TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 1 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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 2 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
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 3 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
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.
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 4 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
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)
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 5 of 13 Date agreed: 03/12/2015
Issue date: 03/12/2015
Version: 1.0
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Review date: 03/12/2017
Children’s Cancer Measure:
Author: Shaun Wilson
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 6 of 13 Date agreed: 03/12/2015
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Version: 1.0
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Children’s Cancer Measure:
Author: Shaun Wilson
PRESENTATION: Symptoms
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 7 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
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 8 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
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.
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 9 of 13 Date agreed: 03/12/2015
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Version: 1.0
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Children’s Cancer Measure:
Author: Shaun Wilson
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 10 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
PRESENTATION: Symptoms
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 11 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
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 12 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
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
TVCN Principal Treatment
Centre
Children’s Hospital Oxford
Filename: Neuro – oncological
Emergencies
Page 13 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
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