neurological oncological emergencies -...

TVCN Principal Treatment

Centre

Children’s Hospital Oxford

Filename: Neuro – oncological

Emergencies

of 13 Date agreed: 03/12/2015

Issue date: 03/12/2015

Version: 1.0

Agreed by Chair Network Chemotherapy Group:

Review date: 03/12/2017

Children’s Cancer Measure:

Author: Shaun Wilson

NEUROLOGICAL ONCOLOGICAL EMERGENCIES: Emergencies covered in this document include:

1) Spinal cord compression 2) Raised intracranial pressure 3) Altered level of consciousness 4) Seizures

SPINAL CORD COMPRESSION: OVERVIEW: Spinal cord compression (SCC) can cause significant morbidity SCC is rare: 3 – 5% paediatric cancer Back pain is reported in 80% of patients with SCC Any child with cancer and back pain should have SCC considered ALGORITHM:

Sign/symptoms suggestive of spinal cord compression?

CONTACT PAED HAEM/ONC CONSULTANT

CONTACT PAED NEUROSURGICAL TEAM

Consider stat dose of IV DEXAMETHASONE 10mg/m

2

TRANSFER TO PTC (if at POSCU)

CONTACT NEURORADIOLOGY

ARRANGE SPINE MRI +/- HEAD MRI

Subsequent management:

FBC and film

Biochemistry: UEC, LDH, Uric acid, Bone profile, AFP, BHCG

CT scan

Biopsy/resection


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PRESENTATION: Symptoms

Back pain – aggravated by movement

Weakness – lower limbs

Sphincter dysfunction – Retention of urine or constipation

Sensory deficits

Gait disturbance Signs

Localised tenderness of spine

Motor weakness

Paraesthesia, paraplegia

Distended palpable bladder

DIFFERENTIAL DIAGNOSES: Extradural lesions:

Solid Tumour: Neuroblastoma, Ewing sarcoma/pPNET, Germ Cell Tumour, Rhabdomyosarcoma

Haematological: Non – Hodgkin Lymphoma

Intradural lesions:

Intrinsic cord tumour: astrocytoma, metastatic medulloblastoma, ependymoma

Intradural extramedullary: meningioma, leptomeningeal metastases

Cauda equina lesions: ependymoma, spinal sheath tumours, metastases

Non – malignant: arachnoiditis, transverse myelitis, acute demyelination, spinal cord infarct/haemorrhage, Guillaim Barre Syndrome

MANAGEMENT:

URGENTLY CONTACT OXFORD HAEMATOLOGY/ONCOLOGY CONSULTANT

URGENTLY CONTACT OXFORD NEUROSURGICAL TEAM

AFTER INITIAL DISCUSSION WITH HAEM/ONC CONSULTANT CONSIDER STAT IV DOSE OF DEXAMETHASONE 10mg/m2 (max. daily dose 16mg)

DISCUSSION WITH NEURORADIOLOGY CONSULTANT (WEST WING) TO ARRANGE URGENT MRI OF WHOLE SPINE WITH CONTRAST


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Investigations: Neuroradiology:

URGENT MRI OF WHOLE SPINE WITH CONTRAST

T1 and T2 Sagittal views of whole spine pre – and post – contrast

NB: Must ask for axial views through areas of pathology

Consider HEAD MRI if concerns re: CNS tumour

Extracranial Radiology:

CT scan (chest/abdomen/pelvis) if suggestion of intra-abdominal mass/solid tumour

Haematology:

FBC and Blood Film Biochemistry:

Urine catecholamines Histology:

Consider biopsy/resection of surgically amenable masses

Consider BM aspirate/trephine Treatment: This MUST be instituted urgently, usually chemotherapy, although surgical decompression may be needed. Symptomatic management:

Initial management: Dexamethasone 10mg/m2 (max. dose 16mg) IV STAT DOSE . After STAT DOSE continue Dexamethasone IV 5mg/m2 BD (max. 8mg BD). Once stable convert dexamethasone from IV to oral dose and wean over 5 – 7 days and stop

Ensure intravascular replete but do not overhydrate as this may worsen cord oedema (1.5 – 2l/m2/day)

Catheterisation may be required.


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Definitive management:

Chemotherapy definitive management for lymphoma, leukaemia or neuroblastoma

Surgical decompression may be required to establish diagnosis or treatment of chemo – or radioresistant tumours

REFERENCES:

1. Beall DP, Googe DJ, Emery RL, et al. Curr Probl Diagn Radiol (2007);36(5):185-98. Extramedullary intradural spinal tumors: a pictorial review.

2. Tantawy AA, Ebeid FS, Mahmoud MA, et al. Spinal cord compression in childhood pediatric malignancies: multicentre Egyptian study. Pediatr Hematolo Oncol (2013); 35(3):232 – 236

3. Pollon D, Tomarchia S, Drut R, et al. Spinal cord compression: a review of 70 pediatric patients. Pediatr Hematol Oncol (2003); 20(6): 457 – 466

4. Oncologic Emergencies (chapter 39) in Principles and Practice of Pediatric Oncology. Eds. Pizzo & Poplack, 5th edition (2006)

5. NICE. Metastatic spinal cord compression. Diagnosis and management of adults at risk of and with metastatic spinal cord compression. CG 75 (2008)

6. Neurological and Neuromuscular Symptoms (chapter 26) in Oxford Textbook of Palliative Care for Children. Eds Goldman, Hain & Liben, 1st Edition (2006)

7. Systematic Review of the Diagnosis and Management of Malignant Extradural Spinal Cord Compression: The Cancer Care Ontario Practice Guidelines Initiative’s Neuro-Oncology Disease Site Group D. Andrew Loblaw, et al Journal of Clinical Oncology (2005)

8. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Vecht CJ, Haaxma-Reiche H, van Putten WL, et al: Neurology 39:1255-1257(1989)


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1. RAISED INTRACRANIAL PRESSURE: OVERVIEW: Most likely cause of ↑ICP will be brain tumours Beware: Bradycardia and hypertension Imaging of choice for possible ↑ICP is CT with contrast DO NOT SEDATE FOR NEUROIMAGING WITHOUT DISCUSSION WITH HAEM/ONC, ANAESTHETIC AND NEUROSURGICAL CONSULTANTS ALGORITHM:

Sign/symptoms suggestive of ↑ICP?

DO NOT SEDATE FOR SCANS

NEWLY DIAGNOSED

BRAIN TUMOUR

CONTACT HAEM/ONC CONSULTANT

DEXAMETHASONE

Subsequent management:

FBC and film

Biochemistry: UEC, LDH, Uric acid, Bone profile, AFP, BHCG

?Further imaging

CONTACT PAEDIATRIC NEUROSURGEON

DEXAMETHASONE

CONSIDER PICU

NO

YES

KNOWN HAEM/ONC

PATIENT

PATIENT ON

STEROIDS?

NO

YES

CONSIDER Posterior reversible encephalopathy syndrome (PRES)

- Steroid induced

Raised ICP


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Headache – esp. morning, aggravated by bending

Vomiting

Confusion, lethargy Signs

Hypertension and bradycardia

Altered Pupil size

Abnormal posturing DIFFERENTIAL DIAGNOSES:

Intracranial tumour (primary or metastatic)

Increased CSF production – Choroid Plexus Papilloma

CSF obstruction - Intracranial Haemorrhage, meningitis, blocked shunt

Posterior Reversible Encephalopathy (PRES) – children with steroids MANAGEMENT:

ALL NEWLY DIAGNOSED BRAIN TUMOURS MUST BE DISCUSSED WITH THE PAEDIATRIC NEUROSURGICAL TEAM ON – CALL

IF KNOWN HAEM/ONC PATIENT DISCUSS WITH HAEM/ONC CONSULTANT

Dexamethasone 0.25 – 0.5mg/kg IV STAT, followed by 0.25 – 0.5mg/kg q6hrly (max. 16 mg daily).

DISCUSS WITH PICU AND NEUROSURGERY IF: GCS <8 Abnormal respiratory pattern Abnormal posture

DISCUSSION WITH NEURORADIOLOGY CONSULTANT (WEST WING) TO ARRANGE URGENT CT SCAN

DO NOT SEDATE PATIENT FOR IMAGING, THIS MAY INDUCE CARDIORESPIRATORY ARREST

DO NOT PERFORM LUMBAR PUNCTURES


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Investigations: Neuroradiology

Radiological examination of choice in ↑ICP is contrast enhanced CT scan

All patients must be accompanied by medical staff to Radiology

Do not sedate for CT scan IF REVIEWED BY NEUROSURGICAL TEAM AND CONSIDERED SAFE:

MRI Head with whole spine +/- contrast as per CCLG Brain Tumour Imaging Protocol

Haematology

FBC

X – match/Group & Save Biochemistry

UEC, plasma osmolarity Treatment of Raised ICP: Symptomatic management:

Ensure ABC safely managed

Initial management: Dexamethasone 0.5mg/kg IV STAT, followed by 0.25 – 0.5mg/kg q6 hourly (max. 16 mg daily).

Consider H2 antagonist or Proton pump inhibitor cover

Ensure intravascular replete but do not overhydrate (1.5 – 2l/m2/day)

Catheterisation may be required. Definitive management:

Neurosurgical intervention – tumour, hydrocephalus, etc

Medical management o Meningitis – IV antibiotics o Posterior Reversible Encephalopathy Syndrome (PRES) – stop steroids,

start antihypertensive o Hypertensive encephalopathy – start antihypertensive


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REFERENCES: 1. The Paediatric Acccident and Emergency Research Group. The Management

of a Child with a Decreased Conscious Level - An evidence-based guideline (2006). www.nottingham.ac.uk/paediatric-guideline

2. Bowker, R., Stephenson, T. The management of children presenting with decreased conscious level. Current Paediatrics (2006). 16, 328-335

3. Allen CH, Ward JD. An evidence-based approach to management of increased intracranial pressure. Crit Care Clin 1998; 14:485.


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ALTERED LEVEL OF CONCIOUSNESS/SEIZURES: ALGORITHM: status guidelines

If already on phenytoin Trust Guideline recommends using phenobarbital

ALTERED LOC?

ENSURE ABC

IV Line

Check Glucose

VASCULAR ACCESS Subsequent management:

FBC and film

Biochemistry: UEC, Bone profile, VBG, lactate, Ammonia

Blood culture

IV Antibiotics

IV Aciclovir (?Encephalitis)

CT imaging

ALTERED LOC SEIZURE?

Diazepam PR Midazolam Buccal

Lorazepam IV

Lorazepam IV

Paraldehyde PR

Phenytoin IV *

RSI with Thiopentone

IV ACCESS?

CALL ANAESTHETIST

NO YES

YES

5 minutes

10 minutes

15 minutes

20 minutes

30 minutes


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Headache

Vomiting

Confusion Signs

Hypertension and bradycardia

Pupils

Abnormal posturing DIFFERENTIAL DIAGNOSES (seizures/ΔLOC):

Infectious (meningitis, encephalitis)

Withdrawal/overdose (opiates, benzodiazepines)

Acute metabolic disorder (electrolytes, hepatic, renal failure, acidosis, alkalosis)

Trauma (head injury, post-operative)

CNS pathology (intracranial tumour, intracranial vascular event, epilepsy, leukaemia infiltration)

Hypoxia (hypovolaemia, anaemia, PE)

Deficiencies (thiamine, folate, B12)

Endocrinopathies (↓/↑glucose, Addison’s, Thyroid, Parathyroid)

Acute vascular event (hypertensive encephalopathy, shock, stroke)

Toxins (alcohol, opiates, ifosfamide, methotrexate, cytarabine, asparaginase, tricyclic antidepressants)

Haemorrhage MANAGEMENT:

ENSURE SAFE AIRWAY, BREATHING, CIRCULATION

SEIZURES: MANAGE AS PER APLS GUIDELINES UNLESS OTHERWISE DOCUMENTED IN NOTES

ALTERED LEVEL OF CONCIOUSNESS: URGENT DISCUSSION WITH HAEM/ONC CONSULTANT DISCUSSION WITH NEURORADIOLOGY CONSULTANT (WEST WING)

TO ARRANGE URGENT CT SCAN DO NOT SEDATE PATIENT FOR SCANS, MAY PRECIPITATE ARREST


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Investigations: Neuroradiology

Radiological examination of choice is contrast enhanced CT scan

Ensure renal function is safe for contrast

All patients must be accompanied by medical staff to West Wing Radiology

Do not sedate for CT scan Haematology

FBC/Blood film

X – match/Group & Save

APTT and PT Biochemistry

Glucose

UEC, osmolarity, LFT, Ammonia

Calcium, magnesium, phosphate

Blood gas (with lactate)

Consider – thyroid function

Treatment: Symptomatic management:

Ensure ABC safely managed

Consider insertion of NGT

Catheterisation may be required Manage seizure as per APLS/Trust guidance (unless otherwise stated in notes)

PR Diazepam (0.5mg/kg max. 10mg in children <12 years, max 20mg in children >12 years)

Buccal Midazolam (0.5mg/kg max.10mg)

PR Paraldehyde (0.4ml/kg rectally with equal volume olive oil)

IV Lorazepam (0.1mg/kg max. 4mg over 30 – 60secs)

IV Diazepam (0.4mg/kg max. 10mg over 30 – 60secs)

IV Phenytoin (20mg/kg max 1000mg over 20minutes with ECG monitoring)

0 – 1 month 1.25mg

1 month – 1 yr 2.5mg

1 yr – 5 yr 5mg

5 yr – 10 yr 7.5mg

> 10 yr 10mg


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IV Thiopentone (4mg/kg to be given by Anaesthetist only) Definitive management (see cBNF for maximum doses):

Infectious: treat with IV antibiotics and antivirals if concerns re: encephalitis

CNS Depressant overdose: Naloxone (0.1mg/kg IV bolus) for opiates; flumazenil 10micrograms/kg IV (max 200 micrograms) given over 15 seconds, repeated at 1 minute intervals if required)

Acute metabolic disorder: correct metabolic abnormalities

Neurosurgical intervention: trauma, post-operative, intracranial tumour, haemorrhage

Hypoxia/hypovolaemia – high flow oxygen, fluid resuscitation

Endocrinopathies: Addisonian crisis (glucose, IV dexamethasone); Hypothyroid – IV thyroxine (Liothyronine)

Acute vascular event (hypertensive encephalopathy, shock, stroke) – stop steroids, consider antihypertensive, discuss with neurology

Ifosfamide: Methylene blue (methylthioninium chloride )1 – 2mg/kg (max. 50mg) IV over 5 – 10 minutes, followed by 1 – 2 mg/kg/dose IV (max 50mg) q8hrly

References: NICE APLS NICU The status epilepticus working party

Carson D et al (2003) Medicines for Children. London: RCPCH Publications Ltd.

Datapharms Communications (2005) Medicines Compendium UK: Datapharms Communications

Guys, St Thomas and (2001) Guys, St Thomas and Lewisham Hospitals.

Paediatric Formulary (6th Ed). UK: Guys, St Thomas and Lewisham Hospitals

Mehta, D.K et al (2005) British National Formulary (49th Ed) London, UK: British Medical Association and Royal Pharmaceutical Society of Great Britain


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Review Name Revision Date Version Review date

Dr Shaun Wilson, Paed Oncology Consultant

New document, amalgamation of spinal cord compression document

May 2014 1.0 June 2017

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