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Clinical Assessment
Table 98.3 presents assessment and management guidelines for leukemia in the ED.
The evaluation should begin with a thorough history and physical examination. The
history should focus on the time frame in which symptoms developed and should
screen for the complications described above. Assess airway patency, which may be
threatened in the setting of a mediastinal mass. Assessment of the patient’s breathing
should include attention to the respiratory rate and oxygenation, both of which can
become compromised in the setting of anemia, leukostasis, congestive heart failure,
and pulmonary infection. In assessing the patient’s circulation, establish
intravascular access and include an assessment for evidence of SVC syndrome. The
physical examination should include an evaluation for lymphadenopathy and
hepatosplenomegaly. Signs of soft tissue infiltration by leukemia cells should be
explored, including skin infiltration (leukemia cutis) and testicular enlargement in
male patients. A thorough neurologic examination is essential to screen for cord
compression and CNS effects of the leukemia. Any abnormalities on neurologic
examination warrant further imaging to determine whether a neurologic
complication of the leukemia has occurred.
Laboratory evaluation should begin with a complete blood count (CBC), WBC
differential, and peripheral blood smear to be reviewed by a hematologist–
oncologist or pathologist. Automated differentials might count leukemic blasts as
either atypical lymphocytes or monocytes so abnormal numbers of these cell types
should raise concern for leukemia. Flow cytometry analysis can provide important
diagnostic clues by analyzing the proteins of the blast cell surface. Specific
diagnosis requires a bone marrow aspirate, which is not routinely performed in the
ED and should be done in consultation with an oncologist.