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Phase 4 Question Knowledge > Palliative care > Flashcards

Palliative care Flashcards

1
Q

Agitation / confusion

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

Mx

  • haloperidol
  • chlorpromazine, levomepromazine
  • terminal - midazolam
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2
Q

Hiccups

A

Mx

  • chlorpromazine
  • haloperidol / gabapentin
  • dexamethasone if hepatic lesions
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3
Q

Secretions

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

Pain

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

Opioid S/Es

A

nausea, drowsiness, constipation

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6
Q

Opioid conversions

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

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

Adjuvant analgesics

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

6 N+V syndromes

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

N+V non-pharmacological tx

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

N+V - reduced gastric motility

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

N+V - chemically mediated

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

N+V - visceral / serosal

A
  • cyclizine
  • levomepromazine
  • hyoscine
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14
Q

N+V - raised ICP

A
  • cyclizine
  • dexamethasone
  • radiotherapy
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15
Q

N+V - vestibular

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

N+V - cortical

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

Breathlessness

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

Syringe drivers

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

Commonly used drugs

N+V – cyclizine, levomepromazine, haloperidol, metoclopramide

Resp secretions / bowel colic – hyoscine hydrobromide/butylbromide, glycopyrronium bromide

Agitation / restlessness – midazolam, haloperidol, levomepromazine

Pain – diamorphine

19
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
20
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
21
Q

MSCC Ix

A
  • MRI
  • CT +/- myelography
22
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
23
Q

SVC obstruction (SVCO)

A
  • SVC blocked/compressed by tumour
  • lung cancer, also lymphoma, mets from breast, bowel etc
24
Q

SVCO Px

A
  • 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
25
Q

SVCO Ix

A
  • CXR
  • Doppler
  • CT / MRI chest
26
Q

SVCO Mx

A
  • loosen clothing, sit up,
  • O2
  • analgesia
  • dexamethasone
  • anticoagulants
  • chemo/radio
  • surgery - stent
27
Q

Malignant hypercalcaemia

A
  • caused by changes to bones in pts with cancer - even if not spread to bone
  • advanced cancer, also multiple myeloma, breast, lung, kidney, thyroid
28
Q

Malignant hypercalcaemia Px

A
  • bones, stones, moans, groans
  • malaise, weak, fatigued
  • anorexia, N+V
  • bone pain
  • thirsty, polyuria
  • constipation, confusion, drowsy, seizures, delirium
29
Q

Malignant hypercalcaemia Ix

A
  • bloods - Ca>2.6 corrected
30
Q

Malignant hypercalcaemia Mx

A
  • IV fluids
  • bisphosphonates
  • ?denosumab
31
Q

Neutropenic sepsis

A
  • 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
32
Q

Causes of neutropenia

A
  • Bone marrow disorders - aplastic anaemia, myelodysplastic syndromes
  • Chemotherapy (10d period after when WCC very low)
  • Immunosuppressants
  • Stem cell transplantation
33
Q

Neutropenic sepsis Px

A
  • sepsis, unwell, flu, fever, shivering, agitation, oliguria, diarrhoea, change in behaviour
  • pale, mottled skin, rash
34
Q

Neutropenic sepsis Ix

A

FBC, U+E, LFT, albumin, CRP, lactate, cultures

35
Q

Neutropenic sepsis Mx

A
  • 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
36
Q

Haemorrhage

A
  • loss of large volumes of blood
  • advanced cancer
  • can be from tumour itself / impaired clotting
  • eg head/neck tumours, lung tumours, GI tumours
37
Q

Haemorrhage Px

A
  • haemoptysis
  • haematemesis
  • melaena
  • haematuria
  • bleeding from ulcers, tumours, wounds on skin
38
Q

Haemorrhage Mx

A
  • discuss plans in advance - respect form, living will, DNAR
  • midazolam - IV/IM/sublingual
  • dark coloured towels
  • plastic aprons, gloves, waste bags
  • pressure, celox etc
39
Q

Stridor

A
  • 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
40
Q

Opioid OD

A

Px

  • reduced GCS
  • reduced RR
  • pinpoint pupils
  • myoclonic jerks

Mx

  • naloxone
41
Q

Verification of death

A
  • 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
42
Q

Deaths to be reported to coroner

A
  • 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

Phase 4 Question Knowledge (30 decks)

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