1. Patients with tracheostomy bleeding can decompensate rapidly and a difficult airway should be expected. To prepare, advanced airway equipment should be gathered, and ENT and respiratory therapy should be notified.

2. Tracheoinnominate fistulas (TIF) have a high mortality rate and up to 50% are heralded by a sentinel bleed; therefore, all tracheostomy bleeds should be worked up for TIF unless the source of bleed is obviously local to the stoma and source is visualized.

3. Clinical red flags suggesting TIF include blood in the oropharynx, pressurized or large-volume bleeding, or trach pulsations in time to the patient’s heartbeat.

4. Imaging with CTA neck and chest is indicated for surgical planning only in hemodynamically stable patients.

5. Attempts to tamponade a tracheostomy bleed should include, first, cuff hyperinflation and, second, blunt finger dissection and compression of the innominate artery. Patients with TIF ultimately need operative correction or else they are certain to rebleed.

1. Acute coronary syndrome (ACS) with thrombocytopenia can arise from malignancy or treatment related complications.

2. Cancer patients with ACS can have atypical symptoms.

3. Therapy will need to dynamically adapt to the patient's platelet count and other risk factors.

4. Do not hold PCI for ACS patients with slight to moderate thrombocytopenia.

5. Prophylactic platelet transfusion is generally reserved for very low counts (often <10,000/µL). However, higher thresholds may be used in patients with fever or other risk factors. Collaboration with Hematology-Oncology is recommended when available.

1. Veno-occlusive disease (VOD) is a complication of Hematopoietic stem cell transplant (HSCT) with significant morbidity and mortality among transplant recipients

2. VOD involves damage to sinusoidal endothelial cells and hepatocytes leading to liver dysfunction.

3. Early recognition and diagnosis using the modified Seattle or Baltimore criteria is crucial.

4. Defibrotide is the only approved treatment for severe VOD and is effective when initiated early.

5. The prognosis of VOD depends on severity of the condition and the timeliness of intervention.

1. Patients with advanced cancer can develop ureteric obstruction and percutaneous nephrostomy tube insertion can relieve this obstruction and prevent renal failure

2. Survival in patients with malignant ureteral obstruction can range widely from a few days to a few years.

3. Nephrostomy tube placement is generally safe and without major complications, however, patients with nephrostomy tubes often present to the ED with a wide array of complications.

4. It is important to have a high index of suspicion for infectious etiologies in nephrostomy tube complications, especially in patients with cancer.

5. Laboratory and imaging studies, along with specialty consultation are often needed to troubleshoot many nephrostomy tube complications.

1. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades.

2. IV fluids may assist in expanding the right ventricle to avoid compression in tamponade.

3. Beck’s triad includes hypotension, jugular venous distention (JVD), and muffled heart sounds. However, shortness of breath and chest pain are the most common presenting symptoms.

4. Echocardiogram is the gold standard for diagnosis of pericardial effusion. Assess for fluid collection, diastolic collapse beginning with the right atrium, and inferior vena cava (IVC) and/or hepatic vein flow.

5. Drainage, typically through pericardiocentesis, is needed when cancer or treatment-related pericardial effusion leads to hemodynamic compromise.

1. Changes in the severity, location, or characterization of pain in patients with solid tumors requires careful and thorough evaluation.

2. Opioids are the cornerstone of management for moderate to severe acute pain. Selection should consider individual patient risk factors, with specific caution for those with impaired kidney function. Morphine, hydromorphone, oxycodone, and fentanyl have distinct profiles and safety considerations.

3. IV formulations are preferred for severe pain due to rapid onset though clinicians should note the variable duration of action among different opioids. All patients require frequent reassessment and possibly dose adjustments to ensure adequate analgesia and to prevent complications such as respiratory depression and oversedation.

4. Practitioners must be aware of implicit biases that may affect opioid administration and prescribing. Studies show disparities in opioid prescriptions for Medicaid, uninsured, Black, or Latino patients in emergency departments.

5. Decisions on hospital admission versus discharge depend on individual cases. Effective communication with the patient's outpatient care team is key for continuity of care and preventing readmissions.

1. Transfusion-associated cardiovascular overload (TACO) is most common in critically ill patients receiving a large amount or rapid infusion of blood products who have a history of cardiac or renal dysfunction.

2. TACO will present with signs of fluid overload, including tachypnea, hypoxia, jugular venous distention (JVD), and/or rales on exam.

3. Bedside ultrasound and chest x-ray can be useful in the diagnosis of TACO.

4. Treatment of TACO consists of oxygenation and ventilation as needed, diuretics, and pausing transfusion until the patient’s fluid status is optimized.

5. To reduce risk of TACO in high risk patients, blood given should be limited to what is necessary, rates should be reduced, and diuresis during/after should be considered.

1. Engraftment syndrome (ES) is a common complication of HSCT.

2. ES is characterized by a constellation of symptoms, including fever, rash, and pulmonary infiltrates, which occur around the time of neutrophil recovery.

3. Prompt recognition and treatment with corticosteroids are essential to mitigate the cytokine inflammatory response.

4. The differential diagnosis of ES should consider infections and acute graft-versus-host disease (GVHD), requiring careful clinical assessment.

5. Distinguishing features of ES from GVHD include early time of presentation, fluid retention and pulmonary edema.

1. It is important to have a high index of suspicion for malignant spinal cord compression (MSCC) in patients who have a history of cancer and present with back pain. In the absence of neurologic symptoms or deficit, close follow up and outpatient imaging is indicated.

2. Pain is the most common symptom of MSCC and is present in 95% of cases.

3. Red flags of MSCC include extremity weakness, difficulty walking, loss of sensation, bowel or bladder dysfunction, thoracic or cervical pain, pain increased with straining, and pain that is worse at night.

4. MRI of the entire spine is indicated for accurate diagnosis and treatment of MSCC.

5. Treatment includes Dexamethasone IV bolus followed by maintenance dosing and radiation therapy with or without surgical decompression.

1. It is important for the provider to maintain a high index of suspicion for those at risk for tumor lysis syndrome (TLS), which includes a large tumor burden, high proliferation rate, pre-existing kidney dysfunction and certain types of cancer such as Burkett lymphoma and acute leukemias.

2. The best form of treatment includes preventive measures with aggressive hydration and urate-lowering agents.

3. In established TLS, in addition to hydration, the use of rasburicase and correction of any electrolyte derangements are key to present complications and preserve renal function.

4. A coordinated approach between the oncologist, nephrologist, and critical care specialists is required to provide effective management.

5. Educating patients and caregivers about the signs and symptoms of TLS is important for early detection and prompt treatment, especially in outpatient settings.

1. Stridor denotes severe airway obstruction with impending respiratory failure that requires immediate evaluation and treatment, regardless of oxygenation level.

2. Obstruction may arise at the level of the pharynx, hypopharynx, epiglottis, larynx, subglottic region or trachea.

3. Regardless of the precise cause, begin therapy with IV corticosteroids and nebulized racemic epinephrine while completing the diagnostic work up. If head and neck cancer is suspected, administering steroids to reduce edema may allow time to organize airway management in a more controlled setting.

4. Keeping both the patient and staff calm is also important in maintaining the airway.

5. If intubation or emergent surgical airway is necessary defer to the most experienced personnel.

1. End of life (EOL) discussions are difficult to initiate in any setting, but especially in the Emergency Department. However, new or worsening illness can be a key moment to start conversations.

2. During discussions, be as honest and direct as possible while employing tools such as compassion, listening and silence.

3. When your patient is a child or adolescent, consider their developmental stage and understanding of death, realizing that often children with chronic illnesses have some delay in achieving developmental milestones.

4. Management of EOL symptoms differs from conventional management, so goals regarding a patient’s care should be thoroughly discussed and established prior to discontinuation and/or escalation of the patient’s medications.

5. Consult and utilize appropriate resources, including the palliative and hospice care team, for assistance with difficult conversations and applying appropriate guidelines for symptom management.

1. The risk of acute or delayed chemotherapy-induced nausea and vomiting (CINV) is dependent on the patient’s chemotherapy regimen and its emetogenic potential.

2. It is important to know the patient’s chemotherapeutic regimen, including the patient’s prophylactic regimen for acute CINV, as the agent utilized for breakthrough nausea and vomiting should have a different mechanism of action.

3. If a patient is considered refractory to an antiemetic regimen, an antiemetic with a different mechanism of action should be added to the current antiemetic regimen.

4. There is no difference in efficacy between PO and IV formulations of antiemetic therapy in the treatment of CINV. As a result, PO is preferred if tolerated due to the decreased number of adverse effects, including QT prolongation.

5. Many antiemetics carry some risk of QTc prolongation, which is a predictor of the risk of Torsades de Pointes. Other risk factors include age = 65 years old, female sex, electrolyte disturbances, cardiovascular disease, and concomitant medications. Since many CINV patients have multiple risk factors for QTc prolongation and cardiac dysrhythmias, caution should be utilized, and providers should consider obtaining an ECG in high-risk patients to help determine optimal therapy.

1. Superior vena cava (SVC) syndrome should be suspected in patients with shortness of breath and swelling of the head and neck. As symptoms progress, arm swelling may develop and in severe cases, distension of neck and chest veins.

2. Once suspected, immediately raise the head of the patient’s bed to decrease hydrostatic pressure. Monitor the patient’s airway for laryngeal edema – patients may require intubation if they have respiratory compromise.

3. Ultrasound can be used to assess for evidence of thrombus. However, CT chest with contrast or MRI is the preferred modality of imaging.

4. If thrombus is suspected, the patient should be started on anticoagulation, typically heparin.

5. In cases where SVC syndrome is caused by tumor infiltration/compression, endovascular stenting has become the most popular method of alleviating the obstruction. Patients may also require tumor debulking with radiation therapy and/or chemotherapy.

1. Causes of constipation in patients with cancer are multifaceted, but opioid induced constipation is the most common cause.

2. Constipation in cancer patients can lead to serious complications, including fecal impaction, bowel obstruction, and decreased absorption of oral medications, which can impact the effectiveness of cancer treatment.

3. Bulking agents can be used in mild cases of constipation but should be avoided in patients with severe disease, taking anticholinergic drugs or opioids, and those with poor oral intake.

4. Stool softeners can be helpful in patients with anal fissures or hemorrhoids to allow for less painful bowel movements. Polyethylene glycol is recommended as first line due to its low cost, rapid onset, and rare adverse side effects.

5. Peripherally acting mu-opioid receptor antagonists (PAMORA) bind only to opioid receptors in the gut, counteracting constipation side effects without decreasing analgesic effects.

1. Hemorrhagic cystitis (HC) is a condition characterized by inflammation and bleeding of the bladder lining.

2. It is important to have a high index of suspicion for HC in patients who complain of urinary changes after starting chemotherapy or who have previously undergone pelvic radiation therapy.

3. Symptoms commonly include blood in the urine, increased urinary frequency and urgency, pain with urination and lower abdominal pain.

4. HC can present as mild non-infectious hematuria, but in more severe cases as gross hematuria with hemorrhage and clots causing acute urinary retention.

5. The best treatment is prevention and supportive care with saline diuresis and mesna.

1. Delirium is an acute-onset disruption in attention and cognition and is very common in patients with advanced malignancy. It can present as hypoactive, hyperactive, or mixed delirium.

2. Episodes of delirium in malignancy are associated with increased length of hospitalization, healthcare cost, and mortality.

3. Rapid identification of delirium and treatment of potential reversible causes is the mainstay of treatment, and there should be emphasis on non-pharmacological interventions for management.

4. There is no specific recommended workup of delirium, therefore lab and imaging studies should be ordered based on the patient’s clinical presentation and risk factors.

5. Physical restraints and psychotropic medications such as antipsychotics and benzodiazepines should be avoided when able as they are associated with worse outcomes, particularly in older patients.

1. An initial assessment and stabilization of airway patency, breathing, and circulation should be performed. Once clinical stability is achieved, urgent neuroimaging should be obtained for rapid and accurate diagnosis of intracranial hemorrhage (ICH).

2. Complete a standardized neurologic assessment to determine baseline severity. The National Institutes of Health Stroke Scale (NIHSS), if the patient is awake or drowsy, or the Glasgow Coma Scale (GCS), if the patient is obtunded or comatose, should be performed and clearly documented.

3. Blood pressure management, treatment of thrombocytopenia (platelet goal of 100,000/mm3), reversal of coagulopathy, and evaluation of the need for early surgical intervention are the mainstays of ICH treatment.

4. Frequent neurological examinations, at least every hour, to detect early clinical deterioration and signs of increased intracranial pressure (ICP) should be part of the initial management algorithm.

5. A complaint of pain in cancer patients with thrombocytopenia may indicate life threatening bleeding. A complaint of headache in a cancer patient with thrombocytopenia, even without abnormal neurologic findings, is ICH until proven otherwise.

1. Hematopoietic cell transplants are becoming increasingly common and ED providers should remain vigilant for post-transplant complications.

2. These patients are at high risk for post-transplant emergencies due to their pre-existing comorbid conditions, toxicities from high-dose chemotherapy, prolonged immunosuppression, and opportunistic infections resulting from their immunocompromised state.

3.Hematopoietic cell transplant patients face significant risks for complications such as Graft-versus-host disease (GVHD), which further complicates their recovery and requires vigilant monitoring.

4. GVHD is a common and treatable post-transplant complication but must be recognized early to avoid complications.

5. Treatment of post-hematopoietic cell transplant complications should be performed in close collaboration with hematology/oncology, and often these complications result in hospitalization.

1. Initial assessment and stabilization of airway patency, breathing, and circulation should be performed.

2. It is important to have a high index of suspicion for adrenal insufficiency (AI) in cancer patients with refractory hypotension. AI can occur as a result of adrenal suppression from chronic glucocorticoid treatment, or less commonly, from metastatic disease to both adrenal glands.

3. Consider obtaining other laboratory work to evaluate for concomitant electrolyte abnormalities.

4. Review patient’s medication lists whenever accessible to evaluate for chronic steroid use.

5. Treatment involves resuscitation of blood pressure acutely with IV hydrocortisone and intravenous fluids followed by admission to the hospital.