Management of SVCS, SCC or hypercalcaemia

[kris02]

Hi was wondering if anyone new the basic EMS/paramedic managment for patients suffering with:

Superior Vena Cava Syndrome/obstruction

Hypercalcaemia?

Spinal cord compression?

Or if you have any of your own hints and tricks to best manage these patients?

Cheers
Kris

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[12R34Y]

How to manage these things in the prehospital arena?!?

You'll never know if your patient has hypercalcemia and those patients are typically asymptomatic. If you knew they had hypercalcemia you'd give them fluids and diuretics (loops).

You'll also never know about spinal cord compression in the field. Just treat their pain.

SVC syndrome is almost always caused by malignancy. There would be NO specific prehospital treatment for this. If they have pain. then treat it.

otherwise take these patients to a hospital.

You have to remember your transporting someone for 5-30 minutes. SVC syndrome develops over days. spinal cord compression is usually always malignancy as a cause as well and doesn't crop up over night. Most hyper calcemic patients are asymptomatic.

there is really no prehospital treatment for any of these conditions except treating pain and going to the hospital.

good luck!

later

 

[niko327]

Hi was wondering if anyone new the basic EMS/paramedic managment for patients suffering with:

Superior Vena Cava Syndrome/obstruction

Hypercalcaemia?

Spinal cord compression?

Or if you have any of your own hints and tricks to best manage these patients?

Cheers
Kris

Kris, I think you asked this question before in another thread? The management of the conditions above would mainly focus on the presenting symptoms and would be mainly supportive in nature.

A slowly evolving neurologic deficit from malignant spinal cord compression might buy the pt a ride to the hospital on a backboard for instance, probably because the ems provider would simply react to the pt presentation. Monitoring of the ABCs, and perhaps initiation of an IV. As far as giving steroids etc, that is something best decided on in the hospital or by the medical control physician. Standing order steroids will probably make little difference in the 10-30 minutes ride to the hospital.

As for hypercalcemia, the ems provider would probably have no idea what the pt's calcium was. As such, correction of hypercalcemia would not likely occur in the field. High clinical suspicion for hypercalcemia should alert the provider
to monitor the vital signs closely and to look out for hypertension or bradycardia. Abdominal and flank pain need to be evaluated in the hospital before pain control measures can be taken, so beyond monitoring of ABCs, initiation of an IV, hydration if needed for evidence of acute hypercalcemia and giving O2 not much else would happen in the prehospital phase.

As far as SVC syndrome, management might include transporting the patient sitting upright and giving O2. Monitoring and management of the patient's airway and respiratory status and providing intervention as needed. Monitoring the patients EKG, initiation of an IV and providing of cardiovascular support as needed. Consideration of steroids should best be done in consult with a physician. The use of diuresis for airway edema or brain edema might be a bit of a stretch in the field and once again, a call to medical control for physician guidance would be helpful. Monitoring the ABCs is pretty key for this particular problem.

Hope this has been helpful, if anyone else has anything to add, by all means please do so.

 

[lizzied2003]

Out of my forum but I recall seeing a patient with SVC in a walk in.
The most important thing was getting him to an acute care setting /ER where he could get heparin/thrombolitics.

He had presented with pallor of his arm and you could see the vasculature in his chest wall. He was a drummer and the nite previous he had an argument and punched the hell out of his car seat.

I believe they have an interesting CXR presentation but I can't recall the specifics. It was a very fascinating case to see at a walk in clinic.

Regarding High Calcium. Usually diagnosed in hospital but you have a heightened awareness of this with those with cancer or kidney patients getting some of the Vit D analogs (zemplar,rocalcitrol).

As stated above...we treat with lasix/saline. try to correct underlying cause.
I believe I would be more concerned about HYPOcalcemia as usually see the tetany symptoms.

My two cents. Thanks for letting me barge in.
good luck

 

[12R34Y]

AGain........you transport the above patients to the hospital. You don't need to treat any of these things in the prehospital setting.

You would never give steroids to back pain in the field (even if they had neuro deficit) b/c you wouldn't know why you are giving them or for what reason.

hypercalcemia. you'll never know.

SVC syndrome. no treatment indicated prehospital.

ABC's for all of the above.

later

 

[niko327]

You would never give steroids to back pain in the field (even if they had neuro deficit) b/c you wouldn't know why you are giving them or for what reason.



later

uhh, yeah, that's what I said.... treatment best decided on by a physician, in a hospital.

 

[kris02]

Thankyou all,
I understand that all you can really do is transport. One of the reasons for this research is that in Australia i think the service is trying to expand our protocol somewhat and are wanting students to provide some suggestions etc. or at least research to find if there is anything additional that we as paramedics can do.

Thanks again
Kris

 

[DropkickMurphy]

The wisest approach is to realize when the best thing you can do nothing more than pick up and haul butt. All too often new medical providers (of all levels) and students especially get so hung up on "advancing their skill set" or otherwise focusing on whether they can do something that they oft times never stop to think whether they should.

Anyhow, I seriously doubt (and this is coming from someone who has been involved in protocol development for several years) that they are wanting you to come in with a protocol for a condition that 99% of the paramedics (probably including myself) out there are not going to recognize even if it jumped up and bit them on the hind end. It's admirable to want to improve things, but try improving the care of something you'll be able to pick out in the field and treat.

 

[leviathan]

How to manage these things in the prehospital arena?!?

You'll never know if your patient has hypercalcemia and those patients are typically asymptomatic. If you knew they had hypercalcemia you'd give them fluids and diuretics (loops).

Well, couldn't you tell based on ECG findings (eg. PR lengthening, ST shortening), or are these not common?

I think based on ECG findings and a certain history (eg. malignancy, renal failure, hyperparathyroidism) you would probably be able to make a good guess.

Hypercalcemia can often present with hypokalemia as well, and the diuresis it produces might make someone severely dehydrated so treatment with fluids might be warranted. Also I remember hearing somewhere that it can cause heart block and other irritability in cases so atropine or lidocaine might be required...

I'm not a medic so I could easily be wrong, but just throwing some ideas out there to think about.

 

[12R34Y]

Well, couldn't you tell based on ECG findings (eg. PR lengthening, ST shortening), or are these not common?

I think based on ECG findings and a certain history (eg. malignancy, renal failure, hyperparathyroidism) you would probably be able to make a good guess.

Hypercalcemia can often present with hypokalemia as well, and the diuresis it produces might make someone severely dehydrated so treatment with fluids might be warranted. Also I remember hearing somewhere that it can cause heart block and other irritability in cases so atropine or lidocaine might be required...

I'm not a medic so I could easily be wrong, but just throwing some ideas out there to think about.

In one large study the most common symptom of hypercalcemia was fatigue/weakness. the other "common" signs of hypecalemia include constipation, depression, malaise, neuromuscular weakness etc.....

My point is if you show up to somones's house as a medic and they have a complaint of fatigue and weakness and you think they have hypercalcemia you are not thinking appropriately for EMS. You should first think MI, sepsis, pneumonia blah blah blah.

life threat stuff, ABC"s and transport.

Also, thanks for talking about hypokalemia.

My point is again that in an ED you will have labs and of course will SEE that there would be low potassium and of course replete that.

the treatment is still fluids and loop diuretics (among others).

Again........you should NOT be treating hypercalcemia in the prehospital environment under any circumstance precisely why you are stating. You won't know if they are in fact hypercalcemic and you also won't know they're mag, potassium etc....so treating it is a moot point.

and NO you cannot rely on EKG changes to diagnose hypercalcemia. EKG findings in electrolyte abnormalities are not very sensitive tools.

so......bottom line. you transport these patients as they will need extensive workups and usually the involvement of a nephrologists/endocrinologists.

later

 

[leviathan]

In one large study the most common symptom of hypercalcemia was fatigue/weakness. the other "common" signs of hypecalemia include constipation, depression, malaise, neuromuscular weakness etc.....

My point is if you show up to somones's house as a medic and they have a complaint of fatigue and weakness and you think they have hypercalcemia you are not thinking appropriately for EMS. You should first think MI, sepsis, pneumonia blah blah blah.

life threat stuff, ABC"s and transport.

Also, thanks for talking about hypokalemia.

My point is again that in an ED you will have labs and of course will SEE that there would be low potassium and of course replete that.

the treatment is still fluids and loop diuretics (among others).

Again........you should NOT be treating hypercalcemia in the prehospital environment under any circumstance precisely why you are stating. You won't know if they are in fact hypercalcemic and you also won't know they're mag, potassium etc....so treating it is a moot point.

and NO you cannot rely on EKG changes to diagnose hypercalcemia. EKG findings in electrolyte abnormalities are not very sensitive tools.

so......bottom line. you transport these patients as they will need extensive workups and usually the involvement of a nephrologists/endocrinologists.

later

Thanks, that makes sense. So basically, if they do have any complications due to their hypercalcemia (eg. heart block, arrythmias, dehydration), you'd be treating it the same way irrespective of the cause.

 

[12R34Y]

Thanks, that makes sense. So basically, if they do have any complications due to their hypercalcemia (eg. heart block, arrythmias, dehydration), you'd be treating it the same way irrespective of the cause.

exactly!

good info to discuss however.

later

 

[docB]

Thankyou all,
I understand that all you can really do is transport. One of the reasons for this research is that in Australia i think the service is trying to expand our protocol somewhat and are wanting students to provide some suggestions etc. or at least research to find if there is anything additional that we as paramedics can do.

Thanks again
Kris

It's always a good idea to look for additional areas where EMS can provide better care but these clinical entities are rare and difficult or impossible to effectively diagnose in the field. There are definitely other problems that EMS research should focus on because it will help many more patients.