from brain metastases.

The card — assess, manage, caution

Oncological emergencies: cord compression, SVCO, hypercalcaemia and tumour lysis — Level 1: CorePrevious Oncological emergencies: cord compression, SVCO, hypercalcaemia and tumour lysis — Level 3: Core practiceNext

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