Pediatric emergency medicine trisk 2718 2718

Clinical Considerations
Clinical Recognition
There are no specific signs or symptoms of neutropenia and emergency clinicians
must assume that any patient actively receiving chemotherapy is neutropenic until
proven otherwise. Symptoms of anemia in the cancer patient often occur at a much
lower hemoglobin level compared with patients who are not receiving therapy
because patients compensate for the chronic anemia. When patients become
symptomatic, the signs and symptoms are typical: pallor, lethargy, headache,
dizziness when rising from a supine/sitting position, and resting tachycardia.
Thrombocytopenia can be accompanied by petechiae, ecchymoses, epistaxis, other
mucosal bleeding and in severe cases, hemorrhage. Bleeding can be associated with
coagulopathy with or without accompanied thrombocytopenia, particularly in
leukemia patients receiving asparaginase therapy. Catheter-related clots may present
with line dysfunction, obvious or subtle signs of edema in the head or one upper
extremity, or collateral vessels visible on the upper chest. The presentation of central
venous sinus thrombosis usually consists of vague and/or nonspecific symptoms
including seizure, headache, nausea, and vomiting. Physical examination may or
may not have focal neurologic findings, altered mental status, or papilledema.
Clinical Assessment
A detailed history of recent chemotherapy administration can be helpful in
predicting risk for cytopenias, febrile neutropenia, coagulopathies, and thrombosis.
Neutropenic patients should be isolated from the potential infectious exposures that
can occur in an ED by rapid triage and placement in a private room. In addition,
routine procedures such as a rectal examination, rectal temperature, or urinary
catheterization increase the risk of bacteremia and should be avoided. Vital signs
may reveal fever, hypotension, orthostasis, tachycardia, and hypoxia. Physical
examination should focus on focal signs of infection, bleeding, cutaneous
manifestations of thrombocytopenia and complications of thrombosis such as
swelling, chest pain, headache, or altered mental status. A CBC with differential,
blood cultures, PT, INR, PTT, and anticoagulant level in patients receiving therapy
for thrombosis should be obtained as indicated.

Management
Management priorities are directed not toward the neutropenia itself but to the
associated infectious risks (see “Infectious Complications of Cancer Treatment”
section). Neutrophil and/or monocytic specific growth factors, such as filgrastim and
sargramostim, can decrease the duration but not the depth of neutropenia. When
neutropenia is present in the setting of sepsis, the literature does not support starting