Suspected Acute Leukemia in the ED

 Key ED Interventions for patients with astronomically high WBC counts:

• Usually talking about WBC counts over 200,000 or so (can be lower in lymphocytic leukemia)
• Hydrate aggressively
• Avoid PRBC transfusions as blood products will increase the patient's cytocrit (combination of WBC, platelets, and RBC) and predispose to organ malperfusion. This may lead to WBC (or blast) sludging in the microcirculation and may result in CNS bleeds. 
• Obviously, call for help immediately! Get a hematologist on the line quickly
• Assume the patient already has Tumor Lysis Syndrome and administer Allopurinol in a dose of 300 mg orally.
• Obtain a uric acid level, and if high, give an intravenous infusion of Rasburicase-eliminates preformed uric acid released from leukemia cell lysis. Renal failure results from high uric acid levels. We have this medication at University.
• The treatment of choice is initiation of definitive chemotherapy....clearly not an option for us in the ED. You can also do leukapheresis (where you take out WBC)....also not an option unless you have a special catheter and a perfusionist/nurse. BUT, you can take off a unit or two of blood (phlebotomy). This will potentially lower the patient's cytocrit.