Table 6.

Oncologic emergencies

Condition	Presenting Symptoms	Rehabilitation Implications
Structural or Mechanically Induced Oncologic Emergencies
Spinal Cord Compression (SCC)	Localized back pain, primarily in thoracic region. Thoracic pain escalating with lying supine, at night, with increased thoracic pressure during sneezing, coughing, or straining. Muscle weakness below the area of spinal involvement.	Worsening pain in a recumbent position helps to differentiate SCC from other forms of mechanical back pain. Pain is the most frequent presenting symptom. Identification of SCC prior to onset of motor or sensory loss improve functional mobility and mortality outcomes. Patients with SCC are at risk for urinary tract infections, VTE, decubitus ulcers, and pneumonia. Pain assessment should be routine in rehabilitation interactions with concomitant assessment of muscle strength and sensory changes.
Malignant pericardial effusion	Due to primary pericardial tumor (rare) or metastatic pericardial disease associated with lung, breast, esophageal, lymphoma, leukemia, and melanoma. Pericardial effusion results in increased intrapericardial pressure, reduced cardiac output and cardiac tamponade. Dyspnea, cyanosis, engorged neck veins, orthopnea, congested cough, fatigue, palpitations, and a drop in systolic blood pressure of > 10mm Hg during inspiration. Hypotensive, tachycardic, narrow pulse pressure, diaphoretic.	Frequent assessment of heart rate, hemodynamic status and respiratory status, including oximetry levels should be carried out during treatment. Assessment of skin color and temperature, capillary refill and peripheral pulses should be tracked. Awareness of mental status changes, confusion, or seizures is necessary due to reduced cerebral blood flow. Following a cardiac tamponade episode, patients should have medical clearance before re-engaging in rehabilitation care. Rehabilitation is indicated to provide strengthening and reconditioning activities, pulmonary hygiene, and postural positioning.
Superior Vena Cava Syndrome	Swelling in the upper thorax, face, neck. Jugular vein distention. In early stages edema is worse in the morning and improves throughout the day. Dyspnea, dry cough. Tachycardia, hypotension, cyanosis, cough, tachypnea, dyspnea. Central nervous system symptoms; confusion, headache and vision changes.	Onset is typically slow and progressive. Symptom recognition and observance of change over time will support differential diagnosis. Avoid valsalva maneuvers with activity and exercise. Heart rate response to activity may be impaired. Use Rate of Perceived Exertion (RPE) scale as a more sensitive self-reported measure during activity.
Metabolic Oncologic
Emergencies Hypercalcemia	Presentation may be vague and symptoms diffuse. Impact on nervous tissue and muscle tissue result in constipation, lethargy, fatigue, bone pain, abdominal pain, polyuria, muscle weakness, confusion, delirium.	Diagnostic testing includes serum ionized calcium levels. The rate of increase of calcium level is more important than the absolute serum calcium in correlating with symptoms. In severe conditions individuals are relatively unresponsive and rehabilitation may not be indicated. In mild to moderate conditions, weight-bearing activities are recommended along with general aerobic conditioning. Consider assistive devices for safety with ambulation. Assess and ascertain mental status changes and impact on safety judgement.
Tumor Lysis Syndrome	Symptoms may include nausea, vomiting, weakness, fatigue, lethargy, and arthralgia. Typical onset is during acute 6 to 72 hours post chemotherapy delivery.	Awareness of sudden changes in patient’s status including weakness, muscle cramping, dysrhythmias, dyspnea, central nervous system changes, irregular heart rhythms. In intensive care settings, early progressive mobility and rehabilitative interventions improve recovery and maintain functional status after discharge.
Hematologic Emergencies
Neutropenic Fever	Greatest risk is with ANC below 500 c/mm3 Trend of change in ANC count overtime is more important than absolute value. Presence of a fever > 101.3° F or > 100.4 ° F for more than 1 hour. Typical symptoms of infection such as redness, swelling and puss exudate from wounds are frequently absent.	Rehabilitation is not contraindicated. Considerations for protective wear including gowns, gloves, masks, and reducing risk of transmission of infectious agents by handwashing, keeping equipment clean, reducing exposure to raw foods and live plants.
Venothrombolic Events	DVT present with swelling in the extremity, redness and extreme tenderness. More commonly occur in the lower extremity but may also occur in the arms. Pulmonary emboli present with dyspnea, tachycardia, crackles, hemoptysis, chest pain, tachypnea, and anxiety. Diagnostic imaging includes Doppler ultrasound for suspected DVT and chest CT, ventilation perfusion scan and pulmonary angiography for suspected PE.	Support protocols for VTE prophylaxis including mechanical compression devices including compression hosiery and pneumatic applications. Ambulation is encouraged to reduce risk for VTE development in high risk populations. Awareness of pharmacologic interventions that alter platelet activity and clotting.