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Palliative Care Flashcards

1
Q

how would you manage agitation / confusion in a palliative patient?

A
  • look for causes
  • eg hypercalcaemia, infection, urinary retention, medications

Mx
- haloperidol
- chlorpromazine, levomepromazine
- terminal - midazolam

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2
Q

management of hiccups in a palliative patient?

A

Mx
- chlorpromazine
- haloperidol / gabapentin
- dexamethasone if hepatic lesions

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3
Q

management of secretions in a palliative patient?

A

Conservative
- avoid fluid overload - stop IV/SC fluids
- pt not likely troubled by secretions

Medical
- hyoscine butylbromide (buscopan)
- glycopyrronium bromide

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4
Q

managing pain in a palliative patient/

A
  • regular oral MR / IR morphine, with oral IR morphine for breakthrough
  • no comorbidities - 20-30mg MR per day + 5mg morphine breakthrough
  • breakthrough 1/6 daily morphine dose
  • prescribe laxatives, antiemetics
  • CKD - oxycodone over morphine, or if severe then alfentanil, buprenorphine, fentanyl
  • metastatic bone pain - strong opioids, bisphosphonates, radiotherapy, denosumab
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5
Q

S/E of opioids?

A

nausea, drowsiness, constipation

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6
Q

what are the opioid conversion rates?

A

Oral codeine ->oral morphine
- Divide by 10
Oral tramadol -> oral morphine
- Divide by 10
Oral morphine -> oral oxycodone
- Divide by 1.5/2

Transdermal fentanyl 12mcg patch = 30mg morphine daily

Transdermal buprenorphine 10mcg patch = 24mg oral morphine daily

Oral morphine -> SC morphine
- Divide by 2
Oral morphine -> SC diamorphine
- Divide by 3
Oral oxycodone -> SC diamorphine
- Divide by 1.5

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7
Q

describe the WHO pain ladder

A

Step 1
- paracetamol, NSAIDs
- adjuvants

Step 2
- codeine
- step 1
- adjuvants

Step 3
- morphine
- step 1
- adjuvants

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8
Q

what are some adjuvant analgesics that could be used in palliative care?

A
  • Amitriptyline, carbamazepine, gabapentin, pregabalin, clonazepam, duloxetine, oxcarbazepine
  • Local anaesthetics, baclofen, diazepam, antidepressants, corticosteroids, bisphosphonates
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9
Q

6 types of n+v syndromes in palliative care?

A

Reduced gastric motility
- May be opioid related – most frequent in palliative care
- Related to serotonin (5HT4) and dopamine (D2) receptors

Chemically mediated
- From hypercalcaemia, opioids, chemo

Visceral / serosal
- Due to constipation
- Oral candidiasis

Raised ICP
- Eg cerebral metastases

Vestibular
- ACh and histamine (H1) receptors
- Motion related, or due to basal skull tumours

Cortical
- Anxiety, pain, fear, anticipatory nausea
- Related to GABA and histamine (H1) receptors in cerebral cortex

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10
Q

non pharmalogical tx of n+v in palliative care

A
  • Control odours from colostomy / wounds / fumigating tumours
  • Minimise sight/smell of food
  • Give small snacks, not large meals
  • Try acupressure wrist bands
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11
Q

how to manage n+v due to reduced gastric motility?

A
  • metoclopramide (CI - obstruction, Parkinson’s - both)
  • domperidone
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12
Q

how to manage chemically mediated n+v?

A
  • correct chemical imbalances
  • ondansetron (also post-op)
  • haloperidol
  • levomepromazine
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13
Q

managing visceral / serosal n+v?

A
  • cyclizine
  • levomepromazine
  • hyoscine
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14
Q

managing n+v related to raised ICP?

A
  • cyclizine
  • dexamethasone
  • radiotherapy
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15
Q

managing vestibular n+v?

A
  • cyclizine
  • metoclopramide / prochlorperazine
  • maybe olanzapine / risperidone
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16
Q

managing cortical n+v?

A
  • lorazepam
  • cyclizine
  • potentially ondansetron / metoclopramide
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17
Q

managing breathlessness in palliative care?

A
  • Morphine
  • Tx cause
  • Anxiolytic may help - eg diazepam / lorazepam
  • Salbutamol / terbutaline
  • Ipratropium
  • Dexamethasone
  • O2 / LTOT
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18
Q

when might you consider using a syringe driver?

A
  • Consider use when patient unable to take medication orally – due to nausea, dysphagia, intestinal obstruction, weakness, coma
  • Majority of drugs compatible with water for injection. Use NaCl 0.9% with - granisetron, ketamine, ketorolac, octreotide, ondansetron
19
Q

commonly use drugs in syringe drivers?

A

N+V – cyclizine, levomepromazine, haloperidol, metoclopramide
Resp secretions / bowel colic – hyoscine hydrobromide/butylbromide, glycopyrronium bromide
Agitation / restlessness – midazolam, haloperidol, levomepromazine
Pain – diamorphine

20
Q

Metastatic spinal cord compression (MSCC)

A
  • cancerous tumour damages / presses on spinal cord
  • most common with multiple myeloma, breast, lung, prostate, kidney, thyroid
  • 10-20% of pts with spinal mets get this
21
Q

MSCC Px?

A
  • back pain
  • chest/abdo pain
  • pain down to legs
  • back pain worse at night / lying down / coughing / straining
  • localised spinal tenderness
  • leg weakness / difficulty standing/walking
  • numbness/tingling in legs
  • urinary incontinence / retention
  • faecal incontinence / constipation
22
Q

MSCC Ix?

A
  • MRI
  • CT +/- myelography
23
Q

MSCC Mx?

A
  • inform GP / hospital acute oncology team / palliative care team
  • lie flat in bed
  • pain relief
  • bisphosphonates
  • dexamethasone
  • surgery
  • radiotherapy
  • OT/PT, psych support
24
Q

SVC obstruction?

A
  • SVC blocked/compressed by tumour
  • lung cancer, also lymphoma, mets from breast, bowel etc
25
SVCO Px?
- headache, feel full in head, worse bending/lying down - SOB - swollen veins in neck/chest - swelling of face, neck, arms, hands - changes to vision - dizziness - red face, blue skin/lips/tongue - engorged conjunctiva - seizure/coma
26
SVCO Ix?
- CXR - Doppler - CT / MRI chest
27
SVCO Mx?
- loosen clothing, sit up, - O2 - analgesia - dexamethasone - anticoagulants - chemo/radio - surgery - stent
28
Malignant hypercalcaemia
- caused by changes to bones in pts with cancer - even if not spread to bone - advanced cancer, also multiple myeloma, breast, lung, kidney, thyroid
29
malignant hypercalcaemia Px?
- bones, stones, moans, groans - malaise, weak, fatigued - anorexia, N+V - bone pain - thirsty, polyuria - constipation, confusion, drowsy, seizures, delirium
30
malignant hypercalcaemia Ix?
- bloods - Ca>2.6 corrected
31
malignant hypercalcaemia Mx?
- IV fluids - bisphosphonates - ?denosumab
32
neutropenia sepsis?
- Temp >38 / sx of sepsis in pt with neutrophils <0.5x10^9/L - Coag-negative, G+ bacteria most commonly, particularly Staph epidermidis - probably due to indwelling lines
33
causes of neutropenia?
- Bone marrow disorders - aplastic anaemia, myelodysplastic syndromes - Chemotherapy (10d period after when WCC very low) - Immunosuppressants - Stem cell transplantation
34
neutropenic sepsis Px?
- sepsis, unwell, flu, fever, shivering, agitation, oliguria, diarrhoea, change in behaviour - pale, mottled skin, rash
35
neutropenic sepsis Ix?
FBC, U+E, LFT, albumin, CRP, lactate, cultures
36
neutropenic sepsis Mx?
- hospital admission - haematology/oncology - GP OOH if not for hospital - sepsis workup - Abx - tazocin / meropenem - if no response after 4-6d - Ix for fungal infections - fluoroquinolone prophylaxis
37
major haemorrhage (palliative care context)
- loss of large volumes of blood - advanced cancer - can be from tumour itself / impaired clotting - eg head/neck tumours, lung tumours, GI tumours
38
haemorrhage in palliative care Px?
- haemoptysis - haematemesis - melaena - haematuria - bleeding from ulcers, tumours, wounds on skin
39
palliative care: haemorrhage Mx?
- discuss plans in advance - respect form, living will, DNAR - midazolam - IV/IM/sublingual - dark coloured towels - plastic aprons, gloves, waste bags - pressure, celox etc
40
discuss stridor in context of palliative care?
- obstructed airway - eg head/neck tumour, lung/upper GI tumour Px - noisy breathing on inspiration - SOB - late sign Ix - clinical dx - ENT / maxfax to dx - CT Mx - O2 / heliox - dexamethasone - ENT / onc review - tracheostomy - stenting - radiotherapy
41
opioid overdose in palliative care?
Px - reduced GCS - reduced RR - pinpoint pupils - myoclonic jerks Mx - naloxone
42
death verification process
- Introduce self to patient / family - Explain / consent, WIPE etc - Identify pt from wristband - Assess voice response - Assess pain response - Feel carotid pulse, listen to chest sounds, heart sounds - for 5 full minutes - Check pupils - fixed / dilated - Can check corneal reflex - Check for pacemaker - document presence / absence - Document time of death - when examination is completed
43
when should deaths be reported to the coroner?
- Unknown cause of death - Identity of deceased unknown - Death occurred during / shortly after period of police custody - No attending medical practitioner available to sign death certificate - Death may be due to undergoing a medical tx / procedure - Death may be attributable to person's employment - All deaths <24hrs of admission to hospital - When not seen by medical practitioner in 28d prior to death - Poisoning - deliberate / accidental - Exposure to toxic substances - inc radioactive material - Overdoses - Death due to violence, trauma, injury - Death due to self-harm / suicide - Death may be due to neglect, self-neglect, or neglect on the behalf of others - Death may be due to abortion

finals (19 decks)

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