Chapter 235

As individual longevity increases and the general population ages, the incidence of cancer increases. This increase, coupled with more intensive and varied treatments being applied in the outpatient setting, makes it increasing likely that patients with active malignancy will come to the ED for care. Many conditions that prompt these patients to come to the ED will not be due to cancer. Conversely, there are disorders often or uniquely related to malignancy that are collectively termed oncologic emergencies.1–3 These malignancy-related emergencies can be broadly categorized as: (1) those due to local physical effects, (2) those secondary to biochemical derangement, (3) those that are the result of hematologic derangement, and (4) those related to therapy (Table 235-1).1–3

Table 235-1 Emergency Complications of Malignancy

### Malignant Airway Obstruction

Malignancy-related airway compromise is usually an insidious process that is the result of mass effect originating from the oropharynx, neck, or superior mediastinum that progressively obstructs air flow.4–6 Acute compromise may occur with supervening infection, hemorrhage, or loss of protective mechanisms, such as muscle tone. Iatrogenic factors, such as radiation therapy, may create additional difficulties by producing local inflammation with tissue breakdown. It is helpful to classify airway impairment due to malignant tumor obstruction in two manners, as to location—from the lips and nares to the vocal cords (upper airway) versus those from the vocal cords to the carina (central airway)—and, as to nature of the obstruction—endoluminal, extraluminal, or mixed.6 Almost regardless of the cause, airway obstruction usually presents with symptoms of shortness of breath and signs of tachypnea and stridor. The physical examination may show evidence of a mass in the pharynx, neck, or supraclavicular area.

Evaluation of patients with airway obstruction due to a malignant tumor involves a combination of plain radiographs, CT, and endoscopic visualization.6 Direct laryngoscopy is discouraged, as injudicious manipulation of the upper airway may convert a partial obstruction into a complete one by provoking bleeding or edema.

Emergency management includes the administration of supplemental humidified oxygen and maintenance of the best airway possible through patient positioning. Heliox—typically a 50:50 mixture of helium and oxygen—has been reported to produce symptomatic improvement in upper airway obstruction due to cancer when combined with other therapy.7

Mechanical intervention for critical airway obstruction from a tumor is rarely required in the ED. For patients with ...

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