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finals > palliative care > Flashcards

palliative care Flashcards

1
Q

e.g. simple anaglesia

A

paracetamol, nsaids

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2
Q

mechanism action paracetamol

A

inhibits production cns prsotaglandins

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3
Q

mechanism of action nsaids

A

inhibit cox enzyme in synthesis of prostaglandins

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4
Q

CI to nsaids

A

GI bleeding, ulcer hx, asthma

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5
Q

strong opioids

A

morphine, oxycodone, fentanyl, buprenorphine, diamorphine

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6
Q

weak opioids

A

codeine, dihydrocodeine, tramadol

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7
Q

opioids only used in palliative care

A

hydromorphone, alfentanil, diamorphine

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8
Q

SE opioid

A

common: constipation, nausea, sedation, dry mouth
less common: psychometric, confusion, myoclonus
rare: pruritis, resp depression, allergy

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9
Q

breakthrough pain dose

A

1/10 to 1/6 24 hr dose

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10
Q

strength of codeine and tramadol compared to oral morphine

A

1/10

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11
Q

what do you prescribe for SE of opioids

A

stimulant laxative and antiemetic

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12
Q

what opioids come in patches

A

fentanyl, buprenorphine

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13
Q

renal friendly opioids

A

oxycodone, fentanyl, buprenorphine, methadone, alfentanil

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14
Q

how strong is SC compared to oral opioid

A

2x

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15
Q

adjuvant analgesics

A

AD, antiepileptics, antisposmodics, steroids, benzos, local anaesthetics, bisphosphonates

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16
Q

how much should you increase the opioid dose by?

A

30-50%

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17
Q

which antiemetics for n+v due to reduces gastric motility

A

metoclopramide and domperidone

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18
Q

antimetic for chemically mediated N+V

A

ondansetron, haloperidol, levomepromazine

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19
Q

antiemetics for visceral/serosal N+V

A

cylclizine, levomepromazine

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20
Q

antimetics for raised icp n+v

A

cyclicine

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21
Q

antiemetic for vestibular n+v

A

cyclizine

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22
Q

antiemetic for cortical n+v

A

short acting benzo=lorazepam

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23
Q

mechanism of action of metocompramide

A

dopamine antagonist
therefore treats n+v due to gastric dysmotility and stasis

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24
Q

mechanism of action ondansetron

A

serotonin (5-HT3) antagnoist
therefore treats N+v due to chemotherapy, radiotherapy, post-op, chemical (opiods)

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25
Q

mechanism of action cyclizine

A

antihistaminic, anticholinergic
therefore treats intracranial causes n+v

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26
Q

mx for agitation and confusion

A

haloperidol
others: chlorpromazine, levomepromazine

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27
Q

mx agitation and restlessness in terminal phase

A

midazolam

28
Q

mx hiccups

A

chlorpromazine

29
Q

mx secretions

A

avoid fluid overload
hyoscine butylbromide or hyoscine hydrobromide

30
Q

causes and mx dyspnoea

A

HF: diuretics, ace i, nitrates, opioids
pneumonia: abx
bronchospasm: bronchodilators, steroids
SVCO: steroids, radiotherapy, chemo, stent
tracheal/bronchial obstruction: radiotherapy, stent
effusion/ascites: drain
anxiety: support, anxiolytics

31
Q

examples of palliative care emergencies

A

febrile neutropenia, stridor, superior vena cava obstruction, hypercalcaemia, spinal cord compression, opioid OD, haemorrhage

32
Q

who is neutropenic sepsis common in?

A

after chemo, haem patients, bone marrow infiltration and pancytopenia

33
Q

sx neustropenic sepsis

A

temp>38, infection-often chest or urine

34
Q

diagnosis neutropenic sepsis

A

clinical sepsis/>38 degrees, neutrophils < 0.5

35
Q

mx neutropenic sepsis

A

dont wait for blood results
broad spectrum abx, fluids,

36
Q

ix in neutropenic sepssi

A

fbc, u+e, lfts, crp, lactate, cultures

37
Q

who is superior vena cava obstruction common in

A

lung cancer or tumour involving mediostinum

38
Q

sx SVCO

A

facial swelling/red, periorbital oedema, engorged conjunctiva, arm swelling, breathless, distended chest veins
can be acute or chronic

39
Q

ix for SVCO

A

CT chest

40
Q

mx SVCO

A

dexamethason IV to reduce oedema
consider anticoag
stents, radio/chemo therapt

41
Q

who is stridor common in

A

head, neck, lung or upper GI tumour

42
Q

how is stridor detected

A

inspiratory noise
may not be breathless-late sign
need to visualise airway or ct

43
Q

mx stridor

A

dexamethasone, oxygen or heliox
ent or oncology
tracheostomy, stent, radiotherapy

44
Q

who is malignant hypercalcaemia common in

A

myeloma, thyroid/breast/lung/kidney cancers

45
Q

sx maligant hypercalcaemia

A

acute: thirst, confusion, constipation
chronic; depression, abdo pain, constipatuon, caliculi=BONES, STONES, MOANS AND GROANS
mimics dying

46
Q

diagnosis malignant hypercalcaemia

A

corrected Ca>2.6

47
Q

mx malignant hypercalcaemia

A

IV fluids, IV bisphosphonates, +/-denosumab

48
Q

who is malignant spinal cord compression common in

A

cancers that spread to bone-breast, lung, thyroid, kidney or prostate

49
Q

sx malignant spinal cord compression

A

paraesthesia, loss of sensation, weakness, cauda equina, loss of bladder and bowel function
back pain at night
non specific

50
Q

diagnosis malignant spinal cord compression

A

MRI
if cant- CT +/- myelography

51
Q

mx malignant spinal cord compression

A

dexamethasone, radiotherpay, surgery if fitter
lost function may not be regained

52
Q

who is massive haemorrhage common in

A

head/neck/lung/GI tumout

53
Q

what is a herald bleed

A

small bleed that gives warning massive haemorrhage may occur

54
Q

mx massive haemorrhagw

A

stop anticoag
depends on ceilings of care
if palliative likely terminal event: dark towels, comfort, midazolam 10mg to relieve stress

55
Q

sx opioid toxicity

A

decreased consciousness, RR<8, myoclonic jerks, pinpoint pupils

56
Q

SE opioids

A

confusion, hallucinations-shadows in corner of eyes, N+V, constipation

57
Q

mx opioid OD in palliative patient

A

dont give full dose of naloxone as otherwise will be in pain
usually give 400mcg in 10ml saline and give 20mcg every 2 mins until improves

58
Q

how to verify death

A

Identify the patient from their wristband
Feel for a carotid pulse to confirm absence
Assess pain response (i.e. squeeze trapezius muscle) to confirm absence
Use a pen torch to assess pupillary light response and confirm absence (i.e. fixed and dilated)
Auscultate for heart sounds for full minute to confirm absence
Auscultate for breath sounds for a full minute to confirm absence
Death is verified when all 6 of these have been done, and absence of all confirmed. The time at which this is completed should be noted - this is the official time of death for all legal purposes.

59
Q

which deaths need referring to a coroner

A

Unknown cause of death
Identity of deceased is unknown
Death occurred during or shortly after a period of police custody
No attending medical practitioner available to sign death certificate
Death may be due to undergoing a medical treatment or procedure
Death may be attributable to a person’s employment
All deaths within 24 hours of admission to hospital
When not seen by a medical practitioner in the 28 days prior to death
Poisoning (deliberate or accidental)
Exposure to toxic substances (including radioactive material)
Intake of medicinal products, controlled drugs or psychoactive substances (i.e. overdoses)
Death may be due to violence, trauma or injury (inflicted by someone else, themselves or an accident, including falls and road traffic accidents)
Death may be due to self-harm, or suicide
Death may be due to neglect, or self-neglect self-neglect or neglect on the behalf of others
Death may be due to an abortion

60
Q

what is 1a on a death certificate

A

These are diseases or illnesses which directly cause death - i.e. infections, acute events, life-limiting chronic illnesses

The Royal College of Pathologists issues a regularly updated ‘cause of death’ list (see References and Resources) as a guide
The top 5 causes of death (1a) in England and Wales (as of 2021):

  1. Dementia
  2. Ischaemic heart disease
  3. Lung cancer
  4. Stroke
  5. Chronic obstructive pulmonary disease
61
Q

what are 1b or 1c on a death certificate

A

1b is what may have led to 1a, and 1c is what may have led to 1b

62
Q

what is 2 on a death certificate

A

2 are other contributing conditions (not directly leading to 1a)

63
Q

how to break bad news-spikes

A

S Setting
P Perception
I Invitation
K Knowledge
E Emotion and empathic response
S Strategy and summary

64
Q

managing medicines in last few days of life

A

current medication reviewed;: unnecessary medicine discontinued, consider alternate route/preparation for essential meds
pre-emptivr prescribing for: Prescribe subcutaneous ‘as required’ pre-emptive medication on the ‘as
required’ part of the medication chart for the following symptoms.
Pain
Breathlessness/Dyspnoea
Terminal Restlessness and Agitation
Nausea and Vomiting
Respiratory Tract Secretions

65
Q

pre-emptive prescribing

A

Pain – morphine, ideally in a syringe driver, dose dependent on current medication
Breathlessness – morphine PRN 1-2 hourly
Agitation – midazolam PRN hourly
Secretions – hyoscine butylbromide PRN hourly
Nausea – haloperidol PRN 4 hourly

Mouth care, comfort cares

66
Q

converting codeine and tramadol to morphine

A

Codeine and tramadol are 1/10th as potent as morphine

finals (31 decks)

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