Palliative Care Emergencies Flashcards
What is the definition of a palliative care emergency?
Any unexpected change in the condition of or symptoms / circumstances in a patient with a life-limiting illness
Categories:
- Physical
- Psychological
- Social
- Spiritual/existential
What are some physical palliative care emergencies?
- Bone (pathological /crush fracture / metastasis)
- Hypercalcaemia
- Superior vena cava obstruction
- Spinal Cord compression
- MI
- DVT / PE
- Gastric / duodenal ulcer
- Infection / neutropenic sepsis
- Haemorrhage
- Seizures
John, 55
- Known prostate carcinoma: diagnosed 7 years ago
- Radical prostatectomy & On hormonal treatment
- PSA recently started to rise
- Recently developed painful left humerus: awaiting bone scan
- Otherwise quite well: PS 2
- Over the last week has developed increasing lower back pain: at rest and on movement: worse with coughing
- Pain band-like around abdomen
- Admitted to hospital as ‘off legs’ and not coping
What is the diagnosis?& explain
Spinal Cord Compression (SCC)
Epidemiology
- 3 - 5% cancer patients
- 10% patients with spinal metastases
- More common in some cancers
- Multiple myeloma
- Prostate carcinoma
- Breast carcinoma
- Lung carcinoma
- Lymphoma
- Renal carcinoma
- Catastrophic event leading to paraplegia, paraparesis and incontinence if left untreated
- Largely clinical diagnosis
- Weakness often attributed to general debility
What are the causes of Spinal cord compression and where is the most common site?
-
Extradural compression
- Vertebral body metastases (80%) +/- vertebral collapse
-
Site of compression
- Thoracic 70%
- Lumbosacral 20%
- Cervical 10%
- More than one level of compression in 20% cases
What is the presentation of spinal cord compression?
-
Pain (90%)
- Back and nerve root irritation
- Aggravated by movement, coughing, lying flat
- May preceed other symptoms and signs by up to six weeks
- Sensory disturbance > 50%:
- Can be early sign.
- Leg Weakness >70%:
- Late sign
- Motor weakness below level of lesion
- Stiffness /falls /gait disturbance
- Sphincter problems >40%
- Late sign, Poor Prognosis
Lesion above L1: UMN signs and a sensory level
Lesion below L1: LMN signs and peri-anal numbness (cauda equina syndrome)
What investigations would you do with someone with a spinal cord compression?
- MRI investigation of choice
- X-ray identifies 80% extradural compression
- Bone scan identifies bone mets but NOT site of cord compression
What is the management of spinal cord compression?
- Consider patient’s performance status and wishes before transfering to oncology centre
- Steroids ASAP
- Dexamethasone 16 mg
- Analgesia
- Refer to Oncologist for radiotherapy
- Consider urgent surgical debulking
- Urinary Catheter/ Bowel Regime
What is malignant hypercalcaemia and its epdemiology
Definition
- Corrected serum calcium concentration above 2.65mmol/l
Epidemiology
- 10% all patients with cancer
- Up to 20% patients develop hypercalcaemia without bone metastases
- Most patients with malignant hypercalcaemia have disseminated disease
- Poor prognosis
- median survival 3 – 4 months
- (< 80% 1-year survival)
What is the pathogenesis of malignant hypercalcaemia?
-
Osteolytic Hypercalcaemia
- Increased osteoclastic bone resorption around malignant cells in marrow space
-
Humoral Hypercalcaemia of Malignancy
- Systemic release of humoral hypercalcaemic factors e.g. ectopic PTHrP, locally active prostaglandins, cytokines, interleukin-1and TNF
- Increased bone resorption
- Reduced renal clearance
- 1,25-dihydroxyvitamin D Secretion (some lymphomas)
- Ectopic secretion of authentic PTH (very rare)
What are the clinical features of malignant hypercalcaemia? (general, gastro, neuro and cardio)
What is the management of malignant hypercalcaemia?
- Treatment Options
- Rehydration (aim: 2-3L 0.9% saline / 24 hrs)
- Calcium-lowering agents
- Bisphosphonates
- E.g. zolendronic acid, pamidronate
- Bisphosphonates
- Withdraw hypercalcaemia-promoting drugs e.g. thiazide diuretics, vitamins A and D
Outcomes
- 70% respond
- Usually takes 3-4 weeks
- Prognosis dependent on whether underlying tumour can be treated
What do bisphosphonates do in malignant hypercalcaemia?
- Reduce bone resorption (inhibit osteoclastic activity)
- Zolendronic acid often 1st choice
- Dose adjustment needed if renal impairment
- Effective in 70-80%
- Side effects:-flu-like symptoms/pyrexia, osteonecrosis of jaw rare
- Recheck calcium:
- 5-7 days after treatment and consider re-treat if still raised
- Monthly (earlier if clinical suspicion)
What to look out for in people receiving chemotherapy?
NEUTROPENIC SEPSIS
- Tazocin+/-gentamycin
What is the epidemiology and aetiology of haemorrhages?
Epidemiology
- Affects approx. 20% patients with advanced cancer
- Contributes to death in 5%
- Catastrophic external haemorrhage is less common than internal hidden haemorrhage
Aetiology
-
Direct:
- related to tumour itself e.g. local bleeding from fungating tumours, erosion of vessels
-
Indirect:
- Haematemesis / melaena / haemoptysis / haematuria
- Drugs e.g. steroids, NSAIDS, warfarin
- Low platelets
What is the management of haemorrhage?
1. Preparation and Anticipation
- Anticipate
- Major bleed often preceded by smaller bleeds
- DNAR, Preferred place of care
- Counselling patients
- Establish what support available at home
- Review use of anticoagulants
- Availability of dark towels etc
- Availability of PRN benzodiazepines
What is the non-acute management of haemorrhage?
Local / Topical:
- Adrenaline 0.1% soaks or tranexamic-soaked gauze (500mg/5mls)
- Silver nitrate sticks to bleeding points
- Haemostatic dressings e.g. alginate
- Sucralfate paste or suspension
Systemic:
- Antifibrinolytics e.g. tranexamic acid 500mg - 1g TDS
- Haemostatic agents e.g. etamsylate 500mg QDS (restores platelet adhesiveness)
-
Other:
- Radiotherapy
- Diathermy
- Embolisation
What is a superior vena cava obstruction and epidemiology?
- Definition: external compression of and/or thrombosis of SVC by mediastinal lymph nodes or tumour in region of right main bronchus.
- 75% caused by cancer of bronchus
- 15% caused by lymphoma
- 10% caused by cancer of breast, colon, oesophagus, testis
What are some symptoms & signs of a superior vena cava obstruction?
Symptoms
- Venous hypertension
- Headache
- Visual changes
- Dizziness
- Swelling of face/ neck/arms
Signs
- Engorged conjuntivae
- Periorbital oedema
- Nono-pulsatile dilated neck veins
What are some investigations and management of superior vena cava obstruction?
Management
- Prognosis hours to days:
- Opioid
- Oxygen
- Keep bed at 30 degrees
- Dexamethasone
- Furosemide 40mg PO/IV
- Treatment for anxiety or seizures
- Crisis medications
Investigations
- Prognosis weeks: as previous +
- Chest x-ray
- Chest CT
- Stent for extrinsic compression
- Stent and thrombolysis for thrombus obstruction
- Anticoagulation for thrombus associated SVCO
- Prognosis months to years: as previous +
- Radiotherapy
- Chemotherapy
What are some investigations and management of superior vena cava obstruction?
Management
- Prognosis hours to days:
- Opioid
- Oxygen
- Keep bed at 30 degrees
- Dexamethasone
- Furosemide 40mg PO/IV
- Treatment for anxiety or seizures
- Crisis medications
Investigations
- Prognosis weeks: as previous +
- Chest x-ray
- Chest CT
- Stent for extrinsic compression
- Stent and thrombolysis for thrombus obstruction
- Anticoagulation for thrombus associated SVCO
- Prognosis months to years: as previous +
- Radiotherapy
- Chemotherapy
What is the diagnosis of this case of Mary?
- 86 year old with lung cancer
- Married to Mary for 50 years
- Preferred place of care/death was home
- Mary initial reticent but agreed with full package of care
- Harry deteriorating at home and reaching end of life care
- Mary calls for an ambulance at 6 am‘ I can’t do this anymore’
SOCIAL CRISIS
- Very common
- Carer fatigue/unable to cope
- Difficult symptoms making home difficult
- Psychological distress
- Important to plan and predict in advance
- Can happen at end of life
- Need to look at different avenues available
- Hospital not always ideal!
