Oncologic Emergency Medicine: Principles and Practice

Description

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