Palliative Care Flashcards

1
Q

Pall Care: emergencies x 5

A

Emergencies:
- superior vena cava syndrome
- malignant hypercalcaemia
- metastatic spinal cord compression
- neutrosepsis
- catastrophic events; terminal haemorrhage & acute/complete airway obstruction

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2
Q

Pall Care: Superior vena cava syndrome x 4 points

A

SVC vulnerable to expanding tumours in upper thorax; non-small cell lung CAs, bronchial carcinomas, lymphomas, mets occurring in the mediastinum

When central venous lines are used for chemo, SVC thrombosis can occur

Abrupt onset: over 2/52
Slow onset: over longer period

SVCS may be life-threatening & req urg* intervention
eg; laryngeal or cerebral oedema

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3
Q

Pall Care: SVCS S&S x 8, Ass x 6, man* x 4

A

Signs & symptoms:
- facial swelling/plethora
- distended neck & chest veins
- arm swelling
- dyspnoea & cough; worsening due to tracheal oedema & sensation of drowning
- dizziness & syncope
- headache (‘fullness’ on bending or lying), confusion, seizures, coma
- hoarseness, stridor
- dysphagia, epistaxis & haemoptysis

Assessment may reveal:
- periorbital oedema w swelling of face, neck & arms
- non-pulsation dilated veins of neck, dilated veins of forehead
- dilated collateral vessels coursing over the upper anterior chest
- tachypnoea, cyanosis
- suffused conjunctivae - redness not involving inflammatory exudates
- Pemberton’s sign; positive when bilateral arm elevated causes facial plethora

Management:
- airway management
- symptom management/relief (pain man, posture, O2)
- dexamethasone - to reduce tumour mass & assoc
inflammation (alt* hydrocortisone)
- prompt specialist referral; radiotherapy, endovascular stent, chemo, etc

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4
Q

Pall Care: malignant hypercalcaemia; x 4 points

A

One of he most common life-threatening metabolic disorders in CA pts, assoc* w; breast CA, non-small cell lung CA, & multiple myeloma

Usually occurs w advanced & widespread malignancy & causes a number of distressing symptoms

Development of this is poor prognostic indicator

Characterised by abnormally high serum calcium levels

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5
Q

Pall Care: Malignant hypercalcaemia; S&S x 4, ass x 1, & man* x 2

A

Signs & symptoms:
- anorexia, nausea, vomiting, constipation
- malaise, lethargy, confusion, delirium
- thirst, dehydration
- hypotension, renal failure, cardiac dysrhythmias & eventually Code 2

Assessment:
- bloods: to confirm; test at risk Pts

Management:
- focus on rehydration
- Tx for biophospohates; even in advanced CA states (for symptom control)

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6
Q

Pall Care: metastatic SC comp* x 5 points

A

Involves spinal cord compression secondary to CA Dx (mostly 60% thoracic) extension of CA into epidural space

Occurs in approx 5% of Pts w advanced CA ( mostly; lung, breast, renal, prostate & lymphoma)

Diagnosed by MRI in Pts w high index of suspicion; effective Rx can limit loss of function & maintain QoL

Needs to be suspected/excluded in any CA Pt w back pain or difficult walking

Rapidity of symptom development implies worse prognosis

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7
Q

Pall Care: Malignant SC comp; red flags x 4

A

Red flags:
- pain - a painful back problem
- new onset or exacerbation of old; radiating circumferentially around chest of abdo, aggravated w movement/coughing
- most common initial presenting symptom 90% of cases

  • autonomic dysfunction - an evacuation problem
    - bowel/bladder dysfunction
    - abdo pain/distension
    - dizziness/syncope due to hypotension
    - cold, shivering, drowsy due to hypothermia
    - usually a Late consequence
  • motor deficits - a movement problem
    - weakness of legs of feet, difficulty mobilising
  • sensory deficits - a feeling problem
    - weakness, tingling or numbness to legs or feet, or circumferential boundary
    - perianal numbness
    - less common
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8
Q

Pall Care: malignant SC comp; man x 4, ongoing Rx x 4, & refer

A

Management:
- assess for any changes in; reflexes, anal tone, motor weakness & any sensory loss
- posture per spinal injury
- pain management - as per normal
- corticosteroids: first dose may be given even without imaging confirmation [dexamethasone 16mg PO/IV, SC across separate injection sites (alt* hydrocortisone)]

Ongoing Rx:
- continuing w corticosteroids
- radiotherapy
- chemotherapy
- surgical decompression

Refer:
- for Urgent MRI - avoid delays in reducing damage

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9
Q

Pall Care: neutropenic sepsis x 3 points

A

Defined as; temp >38C measured x 2 over 1 hr, in a neutropenic Pt (<1.0 x 109/L)

Usually occurs 5-10days post chemo & lasts 2-4 wks

CA Pts on anti-CA home Rx, with or without fever, should be assessed at ED

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10
Q

Pall Care: terminal haemorrhage Rx options

A

If active Rx: O2 therapy, fluid resus, & reverse coagulopathy

If bleeding catastrophic: likely a terminal event STAY w PT!!

Common plans for Fam: use dark towels to hide colouring & volume

Opioid/benzo use should have been pre-approved & documented in plan (if not, use yr brain!)

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11
Q

Pall Care: acute/complete airway obstruction Rx options

A

Individualised approach: only if Pt agrees & even if not, managing anxiety & distress important

Reversible factors: mucous plug, mechanical blockage or kinking of tracheostomy tube, etc. Manage according to Pt preferences

Acute Rx: dexamethasone or hydrocortisone

Acute severe dyspnoea when stridor present: nebulised adrenaline may offer temp relief

Pre-terminal event: single dose of opioid & benzo advised (see Pt plan or consult!!)

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12
Q

Pall Care: specific symptoms seen x 9

A

Symptoms:
- pain
- fatigue
- GIT symptoms; dry mouth, anorexia, nausea & vomiting, constipation & diarrhoea
- Resp symptoms; dyspnoea, cough, hiccups
- Neurological & neuromuscular symptoms; seizures
- Psych symptoms; anxiety, depression & delirium
- Dermatological symptoms; itch & sweating
- bleeding
- GU symptoms

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13
Q

Pall Care: Clin* Ass elements x 6

A

Determine if symptom due to:
- expected manifestation of Dx
- unexpected manifestation of Dx
- temporary relapse, which may be reversible
- exacerbation of an intercurrent problem
- new, acute intercurrent illness, which may be treatable
- deterioration due to irreversible Dx progression or the terminal phase

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14
Q

Pall Care: acute severe pain

A

First focus on prompt relief & then confier underlying cause;

  • aim to maintain comfort & enable their QoL
  • reassure Pt U will get pain under control & stay until U succeed
  • administer meds; opioids, hyoscine for smooth muscle spasms
  • attempt to relieve source of pain; ? Catheter to relive urinary retention
  • continue to observe & manage Pt
  • consult w specialist support
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15
Q

Pall Care: opioids

A
  • consider equivalent doses elements
  • consider age & comorbidities
  • new pain, even exacerbation of existing pain, may require sig* higher doses
  • use SC/IV/IN as appropriate
  • Morphine; 2.5-5mg IV @ 5 min intervals OR SC @ 10 min intervals to effect
  • OR Fentanyl; 25-50mcg IV @ 5 min intervals OR SC @ 10 min intervals OR IN as a single divided dose @ 5 min intervals
  • with any Opioid; if ineffective at Third dose = consult
  • other strategies; different SCIP options for management; ketamine, ketoralac, lignocaine, methadone, dexamethasone etc… dependent upon service scope
  • equianalgensic calculations must be done in consultation with GP, Pall Care Consultant, or AMB Medical Advisor

Breakthrough pain:
- only given hourly, as it takes that long to reach peak effect
- if inadequate after 3 consecutive doses = consult for meds review of dose

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16
Q

Pall Care: acute severe nausea & vomiting

A

Mechanisms:
- GIT or centrally mediated
- nausea; occurs most in haematological CAs & renal failure
- vomiting; most common in GIT, gynaecological & breast CAs

Some causes to consider;
- drugs; opioids, anticholinergics, digoxin tox, antifungals, SSRIs
- chemo; hypomagnesaemia
- metabolic; renal/hepatic failure altering Na+ or Ca2+
- toxins; is had ice bowel, bowel obs*, tumours, infection
- ascites
- hepatomegaly
- tumour - compressing duodenum or stomach
- faecal compaction
- raised ICP, meningeal infiltration, vestibular causes

First line options;
- metoclopramide & haloperidol
- still not for bowel Obs

Chemo/radiotherapy induced;
- ondansetron & dexamethasone

Always discuss w GP/ PC consultant re preference

17
Q

Pall Care: acute sever dyspnoea

A

Particularly distressing, focus on symptom relief.

Common causes/DDxs:
- resp; pneumonia, lung CA, COPD, pleural effusion
- cardiac; pericardial effusion, CCF, arrhythmias
- systemic; anaemia, sepsis, renal failure
- psych; anxiety, panic episodes, depression

Strategies:
- Posture; sitting upright or allowing Pt comfortable posture
- Reassurance; U will stay w them & employ every effort to help
- High-flow O2; less concern about CO2 retention
- Directed air flow; hand held/pedestal fan, open window (facial receptors)
- Pharmacology; opioid w or without a benzo

Management;
- opioid as Pain management PLUS midazolam 1-2 mg IV @ 5-10 min intervals OR 2.5-5 mg SC @ 30 min intervals
- Clonazepam alt*; 0.5 mg SC or SL @ 30 min intervals

If Pt already taking opioids, give prescribed breakthrough dose equivalent

If 3rd still ineffective = consult!

Poss further testing;
- chest X-ray - pneumonia, pleural eff, pulmonary oedema, pneumothorax
- ECG - ACS
- Echocardiography - R heart function, pericardial eff

- CT - PE, SVC obs, progressive airway obs
- iStat - venous blood gases

18
Q

Pall Care: Resp secretion management

A

Occurs in 30-50% of Pt’s at EoL

Management:
- repositioning
- suctioning - rarely ever used!
- pharmacology - anticholinergics, tho lil’ evidence to support this (glycopyrronium ode hyoscine butylbromide)
[may cause urinary retention, poss catheter req]

19
Q

Pall Care: Hiccups

A

Intractable hiccups cause distress.

Common causes:
Gastric stasis & abdo distension

Complete later