Oncology: Emergencies

• Basics: At a Glance | Acute Oncology and Triage
• Infection and metabolic: Neutropenic Sepsis | Tumour Lysis Syndrome | Hypercalcaemia of Malignancy | Low Sodium, High Glucose and Adrenal Crisis
• Structural: Metastatic Spinal Cord Compression | Superior Vena Cava Obstruction | Brain Metastases and Raised Pressure | Airway Obstruction | Malignant Pericardial Effusion | Pathological Fractures | Obstruction and Bleeding
• Treatment-related: Immunotherapy Emergencies | Severe Chemotherapy Toxicity | Infusion Reactions and Extravasation | Cancer-associated Thrombosis
• Revision: Drug Reference Table | Spot the Emergency | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🚑 Oncological emergencies are caused by the cancer itself or by its treatment. Many patients present to the emergency department or acute medicine rather than the oncology ward, and some emergencies are the first sign of cancer. Time matters: antibiotics within 1 hour for neutropenic sepsis, steroids and an MRI within 24 hours for spinal cord compression.
Your four questions for every patient: Is the patient on cancer treatment - what, and when was the last dose? Could this be neutropenic sepsis, cord compression, hypercalcaemia or an immunotherapy reaction? Has the acute oncology team been contacted? What are the patient's goals and treatment ceiling?

At a Glance

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Acute Oncology and Triage

• Acute oncology services in every hospital with an emergency department give rapid specialist advice for:
  • Patients with complications of cancer or its treatment.
  • New cancer diagnoses presenting as emergencies.
  • Malignancy of unknown primary.
• 24-hour triage helplines - patients on treatment call a dedicated number (using the UKONS triage tool). They should be told to call for:
  • Fever (38 °C or more), or feeling unwell.
  • Diarrhoea, vomiting, breathlessness, chest pain, bleeding.
  • New pain or weakness.
• Always ask:
  • Which cancer? What stage?
  • Which treatment (chemotherapy, immunotherapy, targeted, radiotherapy) and when the last dose was?
  • Patient alert card.
  • Treatment intent (curative or palliative).
  • Advance care plan or ReSPECT form.
• Involve palliative care early where appropriate - many emergencies happen in advanced disease, and the right treatment depends on the patient's goals.

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Neutropenic Sepsis

Definition: A neutrophil count of 0.5 × 10⁹/L or less with a temperature over 38 °C or other signs of sepsis (NICE CG151). It can kill within hours.

• Who: Patients within about 6 weeks of chemotherapy (highest risk 7–14 days after a cycle), stem cell transplant recipients, and people with marrow disease.
• Signs may be subtle - fever can be absent (older people, steroids, paracetamol). Some patients are hypothermic, confused or just "unwell". Neutropenia blunts inflammation, so pus and consolidation may be missing.
• Immediate management:
  • Treat on suspicion - give IV antibiotics within 1 hour of arrival ("door to needle"). Don't wait for the blood count.
  • Piperacillin–tazobactam 4.5 g IV (NICE) - don't routinely add an aminoglycoside unless there is shock or local policy says so.
  • Penicillin allergy: Follow local policy (e.g. meropenem for non-severe allergy; other combinations for severe allergy).
  • Sepsis bundle - blood cultures (peripheral and from each line lumen), lactate, fluids, oxygen, urine output.
  • Add vancomycin or teicoplanin for suspected line infection, MRSA or skin infection; antifungals for persistent fever (after 4–7 days).
• Tests:
  • FBC, U&E, LFTs, CRP, lactate.
  • Blood and urine cultures.
  • Chest X-ray if respiratory symptoms.
  • Viral swabs; stool cultures if diarrhoea.
• Risk assessment: The MASCC score identifies low-risk patients who may switch to oral antibiotics (e.g. ciprofloxacin with co-amoxiclav) and go home early with close follow-up.
• Don't routinely give G-CSF for treatment (consider in high-risk patients).
• Avoid rectal examinations, rectal temperatures and suppositories.
• Neutropenic enterocolitis (typhlitis): Fever, right iliac fossa pain and diarrhoea in profound neutropenia. CT; broad-spectrum antibiotics covering anaerobes; surgical review.
• Review the chemotherapy dose and G-CSF prophylaxis before the next cycle.

⚠️ Safety Pearl: Any unwell patient within 6 weeks of chemotherapy has neutropenic sepsis until proven otherwise. Delayed antibiotics are a recurring cause of avoidable death.

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Tumour Lysis Syndrome

What it is: Rapid breakdown of cancer cells releases potassium, phosphate and nucleic acids (which become uric acid) into the blood. This causes AKI, arrhythmias and seizures.

• High-risk situations:
  • Burkitt lymphoma, acute leukaemias (especially with a high white count), bulky lymphoma.
  • Venetoclax in CLL.
  • Rarely solid tumours.
  • Can occur spontaneously.
  • Risk factors: High LDH, large tumour bulk, pre-existing kidney impairment, dehydration.
• Usually starts 12–72 hours after starting treatment.
• Laboratory features (Cairo–Bishop):
  • High potassium.
  • High phosphate.
  • High uric acid.
  • Low calcium (phosphate binds calcium).
• Clinical features: AKI, arrhythmias, seizures, tetany, sudden death.
• Prevention:
  • Aggressive IV hydration (e.g. about 3 L/m² a day, aiming for high urine output).
  • Allopurinol (intermediate risk) - reduces uric acid production.
  • Rasburicase (high risk) - breaks down existing uric acid. Check G6PD first (causes haemolysis and methaemoglobinaemia). Rasburicase interferes with uric acid samples (send on ice).
  • Monitor U&E, potassium, phosphate, calcium and urate every 6–12 hours early on.
• Treatment:
  • IV fluids; rasburicase.
  • Treat hyperkalaemia (calcium gluconate for ECG changes, insulin and glucose).
  • Avoid giving calcium for asymptomatic low calcium (calcium-phosphate deposition in the kidneys) - treat only if symptomatic.
  • Early renal replacement therapy for refractory hyperkalaemia, rising phosphate, fluid overload or oliguria.
  • Avoid nephrotoxins.

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Hypercalcaemia of Malignancy

What it is: The commonest metabolic emergency in cancer (up to 1 in 10 patients with advanced cancer). It usually means a poor prognosis in solid tumours.

Causes:

• PTH-related peptide (PTHrP) from tumours - squamous cell cancers (lung, head and neck), breast, kidney, bladder - the commonest mechanism.
• Bone metastases - breast, myeloma, prostate (less often).
• Myeloma.
• Vitamin D (calcitriol) production - lymphoma.

Symptoms ("bones, stones, groans and psychic moans"):

• Fatigue; weakness.
• Thirst and polyuria (dehydration worsens it).
• Constipation; nausea and vomiting; abdominal pain.
• Confusion, drowsiness, coma.
• AKI.
• Short QT, arrhythmias.
• Often mistaken for "deterioration" in advanced cancer - check calcium in any unwell cancer patient.

Tests:

• Corrected (or ionised) calcium; U&E; magnesium; phosphate.
• PTH - should be suppressed (if normal or raised, consider coexisting primary hyperparathyroidism).
• ECG.

Treatment (corrected calcium over 3.0 mmol/L, or symptomatic):

• IV 0.9% sodium chloride - often 3–4 L over 24 hours if the heart and kidneys allow. Monitor fluid balance.
• IV bisphosphonate after rehydration:
  • Zoledronic acid 4 mg over at least 15 minutes (reduce in kidney impairment), or pamidronate.
  • Calcium falls over 2–4 days; recheck after 3–5 days.
  • Watch for low calcium, flu-like reactions and osteonecrosis of the jaw.
• Calcitonin - rapid but short-lived effect.
• Denosumab for bisphosphonate-resistant hypercalcaemia or severe kidney impairment.
• Steroids for lymphoma and myeloma.
• Stop thiazides, lithium, calcium and vitamin D supplements.
• Treat the cancer where possible.
• Haemodialysis for severe life-threatening cases with kidney failure.
• In end-of-life care, decide with the patient whether treatment fits their goals.

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Low Sodium, High Glucose and Adrenal Crisis

• Hyponatraemia:
  • SIADH - small cell lung cancer (the commonest), head and neck cancer, brain tumours.
  • Drugs - cyclophosphamide, vincristine, cisplatin (salt wasting), opioids, SSRIs, carbamazepine.
  • Vomiting; diarrhoea; adrenal insufficiency.
  • Treatment: Treat the cause; fluid restriction; hypertonic saline for severe symptoms; slow correction. See the Sodium and Water chapter.
• Hyperglycaemia:
  • Steroids (dexamethasone) - monitor glucose; insulin or gliclazide if needed.
  • Immunotherapy-induced type 1 diabetes - sudden onset, often in DKA.
  • Targeted drugs - alpelisib, everolimus, capivasertib.
• Adrenal crisis:
  • Immunotherapy hypophysitis or adrenalitis.
  • Sudden withdrawal of long-term steroids.
  • Adrenal metastases (bilateral, rare).
  • Low BP, vomiting, confusion, low sodium, high potassium (adrenalitis).
  • Hydrocortisone 100 mg IV/IM immediately, then fluids (see the Endocrine Emergencies chapter).
• Carcinoid crisis (neuroendocrine tumours) - flushing, low BP, bronchospasm, often triggered by surgery or anaesthesia. IV octreotide.

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Metastatic Spinal Cord Compression

What it is: Compression of the spinal cord or cauda equina by a tumour (usually from vertebral metastases). Without prompt treatment it causes permanent paralysis and incontinence.

• Who: Commonest in prostate, breast, lung, kidney cancer and myeloma. It is the first presentation of cancer in about 1 in 5.
• Symptoms (NICE NG234):
  • Back or neck pain - usually comes first, often weeks before weakness:
    • Thoracic pain.
    • Progressive pain.
    • Severe unremitting pain.
    • Pain on coughing, straining or lying flat.
    • Night pain.
    • "Band-like" pain around the chest.
  • Neurological symptoms - leg weakness, numbness, unsteadiness, sensory level, bladder or bowel dysfunction (late).
• Action:
  • Pain alone suggesting spinal metastases - MRI within 1 week.
  • Neurological symptoms or signs - MRI of the whole spine within 24 hours (immediately if deficits are progressing). Contact the MSCC coordinator at once.
  • Dexamethasone 16 mg (oral or IV) immediately, unless lymphoma is suspected and there is no tissue diagnosis. Then reduce gradually after definitive treatment; give a PPI; monitor glucose.
  • Analgesia.
  • Spinal stability: Keep the patient flat with neutral spinal alignment if there is severe pain on movement or suspected instability, until assessed.
• Definitive treatment (within 24 hours of MRI):
  • Radiotherapy (most patients).
  • Surgical decompression and stabilisation - for spinal instability, single-level compression in fitter patients with a reasonable prognosis, or radioresistant tumours.
  • Chemotherapy for very sensitive tumours (lymphoma, germ cell, small cell).
• Outcome: Depends on function at diagnosis - patients who can walk at presentation usually keep walking; few who are paralysed recover.
• Supportive care:
  • VTE prophylaxis.
  • Bladder care (catheter if retention).
  • Bowel care.
  • Pressure area care.
  • Rehabilitation.
  • Palliative care.

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Superior Vena Cava Obstruction

What it is: Blockage of the superior vena cava by tumour compression, invasion or thrombosis. Blood can't return from the head and arms.

• Causes:
  • Lung cancer (especially small cell) - the commonest.
  • Lymphoma.
  • Breast cancer; mediastinal metastases; germ cell tumours; thymoma.
  • Thrombosis around central venous catheters or pacemaker leads.
• Features (usually developing over weeks):
  • Facial and neck swelling (worse in the morning); arm swelling.
  • Breathlessness, cough.
  • Distended neck and chest wall veins.
  • Headache; feeling of fullness; worse lying flat or bending forward.
  • Pemberton's sign - facial flushing when raising both arms.
  • Danger signs - stridor (airway compression), confusion (cerebral oedema).
• Tests: CT chest with contrast (CT venography). Obtain a tissue diagnosis if cancer is new - treatment depends on the type.
• Treatment:
  • Sit the patient up; oxygen.
  • Endovascular stenting - the fastest symptom relief, for severe symptoms.
  • Dexamethasone - helps in lymphoma and to reduce oedema, but avoid before biopsy if lymphoma is possible.
  • Treat the cancer: chemotherapy (small cell lung cancer, lymphoma, germ cell) or radiotherapy.
  • Anticoagulation if there is thrombosis (e.g. line-related); remove the line if possible.
• Stridor or airway compromise is an emergency - urgent anaesthetic and ENT input; avoid sedation and lying flat.

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Brain Metastases and Raised Pressure

• Common sources: Lung, breast, melanoma, kidney, colorectal.
• Features:
  • Headache (worse lying, coughing, in the morning), vomiting.
  • Focal weakness; speech or visual problems.
  • Seizures.
  • Confusion; personality change; drowsiness.
  • Papilloedema.
• Imaging: CT, then MRI with contrast.
• Treatment:
  • Dexamethasone for symptoms of swelling (e.g. 8–16 mg daily, then reduce to the lowest effective dose). Give a PPI and monitor glucose.
  • Seizures - levetiracetam. No preventive antiseizure drugs without seizures.
  • Neurosurgery (large single lesions, uncertain diagnosis, hydrocephalus), stereotactic radiosurgery, systemic treatment that crosses into the brain.
  • Whole-brain radiotherapy in selected cases.
  • Best supportive care for poor performance status.
• Signs of herniation (falling GCS, dilated pupil, bradycardia with hypertension) - urgent neurosurgical opinion; high-dose dexamethasone; consider mannitol.
• Driving - DVLA rules apply.
• Leptomeningeal disease - headache, multiple cranial nerve palsies, radicular pain; MRI and CSF cytology.

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Airway Obstruction

• Causes: Head and neck cancers, laryngeal and tracheal tumours, thyroid cancer, mediastinal masses (lymphoma, T-ALL), endobronchial lung tumours.
• Features: Stridor, breathlessness, hoarseness, inability to lie flat, choking.
• Immediate management:
  • Sit upright; high-flow oxygen.
  • Call anaesthetics and ENT early - a difficult airway.
  • Heliox (helium–oxygen) reduces airflow resistance as a bridge.
  • Dexamethasone to reduce swelling.
  • Nebulised adrenaline.
  • Avoid sedation and lying flat (mediastinal masses can cause complete obstruction under anaesthesia).
• Definitive:
  • Tracheostomy (awake, under local anaesthetic).
  • Airway stenting, laser or debulking.
  • Radiotherapy or chemotherapy.
• Palliative: If intervention isn't appropriate - opioids and benzodiazepines for distress; calm presence.

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Malignant Pericardial Effusion

• Causes: Lung and breast cancer, lymphoma, melanoma, leukaemia; radiotherapy; some drugs.
• Features:
  • Breathlessness (especially lying flat), chest discomfort, fatigue.
  • Tamponade - low BP, high JVP, muffled heart sounds (Beck's triad), pulsus paradoxus, tachycardia.
  • ECG - low voltage, electrical alternans.
• Echocardiogram confirms it.
• Treatment:
  • Urgent pericardiocentesis for tamponade (fluid for cytology).
  • Pericardial window or drain for recurrence.
  • Treat the cancer.
• See the Cardiac Emergencies and Pericardial Disease chapters.

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Pathological Fractures

• Common sites: Femur, humerus, vertebrae, pelvis. Commonest with breast, prostate, lung, kidney, thyroid cancer and myeloma.
• Impending fracture: Increasing pain on weight bearing or movement at the site of a known lytic lesion - X-ray and orthopaedic review. Mirels' score helps decide on preventive fixation.
• Management:
  • Analgesia.
  • Orthopaedic fixation (even in advanced cancer, it relieves pain and helps mobility).
  • Radiotherapy after fixation.
  • Bone-targeted drugs (bisphosphonates, denosumab).
  • Check calcium.
• Vertebral fractures - assess spinal stability and for cord compression. Vertebroplasty or kyphoplasty for pain.
• Always consider a possible first presentation of cancer in an unusual fracture after minimal trauma.

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Obstruction and Bleeding

• Malignant bowel obstruction (ovarian, colorectal, gastric, pancreatic cancer):
  • Colicky pain, vomiting, distension, constipation.
  • CT to define the level.
  • Surgical or stenting options for a single-level obstruction in fitter patients.
  • Otherwise medical management - see the Palliative Care chapter (hyoscine butylbromide, octreotide, dexamethasone, antiemetics, venting NG tube).
• Biliary obstruction - jaundice and itch: biliary stent (ERCP); cholangitis needs antibiotics.
• Ureteric obstruction - AKI from pelvic cancers (cervix, bladder, prostate, colorectal): nephrostomy or ureteric stents - discuss whether intervention fits the patient's goals.
• Bleeding:
  • Haemoptysis - lung cancer; tranexamic acid, radiotherapy, bronchoscopy, embolisation.
  • Haematuria - bladder washouts, radiotherapy.
  • GI bleeding - endoscopy, embolisation.
  • Vaginal bleeding - packing, radiotherapy.
  • Catastrophic terminal bleed (e.g. carotid "blowout" in head and neck cancer) - if anticipated, plan ahead: dark towels, staff presence, and midazolam for distress (see the End-of-Life Care chapter).

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Immunotherapy Emergencies

Checkpoint inhibitor side effects can present to any specialty, at any time - even months after the last dose.

• Severe colitis - 7 or more stools a day above baseline, blood, pain, peritonism: admit, IV methylprednisolone 1–2 mg/kg, CT for perforation; infliximab if no response in 48–72 hours.
• Pneumonitis - new breathlessness, cough, hypoxia: CT, exclude infection, high-dose steroids.
• Myocarditis - chest pain, arrhythmia, heart failure, raised troponin, often with myositis or myasthenia. High mortality. Urgent high-dose IV methylprednisolone; cardiology.
• Endocrine:
  • Adrenal crisis from hypophysitis or adrenalitis - hydrocortisone.
  • DKA from new type 1 diabetes - insulin.
  • Severe thyrotoxicosis.
• Hepatitis - ALT over 5 times the upper limit: stop, steroids.
• Neurological - myasthenia (check breathing), Guillain–Barré syndrome, encephalitis: steroids, IVIg or plasma exchange.
• Nephritis - AKI: steroids.
• Severe skin reactions (SJS/TEN) - dermatology emergency.
• Principles:
  • Exclude infection.
  • Grade the toxicity.
  • Contact acute oncology.
  • Steroids for grade 2 or higher (except endocrine).
  • Taper over 4–6 weeks or more.
  • PCP prophylaxis and a PPI on prolonged steroids.
• CAR-T and bispecifics - cytokine release syndrome (tocilizumab) and neurotoxicity (steroids) - see the Leukaemia, MPN and MDS chapter.

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Severe Chemotherapy Toxicity

• Severe diarrhoea (fluoropyrimidines, irinotecan):
  • Assess dehydration, AKI and electrolytes; check stool for C. difficile.
  • High-dose loperamide (4 mg, then 2 mg every 2 hours).
  • Octreotide if refractory.
  • IV fluids; antibiotics if neutropenic or febrile.
  • Hold oral chemotherapy (capecitabine).
• DPD deficiency - severe toxicity (mucositis, diarrhoea, neutropenia) after fluoropyrimidines. Patients are now tested before starting. Uridine triacetate is an antidote in overdose or severe early toxicity.
• Severe mucositis - analgesia (including opioids), mouth care, fluids, nutrition; check for candida and herpes.
• Severe vomiting - antiemetics by mechanism, IV fluids, electrolytes.
• Methotrexate toxicity - high-dose regimens: folinic acid rescue, urinary alkalinisation, glucarpidase if levels stay high with kidney failure.
• Cardiotoxicity - chest pain with 5-FU (coronary vasospasm - stop infusion, nitrates); heart failure with anthracyclines or trastuzumab.
• Ifosfamide encephalopathy - confusion, drowsiness: stop, methylene blue.
• Haemorrhagic cystitis - cyclophosphamide or ifosfamide (mesna prevents); after pelvic radiotherapy or BK virus after transplant.

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Infusion Reactions and Extravasation

• Infusion and hypersensitivity reactions:
  • Common with: Taxanes, platinums (especially carboplatin after several cycles), rituximab, daratumumab and other antibodies.
  • Features: Flushing, rash, fever, rigors, breathlessness, chest or back pain, hypotension.
  • Management:
    • Stop the infusion.
    • ABC; oxygen; fluids.
    • Antihistamines and hydrocortisone.
    • IM adrenaline 500 micrograms for anaphylaxis.
  • Many antibody reactions allow a slower restart with premedication; true platinum allergy may need desensitisation.
• Extravasation (leakage of drug into tissues):
  • Vesicants (cause tissue necrosis) - anthracyclines, vinca alkaloids, mitomycin, some platinums.
  • Signs: Pain, burning, swelling or redness at the cannula site; the infusion slows.
  • Management:
    • Stop the infusion and leave the cannula in place.
    • Aspirate as much drug as possible.
    • Follow the specific protocol - e.g. dexrazoxane and cold packs for anthracyclines; warm packs and hyaluronidase for vinca alkaloids.
    • Elevate the limb; mark and photograph; plastic surgery review.

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Cancer-associated Thrombosis

• Cancer raises VTE risk 4–7 times (higher with pancreatic, gastric, lung, brain and ovarian cancer, chemotherapy, central lines and immobility). VTE is the second commonest cause of death in people with cancer.
• Presentation: DVT, PE (often incidental on staging CT - still needs treatment), line-related upper limb thrombosis.
• Treatment (NICE NG158):
  • DOAC (apixaban, rivaroxaban, edoxaban) or LMWH.
  • Use LMWH with high bleeding risk (GI and urothelial cancers), drug interactions, low platelets or vomiting.
  • Continue for 3–6 months or longer while the cancer is active.
  • Platelets under 50 - dose reduction or temporary pause (specialist advice).
• Prevention:
  • Inpatient VTE prophylaxis.
  • Extended prophylaxis after cancer surgery.
  • Thromboprophylaxis with some regimens (e.g. lenalidomide in myeloma).
• Recurrence despite treatment - check adherence, switch to LMWH or increase the dose, consider an IVC filter rarely.

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Drug Reference Table

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Spot the Emergency

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Exam-style Scenarios

1. A 55-year-old woman 10 days into her second cycle of breast cancer chemotherapy has a temperature of 38.4 °C and HR 110. Bloods are pending.
Answer: Suspected neutropenic sepsis.

• IV piperacillin–tazobactam 4.5 g within 1 hour - don't wait for the FBC.
• Blood cultures (peripheral and line), lactate, fluids; sepsis screen.
• MASCC score to guide inpatient or early oral step-down; inform acute oncology.

2. A 68-year-old with lung cancer is drowsy and constipated. Corrected calcium is 3.4 mmol/L; creatinine 160.
Answer: Hypercalcaemia of malignancy.

• IV 0.9% sodium chloride (e.g. 3–4 L over 24 hours if tolerated); stop thiazides and calcium supplements.
• Zoledronic acid (dose adjusted for kidney function) after rehydration.
• Check PTH; recheck calcium at 3–5 days; discuss prognosis and goals.

3. A 74-year-old with breast cancer has 3 weeks of thoracic back pain and new difficulty walking.
Answer: Suspected MSCC.

• Dexamethasone 16 mg now; whole-spine MRI within 24 hours (immediately if deteriorating).
• Contact the MSCC coordinator; nurse flat if spinal instability is suspected.
• Radiotherapy or surgery; VTE prophylaxis; bladder and bowel care.

4. A man with newly diagnosed high-grade lymphoma is to start chemotherapy. LDH is 2,500 and creatinine is 140.
Answer: High risk of tumour lysis syndrome.

• Aggressive IV hydration; rasburicase (check G6PD).
• Bloods every 6–12 hours (K, phosphate, calcium, urate, creatinine); cardiac monitoring.
• Early renal team involvement.

5. A 60-year-old with small cell lung cancer has facial swelling, arm swelling and breathlessness.
Answer: SVC obstruction.

• Sit up; oxygen; CT venogram.
• Stenting for severe symptoms; urgent chemotherapy (small cell is very chemo-sensitive).
• Anticoagulate if thrombus; check for stridor.

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Key Points

• Always ask what cancer treatment the patient is on and when the last dose was; contact acute oncology.
• Neutropenic sepsis: antibiotics within 1 hour (piperacillin–tazobactam); don't wait for the FBC; fever may be absent.
• TLS: high potassium, phosphate and urate, low calcium - hydrate, rasburicase (check G6PD), early dialysis; don't treat asymptomatic low calcium.
• Hypercalcaemia: fluids then IV bisphosphonate; check PTH; poor prognostic sign in solid tumours.
• MSCC: back pain comes first; dexamethasone 16 mg; whole-spine MRI within 24 hours; walking at presentation predicts walking afterwards.
• SVCO: stent for severe symptoms; get a tissue diagnosis; avoid steroids before biopsy if lymphoma is possible.
• Brain metastases: dexamethasone, levetiracetam for seizures, surgery or radiosurgery.
• Stridor: sit up, heliox, steroids, early airway experts; avoid sedation.
• Immunotherapy toxicity can affect any organ months after treatment; adrenal crisis and DKA can be immunotherapy-related.
• Severe chemotherapy diarrhoea: high-dose loperamide, fluids, check for infection and neutropenia.
• Extravasation: stop, aspirate, follow the drug-specific protocol.
• Incidental PE on staging CT still needs anticoagulation.
• Always match emergency treatment to the patient's goals and prognosis.

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Guidelines and Further Reading

• NICE CG151: Neutropenic sepsis - prevention and management in people with cancer
• NICE NG234: Spinal metastases and metastatic spinal cord compression (2023)
• NICE NG158: Venous thromboembolic diseases (cancer-associated thrombosis)
• UKONS 24-hour triage tool; UK Acute Oncology Society guidance
• ESMO guidelines: management of immunotherapy toxicity; oncological emergencies
• BSH guideline on tumour lysis syndrome
• Society for Endocrinology emergency guidance: hypercalcaemia; immunotherapy endocrinopathies
• BNF - for current doses

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