Palliative Care Flashcards
Approach To Dyspnoea
Acid base balance not a Dx but a catch all
Bad blood = carboxyhaemoglobin/ Methemoglobinemia
Anaemia - don’t worry about the type at first. Just Dx
- SOB, fatigue, tiredness, pale skin, dizziness
Same w CHF - exacerbation the same whichever type
-SOB, Orthopnoea, PND, Crackles, chest pain
Pleuritic Pain + SOB narrows it
- pneumothorx, pneumonia, PE, pulmonary effusion, CA
- Obstructive and restrictive
- DAH = diffuse alveolar Haemorhage
IX
Always these (BNP debatable)
ABG - covers top two
CXR - covers bottoms two
ECG - arythmia/MI
BNP- CHF
SATS - also do these. generally want >92%
order all before you get there and cancel if you don’t need
Pneumothroax
<2cm rim and not SOB discharge
if <2cm SOB then aspiration
if >2cm and >50 or SOB after aspiration then instert chest drain
Headache
Secondary
want to first consider secondary and ask RED FLAGS
SAH = worst HA
Tumour = FND with progressive N/V
Abscess = fever/HA/FND
Meningitis = Fever and HA
will proabbly follow up with one or more of those IX
Primary HA
Tension
Common one that people usualy tx themselves
Bilateral vice like pain that starts in the front and radiates backt to the neck
might be exacerbated by loud noise and exercise but no photo/phonophobia
If they have > 2 days a week consider prophylaxis (10 sessions of accupuncture or amitriptyline 25mg-150mg ON). trail of prphylaxis after 4-6 months.
Analgesic Rebound or medication overuse
most at risk are those using triptans barbituates and opiates >10/month to tx HA
can also be caused by withdrawl from NSAIDS/Paracetamol and even caffeine
tx = push through withdrawl
consider if HA 15 days a month for three months
advised to stop abruptly, not gradually and push through at least a month (but can also do naproxen 250mg TDS for 4 weeks first?!)- give antiemetics
Cluster HA
Asx for months and then a cluster of HAs
increased duration means decreased frequence and vice versa
same each time
unilateral eye pain associated with horner’s syndrome:
rhinorhea, lacrimation, conjunctival injection and lid sags
2nd line triptans
MRI to r/o 2are HA
give parenteral triptan (IN zomitriptam 5-10mg or SC sumatriptan 6mg to terminate or 100% oxygen no rebreath 12l/min for 10-20 mins to terminate in ED) no paracetamol, nsaids, opioids, ergots or oral triptans
Migraine
do dual treatment of NSAID and triptan straight away
nsal triptan in 12-17yo
give antiemetic if naeusea eg prcholorperazine3-6mg bucacal tablets or domperidone 10mg po
prophylaxs with topiramate or propanaol
vascular . . .generally vasodilation
Aura can be any FND
Trigger : eg MSG, menstrule cycle, chocolate, caffeine
Sleep usually aborts but ‘hangover’ following day
NSAIDs best if you get in early
Triptans (can cause vasospasm in CAD)
Idiopathic Intracranial Hten
increased ICP w/o cause
ICP sx esp papiilloedema
associated OCPs
CT scan will be -ve
LP has high opening pressure and releives sx
tx = acetazolamide
refractory tx = serial LPs
last resort = VP shunt
Migraine triggers include the mnemonic CHOCOLATE: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise
Menstrual Migraine
ID relationhip with period for at least two cycles. give triptans or nsaids a couple of days before and after expected HA
Trigeminal Neuralgia
ear to chin shooting pain on eating or cold liquids
tx with carbamazapine
Temporal arteritis
Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR
Asoociated with polymyalgia
Low Pressure Headache
post lumbar puncture
worse on standing up
tx with caffeine and fluids
Antiemetics
Cyclazine good firt line treatmet except cardiac cases
Metoclopramide is contraindicated in PD (worsenign of sx) and young women (dyskinesia)
Pain relief
Oxycodonoe MR 10mg BD (can titrate up to max of 400mg per day)
PRN oxynorm 5mg q4-6hrs
po Morphine breakthrough dose, do 1/6 of total daily dose
conversion of weak opiods to morphine you divide by 10
never increase background by more than 50%
po morphine to po oxycodone = divide by 2
po morphine to sc morphine = divide by 2
po oxycodone to sc oxycodone = divide by 1.5
Patches if they don’t want to be hooked up (buprenorphine or fentanyl - convert using NICE chart)
NSAID - any stage
Neuropathic: Amytriptyline 10mg nightly or pregabalin 75mg 12 hrly
Diabetic Neuropathy: Duloxetine 60mg PO daily
An NSAID (e.g, ibuprofen 400 mg 8-hourly may be introduced at any stage regularly or ‘as required’ if not contraindicated (as discussed earlier under Contraindications). With neuropathic pain (t.e. pain arising from nerve damage or disease and usually described as ‘shooting’, stabbing’ or ‘burning) the first line of treatment is amitriptyline (10mg oral nightly) or pregabalin (75 mg oral 12-hourly): duloxetine (60 mg oral daily) is indicated in painful diabetic neuropathy
GCS
Glasgow coma scale (GCS) scores are generally expressed in the following format ‘GCS = 13, M5 V4 E4 at 21:30’.7
Intubate if GCS <8 (eg cuffed endotracheal tube)
HA Red Flags
Fever
FND
Age >50
Thunderclap Headache
progressivly worseining N+V
Which antiemetic
Higher centres = GABA + H1
comitting centre = ach, h1, nk1
chemotactic trigger zone = d2, 5ht3, nk1
vestibular apparatus = ach, h1
GI tracT = 5HT3, 5HT4, d2
all feed into vomitting centre
regular > prn
syringe drive = xcellent
not po if comitting
dont give cyclazine and metoclopramide togetheer
levomepromazine a good choice in last days of life as broad-spectrum.
Types of Pain
Principles of analgesic use
Morphine Preparations and recommended frequencies
Oxycodone preparations and recommended frequencies
Management of Opioid Side effects
Management of opioid related respiratory suppression
Management of reversible causes of N/V
Management of Specific Causes of N/V
First Line Anti-emetics
Second Line Antiemetics
