Palliative Care Emergencies

Question 1

Which patients are at high risk of neutropenic sepsis?

Answer 1

Patients who have had recent (2-3 weeks) chemotherapy.
Patients with cancer and bone marrow infiltration (pancytopenia)
Haematology patients

Question 2

How is neutropenic sepsis diagnosed?

Answer 2

Clinical sepsis and/or a temperature >38*C and a neutrophil count <0.5

Question 3

How is neutropenic sepsis managed?

Answer 3

May need to be transferred to acute unit for necessary facilities.

BUFALO
Blood culture
Urine output
Fluid resuscitation
Antibiotics- broad spectrum, guided by local policy
Lactate 
Oxygen

Want to closely observe patient
May also do other bloods inc. FBC, U&E, LFT, CRP

Question 4

What causes superior vena cava obstruction?

Answer 4

Lung cancer of the RUL or a tumour in the mediastinum

Question 5

What signs or symptoms would you associate with a SVC obstruction?

Answer 5

Facial swelling and redness
Periorbital oedema, gorged conjunctivae. 
Arm swelling
Breathlessness 
Distended veins on chest

Question 6

How is SVC obstruction diagnosed?

Answer 6

CT chest will confirm clinical presentation

Question 7

How do you manage SVC obstruction?

Answer 7

Dexamethasone 16 mg OD.
+/- anticoagulation (depends on further plans)
Stenting via interventional radiology
Radiotherapy- needs to be done urgently.

Question 8

Who is most at risk of stridor ?

Answer 8

Patients with head, neck, lung or upper GI tumours

Question 9

How is stridor diagnosed?

Answer 9

Clinically. May also try to visualise the upper airway (involve ENT/MaxFax) and image via CT

Question 10

How is stridor managed? Think active treatment & palliation approach

Answer 10

Active treatment- high dose steroids (dexamethasone OD 16 mg), urgent ENT review and stenting or tracheostomy.

Palliation- high dose steroids + midazolam + opioids.

Question 11

Which type of cancers are most likely to result in malignant hypercalcaemia?

Answer 11

Cancers which spread to the bone-
prostate, breast, kidney, thyroid & lung.

Can also get some cancers which produce a PTH related peptide causing hypercalcaemia

Question 12

How does malignant hypercalcaemia present?

Answer 12

Bones, stones, groans, thrones, and psychiatric moans

i.e. bone pain, renal calculi, thirst, polyuria, confusion, constipation, N&V and depression.

Question 13

How is malignant hypercalcaemia diagnosed?

Answer 13

Blood test - Ca >2.6

Question 14

How is malignant hypercalcaemia managed?

Answer 14

Immediate IV fluids

IV bisphosphonates to drive calcium back into bone.

Question 15

Which tumours are most at risk of massive haemorrhage?

Answer 15

Head and neck
Lung tumours with hx
GI tumours with hx
Overall hard to predict.

Question 16

Apart from obvious bleeding, what others signs could indicate massive haemorrhage?

Answer 16

Sudden loss of consciousness/shock

Question 17

How should massive haemorrhage be managed?

Answer 17

1) Stop any anticoagulation
2) If appropriate, treat as a medical emergency
3) If palliative, likely to be a terminal event. Dark towels, Midazolam 10 mg sat, do not leave patient to fetch drug.

Question 18

What might alert you to an opioid overdose?

Answer 18

A patient on very strong opioids.

Change in condition (including sudden improvement in pain)

Question 19

Whats signs and symptoms suggest an opioid overdose?

Answer 19

Reduced consciousness. Reduced RR, SpO2, myoclonic jerks, pinpoint pupils, confusion and hallucinations.

Question 20

How is an opioid overdose treated?

Answer 20

Clinically and good response to treatment

Question 21

How is an opioid overdose managed?

Answer 21

Naloxone 400mcg if life-threatening.
Otherwise can dilute naloxone in 10ml saline and give 20mcg every 2 minutes.
Need to review dosing of opioids