When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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EmergentHeme/Onc

Superior Vena Cava Syndrome

Obstruction of SVC → facial/upper extremity swelling, JVD, dyspnea. Malignancy causes 60-85% (lung cancer #1, lymphoma #2). Thrombosis 20-40% (central venous catheters, pacemaker leads). CT with IV contrast is diagnostic. Endovascular stenting provides fastest relief. True emergency only if airway compromise or cerebral edema.

🔍 Overview

Etiology

Cause	Frequency	Details
Lung cancer	~50%	NSCLC > SCLC. Right-sided tumors compress SVC directly. #1 malignant cause.
Lymphoma	~15%	Mediastinal mass, NHL > Hodgkin. Often highly chemo-sensitive.
Other malignancy	~10%	Thymoma, germ cell tumors, metastatic disease (breast, renal).
Thrombosis (catheter-related)	20–40%	Central venous catheters, ports, pacemaker/defibrillator leads, dialysis catheters. Rising incidence with increasing device use.
Other benign	<5%	Fibrosing mediastinitis (histoplasmosis), aortic aneurysm, goiter, sarcoidosis.

Pathophysiology

SVC obstruction (extrinsic compression, intraluminal thrombus, or direct invasion) → venous hypertension in head, neck, upper extremities
Collateral formation, azygos, internal mammary, lateral thoracic, paraspinous veins dilate over days to weeks to decompress
Gradual onset allows collateral development → most patients are hemodynamically stable
Rapid-onset obstruction (e.g., acute thrombosis) → insufficient collaterals → more severe symptoms, higher risk of cerebral edema

Clinical Presentation

Facial and neck swelling, periorbital edema, facial plethora (worse in the morning, worse when bending forward or supine)
Upper extremity edema, bilateral, non-pitting
Dyspnea, most common symptom (~60%), from laryngeal/bronchial edema or pleural effusion
Cough, hoarseness, vocal cord or recurrent laryngeal nerve edema
Head fullness, headache, worse when bending forward (Pemberton sign)
JVD, prominent chest wall veins, visible collateral circulation across anterior chest
Pemberton sign, facial plethora, JVD, and dyspnea when arms raised above head for 1 minute

Pemberton Sign: Ask the patient to raise both arms above the head for 60 seconds. Positive if facial congestion, cyanosis, or respiratory distress develop. Indicates thoracic inlet obstruction, highly suggestive of SVC syndrome or large mediastinal mass.

Severity Grading

Grade	Description	Symptoms	Urgency
Grade 0	Asymptomatic	Radiographic SVC obstruction only, no symptoms	Non-urgent
Grade 1	Mild	Facial/neck edema, mild dyspnea, no functional limitation	Non-urgent
Grade 2	Moderate	Significant edema, moderate dyspnea with exertion, head fullness	Semi-urgent
Grade 3	Severe	Severe edema, dyspnea at rest, mild cerebral symptoms (headache, dizziness)	Urgent
Grade 4	Life-threatening	Stridor, laryngeal edema, cerebral edema (AMS, seizures), hemodynamic collapse	Emergency

True Emergency (Grade 4 only): Stridor or airway compromise, cerebral edema (altered mental status, obtundation, seizures), or hemodynamic instability. This is an oncologic emergency requiring immediate intervention (stenting, dexamethasone, possible emergent radiation). Most SVC syndrome is Grade 1-3, evolves over days to weeks with collateral formation and is NOT an immediate life threat. Do not panic, get tissue diagnosis first in stable patients.

🧪 Workup

Imaging

Study	Role	Details
CT chest with IV contrast	Test of Choice	Shows mass location/size, intraluminal thrombus, extent of SVC obstruction, collateral vessels, and guides biopsy planning. Sensitivity >95%.
CT venography (CTV)	Alternative	Better visualization of venous anatomy and thrombus extent. Use if contrast allergy with premedication.
MR venography (MRV)	Contrast allergy	No iodinated contrast needed. Good for thrombus and soft tissue detail. Slower, less available emergently.
Chest X-ray	Initial screen	Mediastinal widening (64%), pleural effusion (26%), right hilar mass. Normal CXR does NOT rule out SVC syndrome.
Venous duplex US	Adjunct	Upper extremity venous duplex if catheter-related thrombosis suspected. Cannot visualize intrathoracic SVC directly.

Laboratory Studies

CBC with differential, leukocytosis (infection vs paraneoplastic), anemia
BMP, renal function (contrast planning), electrolytes
LDH, elevated in lymphoma, germ cell tumors
Uric acid, tumor lysis syndrome screen if bulky malignancy suspected
Coagulation studies, PT/INR, PTT (baseline before biopsy, anticoagulation planning)
AFP, beta-hCG, if mediastinal germ cell tumor suspected (young male with anterior mediastinal mass)
Flow cytometry, if lymphoma suspected (peripheral blood or tissue)

Tissue Diagnosis

Tissue diagnosis is CRITICAL before treatment in stable patients. Treatment depends entirely on histology. Empiric radiation can obscure the tissue diagnosis and render the tumor unbiopsyable. Only bypass biopsy if Grade 4 (airway compromise, cerebral edema).

CT-guided percutaneous biopsy, preferred if accessible mass, high diagnostic yield
Bronchoscopy with biopsy, if endobronchial lesion or central mass
Mediastinoscopy, direct visualization, higher yield but more invasive; GA risk in patients with severe SVC syndrome (airway collapse)
Thoracoscopy (VATS), for peripheral or pleural-based masses
Sputum cytology, low yield but non-invasive; reasonable first step
Lymph node biopsy, if palpable supraclavicular or cervical node (excisional preferred for lymphoma)

🚨 Management

Emergent Management (Grade 4, Airway/Cerebral Edema)

Elevate head of bed to 30-45 degrees, reduces venous pressure in head/neck
Dexamethasone 4 mg IV q6h, reduce airway and cerebral edema; especially effective if lymphoma suspected
Endovascular SVC stenting, fastest symptom relief (within hours). >90% technical success rate. Procedure of choice for emergent obstruction regardless of etiology
Emergent radiation, consider if stenting unavailable; 250-400 cGy x 2-4 fractions. Rapid shrinkage of radiosensitive tumors
Secure airway, prepare for difficult intubation (laryngeal edema); consider awake fiberoptic intubation. Avoid sedation that may worsen respiratory compromise
Supplemental O₂, maintain SpO₂ > 92%

Do NOT delay treatment for tissue diagnosis in Grade 4. Stent first, biopsy later. Airway protection takes absolute priority. Tissue can be obtained after stabilization.

Malignancy-Related SVC Syndrome

Tumor Type	Primary Treatment	Response	Notes
SCLC	Cisplatin/Etoposide chemotherapy	Highly chemo-sensitive (77% response)	Most responsive malignancy. Chemo is first-line, not radiation.
Lymphoma (NHL/HL)	R-CHOP or regimen-specific chemo	Highly chemo-sensitive (>80% response)	Steroids alone may produce dramatic shrinkage initially. Need tissue BEFORE steroids if possible (can obscure lymphoma dx).
NSCLC	Radiation ± chemotherapy	Moderate (60% response)	Less chemo-sensitive than SCLC. Radiation provides local control. Consider immunotherapy/targeted therapy based on molecular markers.
Germ cell tumor	BEP chemotherapy	Highly chemo-sensitive	Young males, anterior mediastinal mass. Check AFP/beta-hCG.
Thymoma	Surgery ± radiation	Variable	Surgical resection if feasible. Radiation for unresectable.

Endovascular stenting, symptomatic relief in 24-72 hours, >90% success rate. Used as bridge to definitive chemo/radiation, or for recurrent/refractory obstruction
Radiation therapy, for NSCLC and less chemo-sensitive tumors. Can be combined with chemo. Onset of relief in 1-2 weeks.

Thrombosis-Related SVC Syndrome

Anticoagulation, heparin infusion (aPTT-guided) → transition to warfarin or DOAC (rivaroxaban, apixaban). Duration: minimum 3 months; longer if ongoing risk factor (indwelling catheter)
Catheter removal, remove the offending catheter if no longer needed and safe to do so. If catheter is essential (e.g., chemo port), anticoagulate and consider exchange
Catheter-directed thrombolysis, alteplase infusion via catheter for acute/severe thrombosis with significant symptoms. Best results within 5-7 days of symptom onset
Endovascular stenting, for persistent stenosis after anticoagulation/thrombolysis, or if recurrent thrombosis

Supportive Care

Elevate HOB, 30-45 degrees at all times to reduce venous congestion
Supplemental O₂, titrate to SpO₂ > 92%
Diuretics, limited role (furosemide 20-40 mg IV). May provide temporary symptom relief by reducing intravascular volume but does not address obstruction. Avoid aggressive diuresis in dehydrated patients.
Avoid upper extremity IV access on affected side, elevated venous pressure causes unreliable drug delivery, inaccurate BP readings, and risk of compartment syndrome with tourniquets. Use lower extremity or femoral access.
DVT prophylaxis, consider in lower extremities (upper extremity already anticoagulated if thrombotic)

💊 Medications

Corticosteroids & Supportive

Drug	Dose	Purpose	Notes
Dexamethasone (Decadron)	4 mg IV q6h	Reduce airway/cerebral edema	First-line in emergent SVC syndrome. Especially effective if lymphoma suspected. Taper over 5-7 days once definitive treatment initiated.
Furosemide (Lasix)	20–40 mg IV	Temporary edema reduction	Limited evidence. May reduce intravascular volume and provide symptomatic relief. Avoid in dehydrated patients.

Anticoagulation (Thrombotic SVC Syndrome)

Drug	Dose	Monitoring	Notes
Heparin (UFH)	80 u/kg bolus → 18 u/kg/hr infusion	aPTT q6h (target 60-80s)	Preferred for acute/severe thrombosis. Short half-life, reversible with protamine. Bridge to oral anticoagulation.
Enoxaparin (Lovenox)	1 mg/kg SC q12h	Anti-Xa levels if renal impairment	Alternative to UFH for stable patients. Avoid if CrCl < 30 (use UFH instead).
Rivaroxaban (Xarelto)	15 mg BID x 21 days → 20 mg daily	CrCl, LFTs	Oral option for transition. No monitoring required. Avoid with strong CYP3A4 inhibitors.
Apixaban (Eliquis)	10 mg BID x 7 days → 5 mg BID	CrCl, LFTs	Preferred DOAC in renal impairment (less renal clearance). Safe down to CrCl 15.
Warfarin (Coumadin)	5 mg daily (adjust to INR 2-3)	INR q1-2 days until stable	Traditional option. Overlap with heparin x 5 days AND INR > 2 x 24h before stopping heparin.

Thrombolytics

Drug	Dose	Route	Notes
Alteplase (Activase)	0.5-1 mg/hr infusion x 12-24h	Catheter-directed	For acute thrombotic SVC syndrome (< 5-7 days). Lower dose than systemic lysis → fewer bleeding complications. Monitor fibrinogen q6h.

Chemotherapy by Cancer Type

Cancer	Regimen	Key Agents	Response to SVC Syndrome
SCLC	EP (Etoposide/Cisplatin)	Cisplatin 75 mg/m² D1 + Etoposide 100 mg/m² D1-3	77% response rate. Most chemo-responsive cause of SVC syndrome.
DLBCL (NHL)	R-CHOP	Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone	>80% response rate. Steroids alone may produce initial response.
Hodgkin	ABVD	Doxorubicin, Bleomycin, Vinblastine, Dacarbazine	Excellent response. Highly curable lymphoma.
Germ cell	BEP	Bleomycin, Etoposide, Cisplatin	Highly chemo-sensitive. Cure rates > 90% for good-risk disease.

📋 On Rounds

Pimp Questions

Why should you obtain tissue diagnosis before treating SVC syndrome?

Because treatment depends entirely on histology. SCLC gets chemo (cisplatin/etoposide), NSCLC may get radiation or targeted therapy, lymphoma gets R-CHOP. Empiric radiation can obscure tissue diagnosis and render the tumor unbiopsyable. Exception: Grade 4 (airway compromise, cerebral edema), stent first, biopsy later.

What is the fastest intervention for symptomatic SVC syndrome and what is its success rate?

Endovascular SVC stenting, symptom relief within hours, >90% technical success rate. Works regardless of etiology (malignant or thrombotic). Used as bridge to definitive chemo/radiation or as standalone for refractory obstruction. Preferred over emergent radiation because it provides immediate mechanical relief without obscuring tissue diagnosis.

Why should you avoid upper extremity IV access and BP measurements in SVC syndrome?

Avoid upper extremity IV access, blood draws, and BP measurements on the affected side. Venous pressures are markedly elevated → (1) IV fluids/drugs won't flow properly, (2) BP readings are inaccurate (falsely elevated venous component), (3) tourniquets can worsen edema and cause compartment syndrome. Use lower extremity or femoral access instead.

What is the Pemberton sign and what does it indicate?

Pemberton sign: ask the patient to raise both arms above the head for 60 seconds. Positive if facial congestion, cyanosis, JVD, or respiratory distress develop. Indicates thoracic inlet obstruction, the raised arms compress the thoracic outlet further, worsening SVC obstruction. Highly suggestive of SVC syndrome or large mediastinal mass. Simple bedside test.

Which malignancies causing SVC syndrome are most chemo-sensitive?

SCLC (77% response) and lymphoma (>80% response) are the most chemo-sensitive. For both, chemotherapy is first-line, NOT radiation. NSCLC is less responsive (~60%). Key point: steroids alone can dramatically shrink lymphoma, so avoid giving steroids before biopsy if lymphoma is suspected (can obscure the diagnosis and make tissue non-diagnostic).

How do you manage SVC syndrome caused by catheter-related thrombosis?

Anticoagulation (heparin → DOAC or warfarin) for minimum 3 months. Remove the catheter if no longer essential. If acute/severe (< 5-7 days), consider catheter-directed thrombolysis with alteplase. Endovascular stenting for persistent stenosis or recurrent thrombosis. If catheter is essential (e.g., chemo port), anticoagulate and consider exchange over a wire.

Clinical Examples

📋 Case 1, Lung Cancer with Progressive SVC Syndrome

Patient: 64 y/o M, 40-pack-year smoker, presents with 2 weeks of progressive facial swelling, neck fullness, and dyspnea on exertion. Notes his wedding ring and watch have become tight.

Key findings: Facial plethora, bilateral upper extremity edema, prominent chest wall veins. Pemberton sign positive. SpO₂ 94% on RA. CT chest: 6 cm right hilar mass encasing SVC with 80% luminal narrowing and extensive collateral vessels.

Management:

Elevate HOB to 45 degrees. Supplemental O₂ via NC.
Grade 2-3, stable, NOT an emergency. Pursue tissue diagnosis before treatment.
CT-guided biopsy → NSCLC (squamous cell). PD-L1 testing and molecular profiling sent.
Endovascular SVC stenting for symptomatic relief (facial edema significantly impairing quality of life).
Definitive treatment: concurrent chemoradiation based on staging workup.

Teaching point: Most SVC syndrome from lung cancer evolves over weeks with collateral formation. Resist the urge to treat empirically, tissue diagnosis first. Stenting provides rapid symptomatic relief while awaiting definitive therapy.

📋 Case 2, Lymphoma with Acute Airway Compromise

Patient: 28 y/o M presents with 5 days of rapidly progressive facial swelling, orthopnea, and now stridor. Found to have anterior mediastinal mass on CXR.

Key findings: Severe facial edema, cyanotic, audible stridor, SpO₂ 88% on 15L NRB. CT chest: large anterior mediastinal mass compressing SVC and main bronchi. LDH 1,200, uric acid 9.2.

Management:

Grade 4, TRUE EMERGENCY. Do NOT delay treatment for tissue diagnosis.
Dexamethasone 10 mg IV stat, then 4 mg IV q6h (lymphoma likely, steroids may be cytolytic).
Emergent SVC stenting for airway and venous decompression.
Tumor lysis syndrome prophylaxis, aggressive IVF, rasburicase for uric acid 9.2.
Once stabilized: core needle biopsy → DLBCL confirmed. Start R-CHOP.

Teaching point: Grade 4 SVC syndrome with stridor is the one true emergency. Stent and steroids first. In young patient with anterior mediastinal mass + elevated LDH, lymphoma and germ cell tumor are top differentials. Always screen for TLS in bulky malignancy.

📋 Case 3, Catheter-Related SVC Thrombosis

Patient: 55 y/o F with metastatic breast cancer and right subclavian port placed 6 months ago. Presents with 3 days of right arm swelling, facial puffiness, and mild dyspnea.

Key findings: Right arm edema, mild facial edema, right-sided JVD. No stridor, no AMS. CT chest with contrast: thrombus extending from port tip into SVC with 60% occlusion. No progression of her known lung metastases.

Management:

Grade 1-2, thrombotic, not malignant compression. Not an emergency.
Start heparin infusion (aPTT-guided) → transition to apixaban 10 mg BID x 7 days → 5 mg BID.
Port still needed for ongoing chemo, do NOT remove. Anticoagulate through the port.
If symptoms worsen despite anticoagulation → catheter-directed thrombolysis or stenting.
Minimum 3 months anticoagulation; consider indefinite while port remains in place.

Teaching point: Catheter-related SVC thrombosis is managed medically with anticoagulation, not chemo/radiation. Remove the catheter only if it is no longer needed. Anticoagulation duration extends as long as the risk factor (device) persists.

📣 Sample Presentation

One-Liner

"Mr. Davis is a 64-year-old with 40-pack-year smoking history who presented with 2 weeks of progressive facial and bilateral upper extremity edema, dyspnea, and prominent chest wall collaterals. CT chest shows a 6 cm right hilar mass with 80% SVC occlusion. Biopsy confirmed squamous cell NSCLC. He underwent SVC stenting yesterday with significant improvement and is being staged for concurrent chemoradiation."

Key Points to Cover on Rounds

Etiology: malignant vs thrombotic. Severity grade (1-4). Tissue diagnosis status, biopsy done? Histology result? Stent placed? Symptom trajectory, facial edema improving or worsening? Airway status, any stridor, voice changes, dyspnea trend? Access, all IVs and BP in lower extremities? Definitive treatment plan, chemo/radiation/anticoagulation timeline. TLS risk if bulky malignancy.

Daily Rounds Checklist

Airway assessment → stridor, voice changes, dyspnea severity? Grade today vs yesterday?
Edema trajectory → facial/arm edema improving or worsening? Measure arm circumference daily.
SpO₂ trend → O₂ requirement stable or increasing?
Tissue diagnosis → biopsy done? Pathology back? Flow cytometry results? Molecular markers pending?
Stent status → if stented, any complications (migration, re-occlusion)? Dual antiplatelet therapy started?
Anticoagulation → if thrombotic: aPTT in range? Transitioning to oral? Duration plan?
Access → ALL IVs, blood draws, and BP cuffs on lower extremities? No upper extremity access on affected side?
TLS screen → if bulky malignancy: uric acid, potassium, phosphorus, calcium, LDH trending?
Definitive treatment plan → oncology consulted? Chemo/radiation start date? IR follow-up if stented?
HOB elevated → maintained at 30-45 degrees?

Monitoring

Parameter	Frequency	Target / Action
Airway assessment (stridor, voice)	q4h initially	Any new stridor = emergent reassessment + ICU
SpO₂	Continuous	> 92%; escalate O₂ delivery if dropping
Facial/arm edema	q8-12h	Measure arm circumference. Document subjective improvement.
aPTT (if on heparin)	q6h until stable	Target 60-80 seconds (1.5-2.5x control)
CBC	Daily	Monitor for thrombocytopenia (HIT screen if platelets drop > 50%)
BMP	Daily	Renal function, electrolytes (especially if TLS risk)
LDH, uric acid	q12-24h if TLS risk	Rising uric acid → rasburicase; rising K⁺/PO₄ = TLS
Repeat CT chest	After treatment initiation	Assess response: tumor shrinkage, stent patency, collateral resolution

⚡ Summary

Etiology

Malignancy 60-85% (lung cancer #1, lymphoma #2). Thrombosis 20-40% (catheters, pacemakers). Benign causes rare (<5%).

Presentation

Facial/arm edema, JVD, dyspnea, prominent chest wall collaterals. Worse supine/bending forward. Pemberton sign positive.

Diagnosis

CT chest with IV contrast (test of choice). Get tissue biopsy BEFORE treatment in stable patients. Bypass biopsy only for Grade 4.

Emergent (Grade 4)

Airway/cerebral edema. Dexamethasone 4 mg IV q6h + emergent SVC stenting. Do NOT delay for biopsy.

Malignant Rx

SCLC/lymphoma → chemo (most responsive). NSCLC → radiation ± chemo. Stenting for rapid symptom relief (>90% success).

Thrombotic Rx

Anticoagulation (heparin → DOAC). Remove catheter if possible. Catheter-directed thrombolysis if acute/severe.

Avoid

Upper extremity IVs, BP, blood draws on affected side. Use femoral/lower extremity access only.

Key Pearl

Most SVC syndrome is NOT a true emergency. Collaterals form over days-weeks. Only Grade 4 (stridor, cerebral edema) requires emergent treatment.

📄 One Pager

Heme/Onc · One Pager

SVC Syndrome

Tissue diagnosis first (unless Grade 4). Stenting = fastest relief. SCLC and lymphoma are most chemo-responsive. Avoid upper extremity access.

🔬 Etiology

Lung cancer, #1 cause (~50%), right-sided tumors
Lymphoma, #2 (~15%), NHL > Hodgkin
Thrombosis, 20-40%, catheters/pacemakers/ports
Other, thymoma, germ cell, fibrosing mediastinitis

🩺 Clinical Features

Facial/neck/arm edema (worse bending forward)
Dyspnea, cough, head fullness
JVD, chest wall collateral veins
Pemberton sign (arms raised → facial congestion)
Grades 0-4 (only Grade 4 = true emergency)

⏱️ Emergency (Grade 4) Algorithm

Elevate HOB to 45°. Supplemental O₂. Prepare for difficult airway.

Dexamethasone 4 mg IV q6h, reduce airway/cerebral edema immediately.

Emergent SVC stenting, fastest relief (>90% success). Call IR stat.

Tissue diagnosis AFTER stabilization, biopsy once airway is secured.

💉 Malignant Rx

SCLCCisplatin/Etoposide (77%)

LymphomaR-CHOP (>80%)

NSCLCRadiation ± chemo (60%)

Germ cellBEP (highly sensitive)

SVC stentBridge or refractory

🩸 Thrombotic Rx

Heparin (UFH)80 u/kg → 18 u/kg/hr

Enoxaparin1 mg/kg SC q12h

Apixaban10 BID x7d → 5 BID

Catheter-directed tPA0.5-1 mg/hr x 12-24h

Remove catheterIf no longer needed

⚠️ Pitfalls

Treating before tissue diagnosis
Upper extremity IVs or BP on affected side
Calling all SVC syndrome an "emergency"
Steroids before biopsy (obscures lymphoma)
Missing TLS in bulky malignancy
Forgetting to screen for germ cell (AFP, hCG)