Paediatrics: Urgent care

Urgent care

Emergency treatment needed for acute complication of tumours, e.g.:

·Leukaemias with high peripheral white blood cell count, leading to hyperviscosity.

·SVC or airway obstruction caused by mediastinal masses.

·Raised ICP.

·Spinal cord compression.

Hyperviscosity

·Risk of sludging of venous blood in cerebral vessels.

·Associated with very high count ALL (WBC >200 × 10⁹/L).

Prevention

·Cautious transfusion.

·Prompt ALL treatment: hydration, urate oxidase, chemotherapy.

·Leucopheresis may relieve symptoms.

SVC and upper airway obstruction

·May present with dyspnoea, chest discomfort, hoarseness, cough.

·Findings in SVC obstruction: plethora, facial swelling, engorgement of veins on upper chest wall, venous dilatation of optic fundi.

Causes

·SVC obstruction:

·  upper mediastinal tumours (particularly T cell NHL or ALL);

·  occasionally neuroblastoma.

·Airway compromise:

·  thoracic ES;

·  peripheral PNET;

·  rhabdomyosarcoma;

·  malignant GCT.

Management

·Sedation/anaesthesia for diagnostic purposes unsafe in SVC obstruction.

·Empirical treatment based on imaging and non-invasive investigations may need to be used before biopsy confirmation of diagnosis.

·Presence of pleural effusion, common in T-cell NHL, exacerbates symptoms but tap may relieve symptoms and provide diagnosis.

Spinal cord compression

·Presentation: back pain; gait, sensory, bladder, and bowel disturbance.

·Causes: neuroblastoma, sarcoma, lymphoma, CNS tumours (also infection, osteomyelitis, abscess).

·Multidisciplinary input vital: urgent MRI and surgical decompression and biopsy should precede steroids to avoid tumour lysis under anaesthetic. Perform other essential diagnostic procedures (e.g. LP, BM) under same anaesthetic if possible.

Raised intracranial pressure 

Neurosurgical emer-gency. High dose dexamethasone pre-operatively.