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

Manage now— do this, in order

• Treat on clinical suspicion — the therapeutic window closes before the investigation returns. Correct reversible physiology first (potassium, volume, oedema, infection); never attribute a new, reversible emergency to progression of disease without evidence — the commonest and most costly error in acute oncology; obtain tissue before immunosuppressing an undiagnosed mediastinal or nodal mass wherever the condition permits.
• Neutropenic sepsis — broad-spectrum IV antibiotic within one hour, without waiting for the blood count: piperacillin–tazobactam 4.5 g IV every 6–8 hours (children 90 mg/kg, max 4.5 g/dose); if unavailable, ceftazidime or cefepime 2 g IV 8-hourly plus gentamicin 5–7 mg/kg IV once daily (children 7 mg/kg). Ceftriaxone alone is inadequate — no antipseudomonal activity. Escalate to meropenem 1 g IV 8-hourly for shock (children 20–40 mg/kg, max 2 g); fluid 500 mL over 15 minutes (children 10–20 mL/kg) repeated to 30 mL/kg, then vasopressors.Doctor / NurseNot available at your setup — Blood culture.
• Cord compression — the steroid does not wait for imaging: immobilise with flat bed rest, neutral alignment and log-rolling; dexamethasone 16 mg IV or orally immediately, then 8 mg twice daily with PPI cover (omeprazole 20–40 mg daily) and glucose monitoring (children: 1–2 mg/kg IV load, max 16 mg, then 1–1.5 mg/kg/day divided). Then urgent MRI of the WHOLE spine — decompressive surgery followed by radiotherapy gives superior outcomes to radiotherapy alone.Doctor / Nurse
• SVCO — sit upright, oxygen, and site venous access in the LOWER limbs (arm infusions will not reach the heart reliably and worsen oedema); avoid large-volume fluid and avoid sedation, which may precipitate airway collapse with a mediastinal mass. Dexamethasone 8–16 mg IV immediately only for airway compromise, stridor, cerebral oedema or falling conscious level — otherwise obtain tissue first: steroids can partially treat and thereby obscure a lymphoma. Endovascular stenting gives the most rapid reliable relief.Doctor / Nurse
• Hypercalcaemia — volume first, bisphosphonate alongside: 0.9% sodium chloride 1 litre IV over 2–4 hours, continuing to 2–4 litres over 24 hours (children 2–3 times maintenance, ~3 L/m²/day), target urine ≥0.5–1 mL/kg/h; zoledronic acid 4 mg IV over at least 15 minutes in 100 mL saline, or pamidronate 60–90 mg IV over 2–4 hours — never as a bolus (children: pamidronate 0.5–1 mg/kg, zoledronic acid 0.0125–0.05 mg/kg). Calcitonin 4 IU/kg SC/IM 12-hourly for the first 24–48 hours only in life-threatening cases; stop thiazides, calcium, vitamin D and lithium. Furosemide is not calcium-lowering therapy — given to a dehydrated patient it worsens hypercalcaemia.Doctor / Nurse
• Tumour lysis — prevention is the mainstay: IV hydration plus allopurinol 300 mg orally daily (children 10 mg/kg/day divided, max 800 mg/day) in low/intermediate risk; rasburicase 0.2 mg/kg IV over 30 minutes daily for 3–7 days in high-risk patients (e.g. acute leukaemia with WCC above 100 × 10⁹/L) — contraindicated in G6PD deficiency; urate samples travel on ice.Doctor / Nurse
• Established tumour lysis — treat the potassium first, because it kills: calcium gluconate 10% 10 mL IV over 5–10 minutes for ECG changes (children 0.5 mL/kg, max 20 mL), 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 glucose for at least 6 hours; nebulised salbutamol 10–20 mg (children 2.5–5 mg) — all temporising; renal replacement therapy for definitive removal, anticipated early. Hydration 2.5–3 L/24 h (3 L/m²/day), target urine 100 mL/h adult, 2–3 mL/kg/h child. Be sparing with calcium — treat tetany, seizures, arrhythmia and hyperkalaemic ECG change, not the number; urinary alkalinisation is no longer recommended.Doctor / Nurse
• Raised intracranial pressure from brain metastases: dexamethasone 4–16 mg daily in divided doses for symptomatic vasogenic oedema (children 0.25–0.5 mg/kg/dose) with gastric protection and glucose monitoring; seizures — a benzodiazepine acutely then levetiracetam 40–60 mg/kg IV (max 4.5 g) or phenytoin 20 mg/kg IV (no prophylactic anticonvulsants in patients who have not fitted); impending herniation — mannitol 0.5–1 g/kg IV or hypertonic saline. Lumbar puncture is contraindicated where a mass lesion is suspected.Doctor / Nurse