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Oncologic emergencyAwaiting clinical review

Pediatric oncologic emergencies

Six situations where the intern's first hour changes the outcome: febrile neutropenia, tumor lysis, hyperleukocytosis, SVC syndrome, spinal cord compression, and raised ICP.

Fever definition
≥38.3 °C once or ≥38.0 °C for 1 hour
Neutropenia
ANC <500/µL, or <1000/µL and falling
Door-to-antibiotic
≤60 minutes
TLS labs
K, phos, Ca, uric acid, creatinine q6–8h

Febrile neutropenia — the hour that matters

  • Cultures from every central line lumen (peripheral too if clinically indicated), then antibiotics. Do not wait for the CBC.
  • Empiric monotherapy with an antipseudomonal beta-lactam (cefepime, piperacillin-tazobactam, or meropenem per local resistance).
  • Add vancomycin for hemodynamic instability, suspected line infection, skin/soft-tissue source, or known MRSA colonization — then de-escalate at 48 hours.
  • Reassess perfusion frequently; fluid resuscitate and escalate to PICU early for septic physiology.

Do not miss

  • Antibiotics delayed for imaging, difficult line access, or a pending count is the single most common preventable harm on this service.

Tumor lysis syndrome

  • Highest risk: Burkitt lymphoma, T-ALL, any leukemia with a very high WBC, bulky disease.
  • Chemistry: high potassium, high phosphate, high uric acid, low calcium, rising creatinine.
  • Prevention: aggressive IV hydration without potassium; allopurinol for intermediate risk, rasburicase for high risk or established TLS (check G6PD).
  • Routine urine alkalinization is no longer recommended — it precipitates calcium phosphate.
  • Treat symptomatic hypocalcemia only; correcting it blindly worsens precipitation.

Mass-effect emergencies

  • Hyperleukocytosis: leukapheresis or urgent cytoreduction; avoid raising viscosity with red cell transfusion before the count comes down.
  • SVC syndrome / mediastinal mass: facial swelling, distended neck veins, orthopnea. Keep the child upright, avoid sedation and supine positioning, get tissue by the least invasive route possible.
  • Spinal cord compression: back pain plus weakness, sensory level, or bladder dysfunction — dexamethasone plus emergent MRI of the whole spine, then definitive therapy.
  • Raised intracranial pressure: head elevation, dexamethasone, neurosurgery for CSF diversion; avoid lumbar puncture.

Pearls

  • Culture, then antibiotics, then everything else. The clock starts at triage, not when you are paged.

  • 'No potassium in the bag' is the TLS reflex worth memorizing.

  • An anterior mediastinal mass plus sedation is how children die on the way to a diagnosis.

  • Back pain in a child with cancer is cord compression until MRI proves otherwise.

On the ward

  1. 1Learn where the febrile neutropenia order set lives on your first day.
  2. 2For any new leukemia, verify TLS labs, potassium-free fluids, and urate-lowering therapy in the first orders.
  3. 3Ask for the mediastinal mass positioning plan before any procedure requiring sedation.
  4. 4When in doubt overnight, call the fellow early — this service rewards early calls.

2 vignette questions on this topic.

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Sources

  • IDSA / ASCO febrile neutropenia guidance — US guidance on risk assessment and empiric antimicrobial therapy in neutropenic fever.
  • NCCN Guidelines (Pediatric) — US consensus guidance on treatment and supportive care pathways.