A 66 year old female is rolled in by EMS to the trauma bay. A non-rebreather (NRB) is in place. The patient appears uncomfortable, tachypneic and is utilizing accessory muscles.
Per EMS, patient has a history of CHF and colon cancer. She was found to be in respiratory distress, tachypneic with respiratory rate in the 30s on scene and oxygen saturation in the 80s. She received two combivent treatments without improvement and subsequently placed on a NRB with improvement in saturation to the 90s and transferred to the hospital.
On initial evaluation, the patient is breathless and only able to speak in one word sentences. She is immediately placed on BiPAP to help with her increased work of breathing. A complete history is unable to be obtained at this time.
Physical Exam:
Initial vital signs: BP: 145/88, HR: 120, RR: 30, SPO2: 97% on NRB
Bedside US without evidence of B-lines, consolidation or effusion
General: Alert, elderly female in moderate distress
Skin: Facial flushing, warm to touch
Cardiovascular: Tachycardia, no murmur, normal peripheral perfusion, no lower extremity edema
Pulmonary: Diffuse inspiratory and expiratory wheezing bilaterally, utilizing accessory muscles of respiration, speaking in one word sentences
Gastrointestinal: RUQ tenderness to palpation without rebound or guarding
Neuro: A&O x3
Once the patient has been on BIPAP and reports improvement in her breathing, she is able to start providing additional history. She reports shortness of breath for 2 days that acutely worsened today. It is not associated with chest pain, palpitations, fever, chills, or cough. She endorses a sick contact with cold like symptoms. She reports a history of pulmonary embolism and is currently on Eliquis.
Additionally, she reports that she has CARCINOID not colon cancer and recently missed her octreotide infusion. She states that in past she has required BIPAP as well as intubation for respiratory distress in setting of missed octreotide infusions.
The patient is in carcinoid crisis. She received a 500 mcg octreotide push, followed by an octreotide drip and solumedrol. Oncology was immediately consulted and agreed with ED management.
Her labs were largely unremarkable. CT angio chest did not have a PE. CT abdomen and pelvis redemonstrates a known tumor burden.
Patient was successfully weaned off BIPAP after Octreotide and steroids and admitted to the floor for Carcinoid Crisis.
Take Away #1
Carcinoid Crisis – life threatening form of carcinoid syndrome in which an overwhelming amount of hormones are being produced
Carcinoid – neuroendocrine tumor that secretes serotonin, histamine and bradykinin, once metastatic or primary lung carcinoid can result in carcinoid syndrome described as facial flushing, diarrhea, and bronchospasm
Crisis can happen randomly or during times of stress, after chemotherapy or after anesthesia
Role of ED in Carcinoid Crisis
Airway: Be prepared to place patients in respiratory distress on BiPAP and potentially intubate
Hemodynamics: Carcinoid crisis can cause hypotension that is often refractory to IV fluids. Patients may require pressor support to maintain adequate BP.
Mainstay of treatment: Octreotide
Carcinoid tumors have somatostatin receptors on the surface. Octreotide binds to receptors preventing further hormone production by the tumor.
Octreotide given as a IV Push of 100-500 mcg and the drip runs at 50-100 mcg/hr.
Steroids and anti-histamines have additionally been shown to be beneficial.
Beta agonists should not be given for bronchospasm as they have been shown to worsen symptoms.
Take Away #2
History – obtaining a thorough and accurate patient history is very important. Had we not learned of the patient’s history of carcinoid cancer, treatment would have been delayed with the potential for her respiratory status to decline and require intubation.
Take Away #3
Get consultants on board early. In this case it was important to have oncology involved early to assist with medical management of crisis.
Amanda Correia, DO is a current first year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD