Leukaemia are cancers of the bone marrow in which abnormal white blood cells multiply rapidly, crowding out healthy cells and impairing oxygen delivery, immunity, and clotting. Myeloma (multiple myeloma) is a plasma-cell cancer in the marrow that leads to bone lesions, anemia, infection risk, renal dysfunction, and hypercalcemia.
Left untreated, these leukaemia cells crowd out the healthy cells, leaving the body starved of oxygen, with little immunity to disease or infection and unable to ‘plug’ wounds in the skin and blood vessels.
Types of leukaemia:
- Acute myeloid leukaemia (AML)
- Acute lymphoblastic leukaemia (ALL)
- Chronic myeloid leukaemia (CML)
- Chronic lymphocytic leukaemia (CLL)
Emergency Signs & Complications
Recognize these life-threatening presentations and act without delay:
- Neutropenic Fever • Temperature ≥38 °C in a patient on chemotherapy or with known neutropenia. • Risk of overwhelming bacterial or fungal sepsis—call EMS immediately and keep patient warm.
- Severe Bleeding • Petechiae, spontaneous bruising, gum or nasal bleeding. • Engage a firm, sterile pressure dressing; elevate the bleeding area; seek urgent medical care.
- Anemia-Related Hypoxia • Profound weakness, tachycardia, shortness of breath, pallor. • Position upright; administer oxygen if available; call for emergency transport.
- Bone Pain & Spinal Cord Compression • Acute severe back pain, limb weakness, sensory changes, bladder or bowel dysfunction. • Immobilize spine in neutral alignment; do not flex or extend; summon EMS.
- Hyperviscosity Syndrome (mostly in myeloma) • Headache, visual disturbances, confusion, mucosal bleeding. • Keep patient supine and calm; provide supplemental oxygen; arrange urgent hospital transfer.
Immediate First Aid Steps
- Activate Emergency Response Call local EMS (e.g., 999/911) at first sign of neutropenic fever, unmanageable bleeding, hypoxia, spinal signs, or altered mental status.
- Airway, Breathing, Circulation (ABCs) • Ensure airway patency; sit patient upright if dyspneic. • Administer oxygen, monitor respiratory effort and SpO₂. • Check pulse, blood pressure, and capillary refill every 5 minutes.
- Control Bleeding • Apply direct pressure with a sterile dressing. • Elevate the limb above heart level if no fracture suspected. • Do not use tourniquets for generalized thrombocytopenic bleeding.
- Prevent Shock • Keep patient warm with blankets. • Position supine with legs elevated (~30°) if tolerated. • Reassure continuously to reduce anxiety and catecholamine surge.
- Pain Management & Comfort • Offer prescribed analgesics (e.g., paracetamol); avoid NSAIDs if thrombocytopenic. • Provide emotional support; minimize movement in cases of spinal involvement.
Do’s and Don’ts
| Do | Don’t |
|---|---|
| Call for professional help at first ominous sign | Wait for symptoms to “settle” before seeking care |
| Apply firm, sterile pressure over bleeding sites | Rub, massage, or apply heat to areas of bone pain or bleeding |
| Administer oxygen and monitor vitals | Give anticoagulants or NSAIDs without medical approval |
| Keep the patient warm, calm, and immobile if needed | Encourage oral fluids in nauseated or vomiting patients |
| Document time of symptom onset and interventions | Leave the patient unattended |
Prevention
Preventing bone disease
To prevent bone disease, offer people with myeloma:
- zoledronic acid or
- disodium pamidronate, if zoledronic acid is contraindicated or not tolerated or
- sodium clodronate, if zoledronic acid and disodium pamidronate are contraindicated, not tolerated or not suitable.
Consider immediately referring people with myeloma for dental assessment and treatment before starting zoledronic acid or disodium pamidronate..
For people who need urgent myeloma treatment, consider referring for dental assessment and treatment as soon as possible after they start treatment.
Managing non-spinal bone disease
Offer people with myeloma and non-spinal bone disease who have not already started bisphosphonates:
- zoledronic acid or
- disodium pamidronate, if zoledronic acid is contraindicated or not tolerated or
- sodium clodronate, if zoledronic acid and disodium pamidronate are contraindicated, not tolerated or not suitable.
Consider surgical stabilisation followed by radiotherapy for non-spinal bones that have fractured or are at high risk of fractures.
Consider radiotherapy for non-spinal bones that have fractured or are at high risk of fracture if surgical intervention is unsuitable or not immediately needed.
Consider radiotherapy for people with myeloma and non-spinal bone disease who need additional pain relief if:
- chemotherapy and initial pain management has not led to prompt improvement in pain control
- chemotherapy is unsuitable and current pain medication is not working.
Managing spinal bone disease
Offer all people with myeloma and spinal bone disease:
- bisphosphonates as follows, if not already started:-zoledronic acid or-disodium pamidronate, if zoledronic acid is contraindicated or not tolerated or-sodium clodronate, if zoledronic acid and disodium pamidronate are contraindicated, not tolerated or unsuitable
- systemic pain control, when relevant using the NICE guidelines on neuropathic pain and opioids in palliative care.
Consider the following as adjuncts to other treatments for all people with myeloma and spinal bone disease:
- interventional pain management
- bracing.
In people with radiological evidence of myeloma-related spinal instability, consider immediate intervention with:
- spinal surgery, with or without radiotherapy
- cement augmentation, with or without radiotherapy
- radiotherapy alone, if spinal intervention is unsuitable or not currently needed.
In people with radiological evidence of myeloma-related spinal bone disease without instability, consider:
- cement augmentation, with or without radiotherapy
- radiotherapy alone.
REFERENCES
- Myeloma: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2018 Oct. (NICE Guideline, No. 35.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553585/
- National Collaborating Centre for Cancer (UK). Myeloma: Diagnosis and Management. London: National Institute for Health and Care Excellence (UK); 2016 Feb. (NICE Guideline, No. 35.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK344101/
- H L Amonoo and others, Coping strategies in patients with acute myeloid leukemia, Blood Advances, April 2022. Volume 6, Issue 7, Pages 2435 to 2442
- Zweegman S, Engelhardt M, Larocca A; EHA SWG on ‘Aging and Hematology’. Elderly patients with multiple myeloma: towards a frailty approach? Curr Opin Oncol. 2017 Sep;29(5):315-321. doi: 10.1097/CCO.0000000000000395. PMID: 28763310.
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