Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 2 sections

Pediatric Oncology Emergencies: Febrile Neutropenia & Tumor Lysis

Comprehensive emergency evaluation and protocolized management of acute pediatric oncologic emergencies: Febrile Neutropenia (Absolute Neutrophil Count [ANC] < 500/mcL, central venous line infections, immediate monotherapy antipseudomonal beta-lactam within 60 minutes), Tumor Lysis Syndrome (TLS: hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia; Cairo-Bishop criteria; IV hydration, Allopurinol vs. Rasburicase), Superior Vena Cava (SVC) syndrome/Anterior Mediastinal Mass airway compression, and Spinal Cord Compression.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

ANC Calculation Formula

ANC = Total WBC x [(% Polymorphonuclear Neutrophils + % Bands)/100]; Neutropenia is defined as ANC < 500/mcL

Golden Hour Antibiotic

Administer IV antipseudomonal monotherapy (Cefepime 50 mg/kg IV max 2g) within 60 MINUTES of triage; mortality rises each hour delayed

Central Line Blood Cultures

Draw blood cultures from EVERY lumen of any central venous catheter (Broviac, Port-a-Cath, PICC) PLUS a peripheral culture

Rasburicase (TLS Antidote)

0.15 to 0.20 mg/kg IV in 50 mL NSS over 30 min; recombinant urate oxidase enzymatically converts uric acid to allantoin within 4 hours

Rasburicase G6PD Warning

Rasburicase generates hydrogen peroxide during uric acid breakdown; strictly CONTRAINDICATED in G6PD deficiency (causes fatal hemolysis/metHb)

Anterior Mediastinal Mass Trap

Children with anterior mediastinal masses can suffer TOTAL AIRWAY COLLAPSE upon supine positioning or paralytic administration for intubation

Bottom-Line Clinical Pearl

In pediatric oncology, Febrile Neutropenia is defined as a single oral temperature >= 38.3°C (101°F) or >= 38.0°C (100.4°F) sustained over 1 hour in a patient with an Absolute Neutrophil Count (ANC) < 500/mcL (or expected to fall < 500). It is an extreme medical emergency: administer an IV antipseudomonal beta-lactam (Cefepime 50 mg/kg IV or Piperacillin-Tazobactam 80 mg/kg IV) within 60 MINUTES of arrival. Tumor Lysis Syndrome (TLS) occurs spontaneously or post-chemotherapy in high-bulk hematologic malignancies (ALL, Burkitt lymphoma); administer aggressive IV hydration without potassium (2–3 L/m2/day) and Rasburicase 0.15–0.20 mg/kg IV to convert insoluble uric acid into soluble allantoin.

1. Febrile Neutropenia: The 60-Minute Protocol

Chemotherapy-induced myelosuppression leaves pediatric cancer patients without sufficient functioning granulocytes to mount an inflammatory response. Physical signs of infection (erythema, fluctuance, purulent sputum, meningismus) are typically absent; fever is often the only herald of life-threatening bacteremia. Gram-negative enteric bacilli (Pseudomonas aeruginosa, E. coli, Klebsiella) can progress from fever to septic shock and death within hours.

Component	Clinical Definition & Criteria	Emergency Action Protocol
Fever Threshold	Single oral temperature $\ge 38.3^\circ\text{C}$ ($101^\circ\text{F}$) OR sustained temperature $\ge 38.0^\circ\text{C}$ ($100.4^\circ\text{F}$) over 1 hour	Never check rectal temperatures (risk of mucosal tears and bacteremia).
Neutropenia Definition	Absolute Neutrophil Count (ANC) < 500/mcL (or $< 1,000\text{/mcL}$ with anticipated nadir)	$ANC = \text{WBC} \times [(\%\text{segs} + \%\text{bands})/100]$. If ANC $< 100\text{/mcL}$ ('profound neutropenia'), risk of bacteremia exceeds 30%.
First-Line Antimicrobial	Intravenous monotherapy antipseudomonal beta-lactam	Cefepime 50 mg/kg IV (max 2g) OR Piperacillin-Tazobactam 80 mg/kg IV (max 4.5g). Must be infused within 60 minutes of ED arrival.
Vancomycin Indications	Add Vancomycin (15 mg/kg IV q6h) ONLY for specific criteria	Catheter-site erythema/purulence, hemodynamic instability/shock, mucosal barrier injury, known MRSA colonization, or recent high-dose cytarabine.

2. Tumor Lysis Syndrome (TLS) & Cairo-Bishop Criteria

Massive rapid destruction of malignant lymphoid or blast cells releases intracellular ions and nucleic acids into the circulation, precipitating hyperkalemia, hyperphosphatemia, secondary hypocalcemia (precipitation of calcium phosphate in tissues and renal tubules), and hyperuricemia.

Electrolyte Abnormality	Cairo-Bishop Laboratory Threshold	Pathophysiologic Threat & Resuscitation Target
Hyperkalemia	Potassium $\ge 6.0\text{ mEq/L}$ (or $25\%$ rise above baseline)	Lethal ventricular arrhythmias and asystole. Treat with calcium gluconate, insulin + dextrose, and continuous telemetry. Zero potassium in all IV fluids!
Hyperuricemia	Uric acid $\ge 8.0\text{ mg/dL}$ ($476\text{ mcmol/L}$)	Uric acid crystallizes in acidic renal collecting ducts, causing acute obstructive nephropathy. Treat with Rasburicase 0.2 mg/kg IV.
Hyperphosphatemia	Phosphorus $\ge 6.5\text{ mg/dL}$ in children	Precipitates with calcium into renal interstitium; oral phosphate binders (sevelamer).
Hypocalcemia	Corrected calcium $\le 7.0\text{ mg/dL}$ (or ionized Ca $< 1.12\text{ mmol/L}$)	Tetany, seizures, QT prolongation. Treat ONLY if symptomatic (seizures, tetany); exogenous calcium increases calcium-phosphate precipitation and renal failure!

Board & Shelf Drill 5 Questions • Untimed Tutor Mode

Test Your Pediatric Oncology Emergencies: Febrile Neutropenia & Tumor Lysis Clinical Acumen

Directly launch an active-recall practice block from our 8,400+ validated COMLEX Level 1, 2-CE & 3 board question bank with complete explanations.

Related Emergency Protocols & Differentials

Related EM Protocol