PALLIATIVE CARE

Question 1

what analgesic do you give if egfr <30

Answer 1

oxycodone

Question 2

what are weak opiods

Answer 2

codeine
tramadol
dihydrocodeine

Question 3

what is a PRN dose (generally)

Answer 3

1/6th of daily dose

Question 4

what meds should be included in a palliative care bundle

Answer 4

Analgesics
Antiemetics
Anticholinergics (buscopan - secretions)
Antipsychotics (distress/ agitation/ delirium)

Question 5

how should pre emptive meds be written up

Answer 5

sub cut

Question 6

what are the common palliative / cancer emergencies

What cancers would you associate with each emergency

Answer 6

Neutropenic sepsis - any pt recent chemo (past 3 weeks)
Spinal cord compression (any that met to bone - prostate, kidney, lung, breast, thyroid)
SVCO - lung, thorax
Hypercalcaemia (any that met to bone)
Haemorrhage - GI, lung, head / neck tumours (any that can bleed into cavity)
Opioid overdose (anybody on a strong opioid)
Stridor - head and neck cancer, lung, upper GI

Question 7

What is the presentation of neutropenic sepsis, how do you diagnose and when should you start treatment

Answer 7

Fever >38
Any sepsis symptoms - feeling unwell, increased thirst, drowsy, falling BP, increased HR
Diagnose - temp >38 and neutrophils <0.5
Treat immediately - do not wait for bloods to return

Question 8

What is the management of neutropenic sepsis

Answer 8

IV broad spectrum antibiotics stat
Bloods - cultures, CRP, Lactate, FBC, U&E, LFT
Regular observations
Fluid resuscitation and monitoring

Question 9

What is the presentation of superior vena cava obstruction

Answer 9

Facial swelling 
Distended neck veins 
Breathlessness 
Periorbital odema 
Red face 
(think about acute HF and cerebral odema)

Question 10

what is the management of SVCO

Answer 10

Dexamethasone 16 mg stat
CT chest
Consider anticoagulation
Stenting - interventional radiology

Question 11

what is the presentation of stridor

Answer 11

Noisy inspiration
Harsh breath sounds
(not necessarily breathless)

Question 12

what is the management of stridor

Answer 12

Oxygen 
Dexamethasone 16 mg stat
Urgent ENT review
Tracheostomy 
Stenting 
Radiotherapy

Question 13

Presentation of hypercalcaemia

Answer 13

Acute: thirst, constipation, confusion
Chronic: stones, depression, constipation

Question 14

Management of hypercalcaemia

Answer 14

IV fluids - stat (most important as dilutes plasma calcium and protects kidneys) 
IV bisphosphonates (take a few days to bring calcium down)

Question 15

Cord compression presentation

Answer 15

Weakness (“off legs)
Sensory loss
Back pain
Bladder/ bowel incontinence

Question 16

Management of cord compression

Answer 16

MRI spine 
Lay flat 
Dex 16 mg OD stat
Radiotherapy 
Surgery (most effective)
*Radiotherapy most commonly used for malignant cord compression*

Question 17

Haemorrhage management

Answer 17

Depends on ceiling of care
Stop anticoagulants
Midazolam 10 mg stat

Question 18

Opioid overdose signs

Answer 18

Reduced RR 
Confusion 
Pin point pupils 
Myocolonic jerks 
Hallucinations (side effect)
N&V, constipation (side effect)

Question 19

Opioid overdose management

Answer 19

Naloxone - 400 mcg stat if acute emergency

otherwise 10 ml saline 20 mcg every 2 hours