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Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first‐line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune‐related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune‐related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment‐related toxicities.

Purpose Timely recognition of critical patients by emergency center triage is an ongoing challenge. Peripheral tissue oxygen saturation (Sto 2 ) measurement has been used to monitor shock patients' responses to resuscitation. Interest has developed in evaluating Sto 2 as a triage tool, but limited studies have addressed critically ill patients. Material and methods This is a single-center, retrospective study of 158 emergent cancer patients with hypotension and/or modified systemic inflammatory response syndrome who underwent Sto 2 spot measurement at triage. Results Of the 57 patients with Sto 2 less than 70%, 17 went to the intensive care unit (ICU), whereas only 14 of the 101 patients with Sto 2 of 70% to 89% ( P = .01) went to the ICU. There was no significant difference in non-ICU hospital admission or mortality between the 2 groups. The odds ratio of ICU admission for patients with Sto 2 less than 70% relative to those with Sto 2 of 70% to 89% was 2.64 (95% confidence interval, 1.18-5.87) and 2.87 (95% confidence interval, 1.23-6.66) when adjusted for mean arterial pressure, pulse, and temperature. Conclusions In this patient population, an Sto 2 less than 70% significantly increased the risk of ICU admission. Tissue oxygen saturation at triage identifies critical patients who may not be recognized by vital signs alone. Tissue oxygen saturation measurement could help providers make earlier decisions regarding hospital resource allocation.

Sepsis accounts for only 2% of the hospitalizations worldwide but more than 17% of total in-hospital mortality. Inappropriate antimicrobial selection and delays in appropriate therapy have been associated with reduced survival in severe sepsis and septic shock. No studies to date have exclusively targeted septic oncologic patients without hypotension. This study was a retrospective chart review of 100 adult cancer patients presenting to the emergency department with sepsis without hypotension. We investigated the effect of time to appropriate antibiotics on in-hospital mortality and hospital length of stay. It was hypothesized that increased time to antibiotic administration would worsen patient outcomes including in-hospital mortality and length of stay. Each 1-h delay in administration of appropriate antibiotic therapy increased the odds of in-hospital mortality by 16% (adjusted OR 1.16. 95% CI 1.04–1.34, p = 0.04). Time to appropriate antibiotics had no effect on hospital length of stay. Time to appropriate antibiotics and in-hospital mortality were associated in this population of adult oncologic patients with sepsis without hypotension. Clinicians in the emergency department should strive to ensure the timely administration of a complete and appropriate empiric antibiotic regimen in septic patients with active cancer even in the absence of hypotension.

Chemotherapy toxicity is a common and unfortunate consequence of therapy that can occur even at usual doses. Chemotherapy acts by damaging cancer cells; however, normal cells are susceptible to damage as well, and when this occurs chemotherapy toxicity ensues. Often these toxicities warrant emergency care. Timely recognition and appropriate management of chemotherapy toxicity is imperative.

Background Venous thromboembolism (VTE) is a condition in which a thrombus occludes the vasculature. The incidence of VTE in cancer patients is three times higher than that of the general population. Enoxaparin 1 mg/kg subcutaneously (SC) twice daily and enoxaparin 1.5 mg/kg SC once daily are both FDA-approved dosing regimens for the treatment of pulmonary embolism (PE). The objectives of this study were to assess outcomes of cancer patients treated with once or twice daily enoxaparin for acute PE. Primary outcomes included recurrent or worsening PE and secondary outcomes included mortality or signs of clinically overt, major bleeding. Methods This study was a retrospective chart review of adult cancer patients treated at The University of Texas MD Anderson Cancer Center from 2011 to 2013 who received either 1 mg/kg twice daily or 1.5 mg/kg once daily enoxaparin for acute PE upon discharge. Results Among 48 patients in each the twice daily and once daily group, six recurrent PEs occurred. The incidence of recurrent PE was higher in the once daily group ( n = 4) versus twice daily group ( n = 2). More major bleeding events occurred in the once daily group than the twice daily group (15% vs. 6%). Mortality at 6 months was higher in the twice daily group versus once daily group (13% vs. 6%). Conclusion Cancer patients receiving once daily enoxaparin for the treatment of acute PE may be at increased risk of recurrent PE and clinically overt bleeding. Larger randomized trials are needed to confirm the results of this study.