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