Your ALS EMS unit is dispatched to a residence for difficulty breathing. You are met in the driveway by a 59-year-old woman in obvious respiratory distress. She is gasping for breath and quite anxious. You bring her quickly into the ambulance, apply oxygen and obtain a quick history.
The patient had gone to the doctor for a chronic cough and fatigue. A chest x-ray revealed a mass in her upper right chest. She has an appointment scheduled with a specialist later in the week. Her history includes COPD and hypertension, and she has JVD. She is tachycardic, tachypneic and anxious. The remainder of the physical exam is unremarkable.
You administer a nebulized albuterol treatment, which provides quick and significant relief. Immediately after the neb treatment, though, the significant shortness of breath returns. You keep her on continuous nebulizers and expedite to the emergency department, where you turn the patient over to staff.
You return later and talk to the physician about the patient. He reports that her right main stem bronchus has been reduced to the size of a pinhole by the tumor. She is transferred to a large teaching hospital for urgent radiation to reduce the tumor’s size. She dies two days later.
As of 2012, there were 13.7 million cancer survivors in the United States, with a projected 18 million by 2020. This is due to the aging population and more effective treatment of this disease.
The American Cancer Society states that survivors include those who:
Live cancer-free for the remainder of adult life;
Live cancer-free for many years but experience one or more serious, late complications of treatment;
Live cancer-free for many years but die after a later recurrence;
Live cancer-free after the first cancer is treated, then develop another cancer;
Live with intermittent periods of active disease that require treatments;
Live with cancer continuously with a disease-free period.
Cancer-related emergencies may involve the disease itself and/or treatment effects. Most cancer patients will have existing medical problems (coronary artery disease, COPD, diabetes, hypertension) prior to their cancer diagnosis, adding other factors to their clinical picture.
These emergencies can occur any time during the course of a cancer patient’s life. They are not limited to the time of active disease or the treatment phase but can occur with recurrence of the malignancy after years of being disease-free.
This article will discuss common causes of EMS responses to patients with cancer, with a detailed discussion of the pathophysiology and patient presentation of various related problems and crises.
Superior Vena Cava Syndrome
This is the obstruction of the superior vena cava, a large, thin-walled vessel that can be easily compressed or obstructed due to the extrinsic pressure of a malignant tumor, fibrosis or a thrombus within it from treatment.
The most common obstructive tumors are of the lung, thymoma, enlarged mediastinal lymph nodes (lymphoma) and/or metastatic disease within the mediastinum.
Fibrosis can develop from radiation treatment to the thoracic area, while the establishment of a venous access catheter for systemic treatment can cause irritation during chemotherapy or create a thrombus.
During an obstruction, venous blockage can produce pleural effusions and facial, arm and tracheal edema resulting in respiratory distress. For most patients the signs and symptoms can be subtle, and progress is slow. Early signs and symptoms include dyspnea, facial and neck swelling, facial plethora (ruddy complexion), upper extremity edema, neck vein distention, tachypnea and hoarseness (through vocal cord paralysis).
Late signs and symptoms include:
Cyanosis of the face and upper torso;
Decreased or absent peripheral pulses;
Decreased blood pressure;
Congestive heart failure;
Mental status changes (e.g., confusion, changes in level of consciousness, sleep, coma);
The cranium encases the brain tissue and cerebrospinal fluid in a fine balance. Common causes of intracranial pressure in a cancer patient are primary brain tumor and a metastatic brain tumor blocking the flow of the cerebrospinal fluid. As the tumor expands, it displaces blood and cerebrospinal fluid, then compresses and shifts the neural structures. These tumors rarely invade and destroy the brain tissue and are hematogenously spread through the arterial system to the brain.
As many as 45% of cancer patients will have metastatic disease to the brain, with 50% having a single lesion; for 15% this will be the presenting factor (symptom) of the patient having cancer. Most primary sites (places of origination) can metastasize to the brain, with the lung, breast and melanoma being the most common. Intracranial pressure may also result from whole-brain radiation or chemotherapy.
The most common symptom is a headache present at the time of awakening with dissipation a brief time later. This headache will worsen with bending over or Valsalva maneuvers. Regular analgesics do not relieve the pain, and the headache will not be an indicator of the location of the brain lesion. Other symptoms include vomiting, nausea and mental status changes.
The mental changes begin with irritability and progress to apathy. The patient will sleep longer and appear preoccupied when awake. They will fail to initiate any activity, including conversation. They will answer appropriately when spoken to in the interview. Other nonspecific symptoms can include blurred vision and diplopia. Vital signs can remain stable in the early stages of developing tumors. As the tumor expands in size, we can find Cushing’s triad. A very small lesion in the critical area of the brain stem can quickly cause severe symptoms and lead to seizures.
Intracranial pressure can lead to cerebral herniation. Intracranial pressure and/or an expanding tumor shifts brain tissue in the direction of least resistance through the foramen magnum. General signs and symptoms include headache, vomiting, hiccups and hypertension, gradually leading to decreasing levels of consciousness, pupillary changes and Cheyne-Stokes respirations.
Spinal Cord Compression
Primary cancers of the spinal column are rare. The majority of spinal cord problems come from metastatic disease from other tumors. These problems can occur abruptly or progress gradually. Unlike spinal degenerative disease, their pain is not relieved by recumbency, which will most often make it worse. Seventy percent of cases of metastatic disease of the spine are in the thoracic spinal area. This area contains the largest volume of bone and active bone marrow, which will support the growth of metastatic disease. Invasion of the spine by the cancer will weaken and compress the spinal cord.
Compression of the cord leads to edema of the cord and loss of myelin (protective of nerve cells). Back pain is the most common symptom. It can localize to a specific area or radiate either unilaterally or bilaterally, and can be exacerbated by flexion of the neck. The patient may complain of numbness and tingling in the lower extremities. Often they will say the pain increases overnight and sometimes gets worse with movement, especially bending forward. Common analgesics do not relieve this pain.
Cardiac Tamponade/Pericardial Effusion
Cardiac tamponade is fluid accumulation in the pericardial sac from malignant effusions, radiation and/or systemic therapy injuries causing decreased cardiac output, circulatory collapse and then death. Cancers of the lung or esophagus can grow directly into the pericardium, and other distant primary cancers metastasize to the pericardium hematogenously. The most common are the lung, breast and gastrointestinal primary sites, lymphoma, leukemia, melanoma and sarcoma having metastases associated with pericardial effusions.
Large doses of chest radiation therapy to the heart, internal mammary lymph nodes and mediastinum can damage any component of the heart. Coexisting heart disease, systemic lupus erythematosus, rheumatoid arthritis, scleroderma, tuberculosis and bacterial endocarditis are contributing factors. A patient taking anticoagulants can precipitate this problem.
Because pericardial effusion can develop slowly, the patient may initially be asymptomatic. Early signs and symptoms include complaints of fatigue; malaise; light-headedness; dyspnea on exertion; dull, diffuse, nonpositional chest pain; and vague abdominal distress with palpations. The chest pain described by the cancer patient is frequently heavy, and the symptoms may improve as the condition worsens. The patient may complain of shoulder pain, nausea and/or right upper quadrant pain. The EMS responder may find tachycardia, mild peripheral edema, mild abdominal distention, decreased peripheral pulses, mild jugular venous distention (JVD) or muffled heart sounds. Often the electrocardiographic abnormalities are nonspecific.
As the effusion worsens, the patient can complain of dyspnea at rest, orthopnea and retrosternal chest pain, which may be relieved by bending forward. The patient can become tachycardic, tachypneic, hypotensive and diaphoretic.
There is increased JVD and pedal edema. The muffled heart sounds and friction rub can disappear as the effusion increases. Decreased carotid pulse and massive edema may not be present if this is a rapid development. Prolonged hypotension can cause oliguria and anuria because of decreased kidney perfusion. Other late symptoms may include decreased levels of consciousness and seizures because of increased hypoxia.
Malignant Pleural Effusion
Pleural effusion, the abnormal collection of fluid within the pleural space, is common with late-stage disease, with 50% of patients having this problem. Symptoms will include dyspnea, cough, pleuritic-type chest pain, orthopnea, paroxysmal nocturnal dyspnea, anxiety, fear of suffocation and the desire to lie on the affected side.
Signs will include tachypnea, labored breathing, decreased/absent breath sounds, bronchial breath sounds, pleuritic rub over the affected area, restricted chest expansion and dullness to percussion. Large effusions will exhibit cyanosis, chest tenderness, bulging intercostal spaces, lymphadenopathy and the use of accessory muscles. Radiation to the mediastinum and chest will increase the risk of pleural effusion development. This will become life-threatening when restriction of chest expansion decreases the respiratory function.
Airway obstructions in cancer patients are commonly caused by direct extension from an adjacent tumor in the mediastinum or head and neck. Blockage at the level of the main stem bronchi or above can result from intraluminal tumor growth or extrinsic compression of the airway. Airway edema and/or hemorrhage can be a contributing factor.
Dyspnea is frequently the only symptom exhibited. Other symptoms include hemoptysis, wheezing, hoarseness, difficulty clearing secretions, and a cough. Stridor is common and is most marked on inspiration. This is often mistaken for other underlying coexisting medical problems: COPD, asthma, infections, bronchitis and heart disease. This can progress to complete airway obstruction.
Infusion Reactions/Hypersensitivity Reactions
All chemotherapy agents have the potential for infusion reactions that can affect any organ system within the body. Most of these reactions are mild and occur either within a few hours of the infusion or occasionally 1–2 days later. Signs and symptoms include flushing and itching of the skin; alterations in heart rate and blood pressure; dyspnea/chest discomfort; back or abdominal pain; fever and/or shaking chills; nausea, vomiting and/or diarrhea; various skin rashes; throat tightening; hypoxia; seizures; and dizziness and syncope. With the change of treatment settings from inpatient to outpatient, the EMS provider is more likely to encounter this.
Fatigue is a common and troubling side effect of both cancer and cancer treatment, affecting more than 75% of patients. Fatigue can be a presenting factor in the beginning of the disease. Often in lung cancer the first symptom detected is the overwhelming feeling of fatigue caused by an obstructive lesion or with the advanced spread of cancer causing debilitation. Note that fatigue is self-perceived like pain; cancer patients may describe themselves as tired, drained, lazy, slow, weak, sluggish or run down. In a cancer patient, the sensation of fatigue is not connected to muscular performance or focal neurological damage.
A cancer patient’s fatigue differs from a healthy person’s fatigue:
• Cancer-related fatigue is not completely relieved with sleep and rest; in a cancer patient this restorative ability is impaired.
• Cancer-related fatigue is not directly linked to activity. A cancer patient will often experience a sudden overwhelming feeling of fatigue with no activity involved.
• Cancer patients’ fatigue is a background sensation that is there from the time they awaken and can vary through the day. A healthy person uses fatigue as a warning of overexertion.
A cancer patient will make mental adjustments for their fatigue, and what they initially describe as being a “little tired” at one point will become “not tired.”
A common pattern in cancer-related fatigue begins with surgery. Most cancer patients will begin their treatment with some type of surgical procedure. Often they begin the next phase of treatment before they fully recover from postoperative fatigue.
Radiation treatment fatigue will begin to increase during the second week and peak midway through the treatment. It will take several months before it resolves.
Chemotherapy fatigue will begin within the first few days of treatment, peak midway through and gradually begin to decrease until the next treatment. Some chemotherapy agents will prohibit the production of red blood cells in the bone marrow, resulting in anemia. Biologic response modifiers will cause intense fatigue with flulike symptoms, including aching in the muscles and joints. Chills and fatigue will begin soon after administration of chemotherapy agents.
Long periods of fatigue in the cancer patient can create irritability, lapses in attention and sometimes mood swings. They can interfere with concentration and result in negative moods. Remember that cancer-related fatigue is neither the result nor a symptom of depression.
Assessment of fatigue can include the level of fatigue days after treatment and how it interferes with everyday life by using the numeric scale used in the assessment of pain. Cancer-related fatigue has the most negative impact on the quality of the cancer patient’s life.
Bleeding and Thrombosis
Bleeding and thrombosis can develop from the reduction in platelets and the alteration of the clotting process within a cancer patient. Both of these can be caused by either the progression of the disease and/or treatment processes used.
Bleeding can develop with any type of cancer. However, it is more common in the hematological cancers (leukemia/lymphoma) because of their origination within the bone marrow. Here the tumor cells will interfere with normal cell development. Tumor growth invading the mucosal linings of any organ or blood vessels can cause active bleeding. Tumors that invade a major vessel can produce a massive hemorrhage. Signs of bleeding in cancer patients often overlooked include petechia, ecchymosis and bruising.
Obvious signs of active bleeding in a cancer patient can be epistaxis, hemoptysis, hematemesis, melena, hematuria, vaginal bleeding and bleeding around a venous access device. This bleeding can begin with gradual oozing and become an acute hemorrhagic event.
Bleeding can be caused by cancer treatment. Chemotherapy will increase the risk by the damage it inflicts on normal tissues not involved with the cancer. Radiation and steroid therapy can create thinning of vessel walls, making those vessels susceptible to injury. The combination of chemotherapy and radiation therapy will cause myelosuppression.
There has been a dramatic increase in septic shock in the past 20 years. Sepsis will occur as the result of an overwhelming infection to which the body fails to provide an adequate immune response. Cancer patients on active treatment will have a lower immunity against secondary infection. It can be found in patients with indwelling IV lines (like the Port-A-Cath that enables prolonged chemotherapy treatment), disruption of the patient’s immune system from treatments, and cross-contamination from healthcare providers. Some early signs of sepsis include flushed, warm skin; increased respirations; anxiety; confusion; low oxygen saturations; hypotension; and inflammation around the area of the indwelling IV line. Patients with extensive septic shock will exhibit disorientation; hypotension; a rapid, thready pulse; cool, clammy skin; hypoxemia; and subnormal temperature. As with other patients, the first responder must practice strict infection-control measures.
Patient History and Care
Cancer patients with acute emergencies are handled the same as any other patient without cancer. Although cancer is the cause of the conditions listed in this article, treatment for conditions such as respiratory distress, effusion, tamponade and other emergencies remains the same.
Important history questions specific to the cancer patient include:
• How long has the patient had cancer?
• What type or types of cancer have been identified?
• If the patient has active disease, are they being currently treated?
• What type of treatment and when was it last given?
• Who is the oncologist treating the patient?
These questions will save the emergency room staff time in getting the necessary measures in place. In most cases cancer patients have some basic knowledge of their disease. Many are proud of their survival and willing to share their knowledge with first responders.
Alberta Health Services. Oncologic Emergencies: A Guide for Family Physicians, www.albertahealthservices.ca/hp/if-hp-cancer-guide-oncologic-emergencies.pdf.
Cervantes A, Chirivella I. Oncological emergencies. Ann Oncol, 2004; 15 Suppl 4: iv299–306.
Govindan R. The Washington Manual of Oncology, 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 2007.
Kaplan M, ed. Understanding and Managing Oncologic Emergencies: A Resource for Nurses, 2nd ed. Pittsburgh, PA: Oncology Nursing Society, 2012.
Lenhard RE, Osteen RT, Gansler T. Clinical Oncology. Atlanta, GA: American Cancer Society, 2001.
Lewis MA, Hendrickson AW, Moynihan TJ. Oncologic emergencies: Pathophysiology, presentation, diagnosis, and treatment. CA Cancer J Clin, 2011 Aug 19; 61(5): 287–314.
National Cancer Institute. Causes of Fatigue in Cancer Patients, www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/Patient/page2.
Nevidjon BM, Sowers KW, eds. A Nurse’s Guide to Cancer Care. Philadelphia, PA: Lippincott, Williams & Wilkins, 2000.
Bonnie Belfance, CTR, EMT, is an EMT with the Beukendaal Fire Department, Scotia, NY, and a nationally certified cancer registrar for Albany Memorial Hospital, St. Peter’s Health Partners, Albany, NY.
Daniel Limmer, AS, EMT-P, is a paramedic, author and conference speaker. He will be presenting at EMS World Expo in Nashville in November, 2014.