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Palliative Care > Chapter 6 - dealing with emergency conditions > Flashcards

Chapter 6 - dealing with emergency conditions Flashcards

1
Q

what are some emergency conditions that can occur in palliative care?

A 
malignant spinal cord compression
haemorrhage
neutropenic sepsis
SVC obstruction
hypercalcaemia 
seziures
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2
Q

what is malignant spinal cord compression?

A

compression fo the spinal cord or caudal equine (if below level L1/L2) by pressure from metastatic spread to and around the spine

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3
Q

how common is MSCC?

A

5-10% of all cancer patients

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4
Q

which cancers commonly metastasise to the spine?

A

breast
myeloma
lung
prostate

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5
Q

which area of the spine is affected most commonly in MSCC ?

A

thoracic spine (70%)

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6
Q

signs and symptoms of MSCC?

A

back pain - exacerbated by straining or coughing
sensory disturbance
sphincter disturbance
motor weakness - unexplained clumsiness or dragging feet

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7
Q

what two questions are commonly asked in patients with symptoms suggesting MSCC within palliative care to inform decision making re treatment?

A

1) does the patient have a reasonable likelihood of developing MSCC?
2) would the patient benefit from instigating emergency interventions and treatment?

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8
Q

what investigation is gold standard for MSCC?

A

MRI spine in 24 hours

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9
Q

initial immediate management of MSCC?

A

dexamethasone 8mg BD as soon as suspected - to reduce oedema
neurological symptoms can often be reversed if treatment is started in 24-48hrs of onset of symptoms

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10
Q

what are the indications for radiotherapy in MSCC?

A

radiosensitive tumour
multiple levels of compression
major surgery is contraindicated
usually 4-5 fractions

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11
Q

what is a vertebroplasty?

A

procedure to treat painful vertebral compression fracture, imaging is used to guide a percutaneous injection of cement into a fracture bone, or to insert a balloon into the bone to create space to then fill with cement

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12
Q

what are the indications for chemotherapy in MSCC?

A

tumour that is responsive to chemotherapy

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13
Q

what is the indication for corticosteroid treatment only in MSCC (i.e. not for radio or chemo)

A

final stages of terminal illness
patient too unwell or unlikely to respond to aggressive treatments
patient choice

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14
Q

what is the likelihood of improvement with treatment in MSCC?

A

70% of patients who could walk prior to MSCC, are able to regain the ability to walk
30% of patients with paraparesis will regain the ability to walk
5% of patients with established paraplegia will regain the ability to walk

however - only 30% of patients with MSCC survive longer than one year

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15
Q

what is SVC obstruction?

A

Obstruction of blood flow through the SVC, most commonly caused by compression or invasion by mediastinal lymph nodes, tumour or thrombus in the region of the right main bronchus

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16
Q

what cancers most commonly cause SVC obstruction?

A

cancer of right main bronchus + lymphomas (75%)

cancers of breast, colon, oesophagus and testes account for the rest

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17
Q

signs and symptoms of SVC obstruction?

A 
swelling of face, arms and neck
dilated neck vessels
breathlessness (laryngeal oedema) 
blue/purple discolouration of the face
headache
visual changes, engorged conjunctivae, periorbital oedema 
swelling around the eyes
18
Q

investigation for SVC obstruction?

A

CT - gold standard

19
Q

Management of SVC obstruction?

A

sit patient upright, and give 60% continuous oxygen
reassure patient
maintain calm environment
dexamethasone 16mg IV or orally
consider low dose anxiolytic to reduce anxiety
consider furosemide 40mg orally or IV
morphine for breathlessness

refer to oncology if appropriate, for consideration of stent, radiotherapy or chemotherapy

20
Q

what is the outcome for SVC obstruction (stats)?

A

only 17% of patients with SVC obstruction are alive after one year

21
Q

what causes hypercalcaemia?

A

increased osteoclast activity which release calcium from bone
decreased excretion in form of urinary calcium
this is caused by locally active products released from bone or by factors such as ectopic parathyroid hormone related protein

22
Q

how common in hypercalcaemia in the cancer population?

A

10%

23
Q

what tumours are most commonly associated with hypercalcaemia?

A

SCC of bronchus
breast Ca
prostate Ca
MM

24
Q

symptoms of hypercalcaemia?

A

groans moans bone and psychic undertones:

drowsiness, lethargy, fatigue 
confusion
nausea and vomiting 
thirst and polyuria 
constipation
weakness
25
Q

what level of calcium is considered to be hypercalcaemia?

A

> 2.6mmol/l is considered hypercalcaemia - however often mild and asymptomatic
3.0 usually causes symptoms
4.0 can cause death in a few days if not treated

26
Q

what is the management of hypercalcaemia?

A

1) fluids
2) bisphosphontes - inhibit osteoclast activity - pamidronate (60-90mg in 500ml NaCL over 3-4 hours will have effects for 2-3 weeks), zolendronate (4mg in 100ml NaCL over min 15 mins, effects will last up to 6 weeks, but is much more expensive than pamidronate)
3) check Ca levels - should be expected to fall in 48 hrs + keep falling for 6 days

27
Q

what is a serious side effect of bisphosphonates?

A

osteonecrosis of the jaw

after treatment patients should be encouraged to have good oral hygiene and regular check ups before each treatment

28
Q

what is the prognosis for patients who have hypercalcaemia?

A

poor - 80% of patients will survive less than 1 year

29
Q

what are the different levels of neutropenia in neutropenic sepsis (i.e mild - severe)?

A

mild neutropenia - 1 - 1.5 x 10^9/L = minimal infection risk
moderate neutropenia - 0.5-1 x 10^9/L = moderate risk of infection
severe neutropenia - <0.5 x 10^9/L = significant risk of infection

30
Q

what is neutropenic sepsis defined as?

A

symptoms or signs of infection in a patient who has a neutrophil count of <1.0 x 10^9/L

31
Q

which patients are most at risk of neutropenic sepsis?

A

post-chemo -> usually 7-10 days post treatment
haematology - oncology patients
elderly patients
poor general health
indwelling devices such as urinary catheter
co-morbidities

32
Q

what are some early symptoms of neutropenic sepsis?

A 
general feeling of malaise
hypotension and tachycardia
temp > 38 on one occasion
shivering and feeling hot and cold 
diarrhoea
33
Q

what may make diagnosing neutropenic sepsis more difficult?

A

administration of corticosteroids - this may mask infection and delay diagnosis

34
Q

what are some later signs of neutropenic sepsis?

A 
confusion
hypotension
tachycardia
febrile convulsions
hyperthermia
35
Q

what is the HEAT acronym?

A

History - is the patient at risk? are there signs and symptoms?
Examine - assess patients condition - temp, pulse, BP, RR, neutrophil count, blood cultures
Action - emergency admission to unit where IV abx can be given
Treatment- IV abx within 60 mins

36
Q

how common are seizures in palliative care?

A

13% of the palliative population experiences seizures
25-50% of these patients will have brain mets
20-45% of patients with a primary brain tumour will present with seizures, and more will develop them as their disease progresses

37
Q

what are some causes for seizures in the palliative population?

A

pre-exisitng epilepsy
primary or secondary brain tumour
metabolic complications i.e. hypercalcaemia, hypoglycaemia

38
Q

what can be some differential diagnoses for seizure?

A

hypoglycaemia causing LOC, vasovagal, postural hypotension, extrapyramidal effects of dopamine antagonist

39
Q

management of seizure?

A 
midazolam 10mg buccal 
or midazolam 5mg CSCI 
or rectal diazepam 
safe positioning of parent
support family
40
Q

what is a terminal haemorrhage/catastrophic bleeding?

A

patients with head and neck tumours, or oesophageal varices are at risk of having a terminal bleed from the tumour

41
Q

management of terminal haemorrhage?

A

non-drug:

  • call for help, but STAY with the patient
  • reposition as appropriate
  • use dark (green, blue, black) towels to hide the extent of the bleeding

emphasise comfort rather than medications, as they will lose consciousness quickly

drug:

  • midazolam 5-20mg IV in small boluses
  • midazolam 5-10mg IM
  • midazolam 10mg buccal

Palliative Care (10 decks)

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