Acute Oncologic Complications: Clinical–Therapeutic Management in Critical Care and Emergency Departments

Abstract

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient’s admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981–April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Cardiogenic Pulmonary Edema in Emergency Medicine

“…Although CPE usually occurs in the absence of change in the permeability of the alveolar-capillary barrier [20], the capillary wall's permeability may also be affected during CPE. A sudden increase in pulmonary capillary hydrostatic pressure (i.e., flash pulmonary edema) [7] can cause mechanical damage on the alveoli-capillary barrier through a process known as "stress failure" [8]. Renal artery stenosis, particularly when bilateral, has been identified as a common cause of flash pulmonary edema [7].…”

“…A sudden increase in pulmonary capillary hydrostatic pressure (i.e., flash pulmonary edema) [7] can cause mechanical damage on the alveoli-capillary barrier through a process known as "stress failure" [8]. Renal artery stenosis, particularly when bilateral, has been identified as a common cause of flash pulmonary edema [7]. In case of stress failure, both hydrostatic pressures and raised permeability increase fluid transfer into alveolar spaces.…”

“…In case of stress failure, both hydrostatic pressures and raised permeability increase fluid transfer into alveolar spaces. Finally, inflammation associated with stress failure may cause surfactant alterations [7,8,21]. As a result, there is an increase in permeability due to the loss of tight junction-mediated cell-to-cell contact, changes in extracellular matrix (ECM), and surfactant dysfunction.…”

“…The most frequent cause of NCPE (also called Adult Respiratory Distress Syndrome (ARDS)) is due to direct (e.g., pneumonia) or indirect lung injury (e.g., sepsis). Increased alveolar-capillary permeability may also occur in CPE, especially in some patients with abrupt, severe increases in pulmonary capillary pressure [7]. This associated barrier dysfunction was defined as "stress failure" [8] and may lead to more edema formation [9].…”

Current Trends for Delirium Screening within the Emergency Department

“…This tool was developed in 1997. It was used to assess the severity of delirium in patients with advanced cancer [ 24 ]. It is composed of 10 items rated 0 to 3 points for a maximum total score of 30 points, with higher scores representing more severe delirium.…”