339) A 55 year old man presents to the Emergency Room with complaints of swelling of his face and worsening cough for the past two days. Swelling increases on lying down. He complaints of shortness of breath for past 2 hours. He has no significant past medical problems. He smoked about 1 pack per day for the past 25 years and consumes alcohol socially. On examination, he is in moderate respiratory distress with audible, loud Stridor. His face is grossly swollen and the veins over the neck, anterior chest and the face are engorged. On auscultation, there are no crepitations, s1 and s2 are regular and normal and there is no s3 gallop . A chest X-ray is shown below:
Which of the following is the most appropriate next step in management?
A) Radiation Therapy
B) Chemotherapy
C) CT guided Per-cutaneous Needle Biopsy
D) Video-Assisted Thoracoscopic Surgery (VATS)
E) Epinephrine
Filed under: Uncategorized, USMLE Test Prep | Tagged: Archer cardiology, Archer oncology, Archer pulmonology, Archer radiology, USMLE STEP 3 CARDIOLOGY, USMLE STEP 3 ONCOLOGY, USMLE STEP 3 PULMONOLOGY, USMLE STEP 3 RADIOLOGY |
Archer USMLE Step 3 Blog 
E) Epinephrine
I’m guessing its
A) Radiation Therapy
we need to address the respiratory distress first here…not sure if epinephrine will help much with the respiratory compromise caused by a tumour (Pancoast) so directly give radiation therapy to relieve obstruction??
Radiation therapy might itself cause swelling resulting further obstruction…so give epinephrine/steroid after radiation??
c
E: patient has difficulty breathing and face swelling, he may have some sort of allergic reaction which progressed to breathing compromise.
radiation therapy
D-its superior venacava obstruction due to pancost tumor
~E.
Finally I got the answer>…
SVC syndrome alone is not considered as an emergency unless life threatening condition.
If the patient condition is stable -> get the diagnosis first, biopsy for further management. If tumor is response to chemo –> chemo, if tumor type is response to radio –> radio Rx. According to histology.
If the patient condition is unstable and life threatening –> Emergency radiotherapy.
This patient has loud stridor – that is severe laryngeal odema and it is life threatening — so Emergency Radio therapy should be done.
http://en.wikibooks.org/wiki/Radiation_Oncology/Palliation/SVC_Syndrome