Med D CBLs Flashcards
Red flags for spinal cord compression
Red flags
- Pain
a. In thoracic or cervical spine
b. Spinal pain aggravated by straining
c. Localised spinal tenderness
d. Nocturnal pain - Motor dysfunction
- Sensory dysfunction
- Bladder and bowel dysfunction
Management of Spinal cord compression
- Contact the MSCC co-ordinator
- Lie flat, log roll
- MRI WHOLE SPINE within 24hrs (T1,T2 sequences)
- DEXAMETHASONE 16MG STAT or split dosing (8MG BD)
- PPI
- Monitor glucose (due to giving steroids)
- Monitor for candida
- LMWH unless for surgical intervention
- WHO ladder for analgesia
- Consider DRE
- loss of anal tone in cauda equina
Measurement of what is associated with poorer prognosis in metastatic spinal cord compression?
- LDH
Side effects of opioids
- nausea and vomiting
- constipation
- confusion
- itch
- dry mouth (xerostomia)
- drowsiness
- hallucinations
- sweating
- LONG TERM: addiction, hypogonadism
Signs of opioid toxicity
- Drowsiness
- Hallucinations
- Confusion
- Pin point pupils
- Vomiting
- Respiratory depression
- myoclonus (involuntary jerking)
How much stronger is oxycodone immediate release liquid than morphine modified release?
1.5x more potent
Indications for continuous subcutaneous infusion
- Poor swallow and unable to tolerate essential medications: analgesia and anti-seizure medication
- Reduced consciousness and requiring essential medications like analgesia and anti-seizure medication
- Nausea and vomiting
- If absorption via the oral route is impaired for example in bowel obstruction
- Requiring more than 2 doses of injectable medication within 24hrs
How much stronger is oxycodone injection than oxycodone liquid:
2x more potent
Morphine should not be used with a GFR of what, what could be used instead?
GFR < 30
Use alfentanil instead
- can bypass renal excretion
- metabolises in liver
Managing constipation in palliative care patients
1st : Give either Senna (Stimulant) or Lactulose (osmotic)
2nd: Give BOTH Senna and Lactulose
THEN consider if opioid induced or not:
OPIOD INDUCED
- methylnaltrexone
- naloxagol
—-> peripherally acting opioid receptor antagonists
NOT OPIOD INDUCED
- try another laxative
- e.g. macrogol (osmotic)
- co-danthramer
- hydrogen hydroxide
LAST RESTORT –> RECTAL INTERVENTIONS
What might you give to help manage a palliative patients nausea?
- Assess potential causes
- Carry out IX and infection screen
- Consider antiemetics
—-> SUBCUT METOCLOPRAMIDE
———> cyclizine may help but might be constipating
Benefits and burdens of clinically assisted hydration for some palliative care patients:
BENEFITS
- symptom relief
- prolong or improve quality of life
- suffering because needs for nutrition or hydration are not met
- may worsen delirium, fatigue and thirst witholding CAH
- will make family feel better
BURDENS
- hindering natural death
- hydration may increase: nausea, dyspnoea, cough, resp secretions and need to urinate
- does not change prognosis
Cyclizine acts on what receptor
HISTAMINE H1
Haloperidol acts on what receptor
Dopamine D2 receptor
Odansetron acts on what receptor
Serotonin 5HT3 receptor
What is agonal breathing?
When someone who is not getting enough oxygen is gasping for air?
Signs and symptoms a patient may be entering last days or hours of life and likely to be dying?
- Reduced oral intake
- Difficulty swallowing
- Agonal breathing
- Overwhelming fatigue
- Fluctuating consciousness
- Confusion / delirium
- Reduced social interaction
Late signs a patient may be entering last stages of life
- Mottled skin
- Cool extremities
- Irregular respiration (Cheyne-Stokes breathing)
- Respiratory secretions
Converting from morphine modified release tablets to a continuous subcutaneous infusion?
Divide by 2
Please describe common symptoms a patient may encounter when dying and what medications you might give to combat this?
1. Agitation –> Midazolam 2.5-5mg PRN 1hrly
2. Resp secretions –> Glycopyrronium (also hyoscine hydrobromide or hyscine butyl bromide) 200 micrograms PRN 1hrly
3. Nausea –> cyclizine, haloperidol, levomepromazine
4. Pain/ breathlessness –> 1/6th of total opioid dose in continuous sub cut infusion
5. Delirium –> haloperidol 0.5-1.5mg (max 10mg in 24 hrs)
What information should be considered in an individualised care plan of a patient who is thought to be dying?
- Preferred place of care and death
- Preferences for symptom management, including anticipatory medications
- Any care needs after death
- Religious / spiritual needs
- Personal goals and wishes
- Resuscitation status
- Review of long term medications
- Physical needs
- Eating and drinking: hydration status
- Concerns regarding carers
How would you verify a death:
Listen for a minimum of 5 minutes:
- No visible respiratory effort
- No palpable large pulses
- No response to painful stimuli
- Pupils fixed and dilated
- No audible heart or breath sounds
- Absence of corneal reflex
Which patients should be discussed with the Coroner?
- if unknown cause of death
- death following an accident: road, work, inpatient
- not seen within last 28 days
- post operative death
- any suggestion of neglect, poor care
- death in detention - custody, prison
- industrial illness e.g. mesothelioma
- suicide
Death confirmation assessment notes
- Identify confirmed from wrist band
- Patient in bed , eyes closed, no signs of life or respiratory effort
- no palpable carotid pulse for 5 minutes
- no heart of respiratory sounds for 5 minutes
- pupils fixed or dilated
- no corneal reflex
- no response to supra-orbital pressure
- no concerns
Differential diagnoses for lump in neck:
Vascular: carotid body tumour
Infective: reactive lymphadenopathy, sialadenitis
Trauma: haematoma
Autoimmune: Grave’s disease
Neoplasm: Lymphoma, H&N ca. , salivary gland tumour, lipoma, malignant skin cancer
Congenital: cystic hygroma, thyroglossal cyst, branchial cyst, dermoid cyst
What type of cell is present in Hodgkin lymphoma?
Reed Sternberg cells
Which symptom is often diagnostic for Hodgkin Lymphoma:
Summary of symptoms
1. High temperature
2. Heavy drenching night sweats
3. Weight loss
4. Fatigue
5. Painless swollen lymph nodes: armpit, neck and groin
6. Splenomegaly
7. cough or breathlessness
Key symptoms
- PEL EBSTEIN FEVER
——> high fevers one to two weeks alternating with an afebrile period of around 1 week
What bloods and histological investigations may aid in the diagnosis of Hodgkin Lymphoma?
-
FBC —>
a. Anaemia? (anaemia of chronic disease, autoimmune haemolytic anaemia)
b. Thrombocytopenia (bone marrow involvement, ITP or splenomegaly)
c. Neutropenia
d. Lymphopenia
e. Eosinophilia - Hypercalcaemia (unusual)
a. vit D secretion by Hodgkin Reed Sternberg cells. - Biopsy + histology
a. Cell surface markers diagnostic:
1. CD30+
2. CD15+
3. CD20-
Key imaging in Hodgkin Lymphoma and clinical significance
- X-Ray
–> symptoms: SOB, chest pain and cough - USS
–> for cervical or supraclavicular lymph nodes
–> guide core biopsies
–> assess spleen size - CT Staging
–> to guide biopsy
–> staging of Hodgkin lymphoma - PET scan
–> for more accurate staging
–> patients assessed with PET after 2 cycles of chemo to guide further tx
Summarise treatment modalities for Hodgkin Lymphoma
1. Radiotherapy
- early disease
- tx for superior vena cava obstruction
2. Chemotherapy
- ABVD
- if still PET positive after 2 cycles —> BEACOPP
3. Chemo-immuno
- Brentuximab Vedotin
(anti-CD30 conjugate)
- if pt resistant to chemo OR replapse
4. Immuno
- PDL1 inhibitor
- Nivolumab
5. Transplant
- Autologous w/ high dose chemo
- allogenic from donor
Acute complications of Hodgkin lymphoma due to treatment
- Neuropathy
- Constipation (Vinblastine)
- Pulmonary toxicity (bleomycin –> lung fibrosis)
Late complications of Hodgkin lymphoma
-
Secondary malignancies
- acute myeloid leukaemia and other haematological malignancies
-
Cardiovascular disease
- Coronary artery disease, arrhythmias, cardiomyopathy and peripheral vascular disease
-
Pulmonary dysfunction
- pulmonary fibrosis, bronchiectasis and recurrent chest infections
-
Endocrine dysfunction
- hypothyroidism, diabetes mellitus
-
Fertility and pregnancy
- gonadal dysfunction with alkylating agents and radiotherapy to pelvic area.
- IVF may be required in young females
-
Neuromuscular complications
- neuropathy and muscular atrophy
— vinblastine and brentuximab
- neuropathy and muscular atrophy
-
Psychological issues
- impaired quality of life
- various mental health issues
Further investigations for suspected breast cancer
-
Grade and receptor status of the breast cancer
- oestrogen receptor
- progesterone receptor
- HER2
- Staging CT scan and bone scan
-
ECG and cardiac ECHO
- any cardiac issues that may influence treatment
- Grading determined with pathologist
- Staging via TNM system
Treatment summary for breast cancer
1. Neoadjuvant
- shrink tumour before surgery
2. Adjuvant
- Tx AFTER surgery
—> ANTHRACYCLINE & TAXANE
—–> 2-3 week cycles
3. Radiotherapy
- chest wall / breast
- given in fractions
- damages DNA
4. Hormone
- tamoxifen
- anastrozole (post menopausal)
5. Trastuzumab
- herceptin
6. Palliative
What is given in Adjuvant treatment for breast cancer to prevent neutropenic sepsis?
anthracycline and a taxane (cycles ever 2-3 weeks)
- G-CSF (growth factor) given to prevent neutropenic sepsis.
What scoring system is used to see who would benefit from adjuvant breast cancer treatment?
ONCOTYPE DX score
PREDICT score
Types of benign breast lumps
- Fibroadenoma
- papilloma
- adenoma
- lipoma
- phyllodes tumour
