Palliative Care/ Oncology Flashcards

1
Q

What is terminal agitation?

A

Agitation occurring in the last few days of life

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2
Q

How is neutropenic sepsis diagnosed? Presentation? Time to administer antibiotics to treat?

A

Neutrophil count<1.0 x 10^9 + clinical sepsis/ pyrexia>38 degrees- usually a consequence of anti-cancer or immunosuppressive treatment, from clinical infection- CHEST, URINE, skin, GI, lines
Sometimes just fever- suspect in any patients presenting with a new clinical deterioration within 6 weeks of cytotoxic chemo
1 hour(piperacillin with tazobactam (tazocin)

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3
Q

Medications can cause neutropenic sepsis? Tx?

A

Anti-cancer chemotherapy
Clozapine (schizophrenia)
Hydroxychloroquine (rheumatoid arthritis)
Methotrexate (rheumatoid arthritis)
Sulfasalazine (rheumatoid arthritis)
Carbimazole (hyperthyroidism)
Quinine (malaria)
Infliximab (monoclonal antibody use for immunosuppression)
Rituximab
Antibiotics + same as sepsis w/ extra precaution

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4
Q

RFs ass w/ neutropenic sepsis? Investigations? What to do after 24-48 hours of IV antibiotics if clinically improving? If no improvement after 48 hours or 5 days? What might those high risk on chemo be offered?

A

Poor nutrition, mucosal barrier defect, central venous lines, abnormal host colonisation
FBC, U&E, creatinine, LFT, CRP/ ESR, coag screen
Septic screen: blood cultures, relevant swabs/ cultures, CXR
Consider adding second line antibiotics
Consider opportunistic infections e.g. fungal, PCP
Granulocyte colony-stimulating factor (G-CSF)

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5
Q

Causes of malignant spinal cord compression? Presentation? Ix?

A

Malignancy- primary, secondary= most common
Mechanism= crush fracture, soft tissue tumour extension
Limb weakness below level of compression, bowel/ bladder dysfunction, radicular pain, abnormal neurological examination–> LMN signs at level of the lesion and UMN signs below that level
MRI WHOLE SPINE, can’t have= CT, +/- myelography

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6
Q

Management of malignant spinal cord compression? Prognosis?

A

High-dose corticosteroids, definitive treatment; depends on patient and disease factors
Surgery; spinal decompression + spinal column stability
Radiotherapy- those unsuitable for surgery, can be used for pain control
Chemo- chemosensitive tumours
Hormone deprivation- newly diagnosed prostate cancer–> MSCC
Analgesia, laxatives, VTE prophylaxis, pressure sore prevention
Related to severity of neurological deficit at time of presentation, paraplegia + sphincter involvement= recovery uncommon

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7
Q

Who is hypercalcaemia common in? Symptoms? Often ass w/ what? How is it diagnosed?

A

In advanced cancer- bone mets(breast, lung, kidney, thyroid, prostate,) production of ectopic PTHrp(parathyroid hormone related peptide) by cancer- esp squamous cell cancers
Thirst, constipation, depression + calculi(bones, moans, stones, abdominal groans)
AKI
Blood test, corrected >2.6= abnormal, >2.8 is usually symptomatic, PTH, ECG- shortened QT interval, imaging for bone mets if appropriate

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8
Q

Tx of hypercalcaemia?

A

IV fluids- manage AKI, IV bisphosphonates- zolendronate, pamidronate(can take days to work), denosumab if resistant to bisphosphonates

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9
Q

Level for mild hypercalcaemia? Moderate? Severe? Causes?

A

2.6-3.0, 3.01-3.39, >3.4 mmol/L
Osteolysis(lytic bone mets,) humoral(PTHrP in squamous cell lung ca,) dehydration, other tumour specific mechanisms

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10
Q

Acute treatment for malignant hypercalcaemia? Persistent or relapsed hypercalcaemia of malignancy?

A

Correct dehydration- 0.9% saline 4-6L, dependent on clinical condition and past medical hx
Rehydration–> IV bisphosphonates= inhibits osteoclasts therefore reduces bone turnover, reduces calcium levels over several days
Zolendronic acid and pamidronate commonly used
Thiazides, calcitriol/ calcium supps, antacids, lithium
Denosumab= human MAB that inhibits RANK ligand inhibiting maturation of osteoclasts, furosemide

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11
Q

Causes and signs of SVC obstruction?

A

Inside the vessel- thrombus or IV device
Inside the vessel wall- direct tumour invasion
Outside the vessel- tumour, lung cancer, lymphoma
Dyspnoea, chest pain- often at rest, cough, neck and face swelling, arm swelling, others- dizziness, headache, visual disturbance, nasal stuffiness, syncope/ dilated veins over arms, neck and anterior chest wall, oedema of upper torso, arms, neck and face, severe resp distress, cyanosis, engorged conjunctiva, convulsions and coma

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12
Q

Ix and tx for SVC obstruction?

A

May be clinical diagnosis, CXR(widened mediastinum or mass on right side of heart,) CT scan
Elevation of head and O2 therapy for symptomatic relief, high-dose steroids in acute SVCO e.g. dex 16mg OD, endovascular stenting, consider RT, CT- especially chemo-sensitive tumours e.g. small-cell lung cancer, anticoagulation; if central vein thrombosis present
(Can rapidly progress, life-threatening if acute, can develop chronically)

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13
Q

Other oncological emergencies?

A

Brain mets- raised ICP, seizures, VTE/ arterial thromboembolism, pleural effusion, bowel obstruction, ask acute oncology team for advice, be aware of common SEs of systemic therapy and radiotherapy

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14
Q

General SEs of chemo? Immunotherapy? Radiotherapy?

A

Fatigue, N&V, mucositis, myelosupression, sepsis, impact on renal and liver function, alopecia, taste change, unstable BMs, blood clots, infertility, allergic reactions
Multisystem inflammation- endocrine disturbance, tx= high dose steroids
Localised tx and SEs= dependent on anatomical site being treated

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15
Q

What is stridor usually due to? Signs? Ix? Tx? Management?

A

A head and neck/ lung/ upper GI tumour
Noisy breathing- on inspiration, harsh breath sounds, breathlessness- not necessarily
Clinically, upper airway visualisation- ENT/ max-fax, upper airway imaging- CT
Active tx= ABC: oxygen/ heliox, high dose steroids- dex 16mg OD, urgent ENT review, stenting/ tracheostomy, radiotherapy
Palliation- high dose steroids, midazolam, opioids

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16
Q

Who is massive haemorrhage common in? S+S?

A

Head + neck tumours, lung tumours w/ h/o bleeding, GI tumours w/ h/o bleeding, can be hard to predict, “herald bleed”- an episode of haemorrhage, often accompanied by abdominal pain, which may precede, by hours to weeks, a catastrophic haemorrhage
Large volume sudden blood loss, pt rapidly losing consciousness

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17
Q

Tx massive haemorrhage?

A

Stop anticoagulation, if palliative- dark towels, remain w/ patient, midazolam 10mg stat, DEBRIEF W/ SENIOR

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18
Q

S+S of opioid overdose? Ix? Tx?

A

Reduced level of consciousness, reduced RR/ SpO2, myoclonic jerks, pinpoint pupils, SEs= confusion, hallucinations, N&V, constipation
Clinical assessment, response to tx- naloxone, dose reduction
Naloxone- 400mcg in 10ml N saline, 20mcg every 2 minutes until resp function/ conscious level improves, close obs, review dosing and discuss with senior/ palliative care
(Tx in non-palliative contexts e.g. heroin OD= very different)

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19
Q

Pitfalls in opioid overdose?

A

Toxicity vs SEs, sudden resolution of pain: ruptured abscess, pain intervention, renal/ hepatic impairment, opioid patches and fever, patients who “swig,” methadone, short half-life of naloxone- may need infusion, dying patients on opioids- naloxone unlikely to be appropriate, can precipitate sudden increase in pain

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20
Q

What is tumour lysis syndrome? Who’s at risk? Renal saturation causes what?

A

Metabolic and electrolyte abnormalities and renal impairment- due to lysis of rapidly dividing cancer cells releasing intracellular contents into circulation
Usually days/ hours in to chemo
Usually chemosensitive lymphoma/ leukaemia
If dehydrated, renal impairment, prechemo, high urate and lactate
Hyperuricaema- can–> uric acid nephropathy and AKI
Hyperphosphotaemia, secondary hypocalcaemia, hyperkalaemia

21
Q

Presentation of tumour lysis syndrome? Ix? Prevention? Tx?

A

Weakness, paralytic ileus- constipation, vomiting, abdo pain/ cardiac arrhythmias- palpitations, chest pain, collapse/ AKI- reduce UO, lethargy, nausea
FBC, 25% increase in uric acid, phosphate, K+, 25% decrease in Ca2+, high creatinine and LDH
Prechemo IV fluids, avoid nephrotoxic meds, use allopurinol
Hydrate, correct high K+, rasburicase- oxidises uric acid, aluminium hydroxide(phosphate binder)

22
Q

What does approaching the end of life mean? Includes who? As well as?

A

Likely to die within the next 12 months
Includes those whose death is imminent- hours- days
Advanced, progressive incurable conditions, general frailty and co-morbidities that mean they are expected to die within 12 months
Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
Life-threatening acute conditions caused by sudden catastrophic events

23
Q

What is involved in formal advanced care planning?

A

What they want to happen- advance statement of wishes(preferences, wishes, beliefs and values)
What they don’t want to happen- advanced decision to refuse treatment(ADRTs)
Who will speak for them- lasting power of attorney for health and welfare= submitted by the patients; gives someone else the power to make decisions about health and welfare(once they lose capacity,) or finance(registered with the office of the public guardian)

24
Q

What is the 2014 Court of Appeal judgement?

A

Presumption in favour of involving a patient in a decision whether to complete a DNACPR, unless consulting the patient is likely to cause physical or psychological harm(not just cause distress)
If CPR= deemed medically futile - the patient cannot demand CPR, but entitled to know the clinical decision

25
Q

Things to consider when recognising dying?

A

What has changed in the last few weeks/ days/ hours
Has their level of function changed for the worse
Is there evidence of progressive and irreversible organ failure
Have relevant treatments/ interventions been effective
Has the patient/ relevant others seen a decline or do they think they are dying - are the above things iatrogenic, are they reversible?

26
Q

Signs to look for when considering death?

A

Weight loss and poor appetite, fatigue and sleeping more, deteriorating mobility, social withdrawal, changes in consciousness, struggling with medications, worsening performance status and needing more assistance for ADLs
CV changes= pulse strength, change in colour, mottle skin from peripheries
Respiratory changes= noisy secretions, laboured breathing, apnoeic episodes and Cheyne- Stokes breathing

27
Q

What is Cheyne-Stokes breathing? What are the 5 priorities of care of the dying?

A

Cyclical pattern of breathing in which movement gradually decreases to a complete stop and then returns to normal
1) Possibility that a person may die within the coming days and hours is recognised and communicated clearly
2) Sensitive communication takes lace between staff and the person who is dying and those important to them
3) Dying person those identified as important to them are involved in decisions about treatment and care
4) The people important to the dying person are listened to and their needs are respected
5) Care is tailored to the individual and delivered with compassion

28
Q

Acronym for breaking bad news?

A

Situation: identify yourself to patient and loved ones, confirm responsible consultant and nurse in charge, describe how the person is today
Background: what brought the person to hospital, what has happened to the person since they were admitted, what tx and intervention has happened, how has the person responses
Assessment: because of what you have discussed today you believe the person is DYING (you have to be specific with this) in the next few hours to days (give your best estimate)
Recommendations: Develop an individualised plan of care for last days of life, which incorporates the needs and wishes of the dying person. This plan will include:
Ceiling of care
Interventions that will and won’t be done
Rationalise medications
Pre-emptive prescribing +/- syringe driver
Nursing care e.g. pressure areas and mouth care
Fluid and nutritional support if appropriate
DNACPR form to allow a natural death
What to expect as death approaches
Emotional, cultural and spiritual needs
Preferred place of ongoing care: DOCUMENT IT

29
Q

5 key symptoms to control near the end of life? Medicines management in their last few days of life?

A

Pain, breathlessness, respiratory secretions, nausea/ vomiting, distress/ agitation (delirium)
Pain= morphine 1.25-2.5mg SC or 2.5-5mg PO hourly (max 10mg/ 24 hours)
Breathlessness= morphine 1.25-2.5mg SC or 2.5-5mg PO hourly (max 10mg/ 24 hours)
Secretions= buscopan 20mg SC PRN (max 240mg/ 24 hours)
Agitation= midazolam 1.25-2.5mg SC hourly max 15mg/ 24 hours
Nausea= haloperidol 0.5-1.5mg 4 hourly max 5mg/ 24 hours

30
Q

What and what dose to prescribe for SOB, secretions, pain and nausea/ vomiting? Things to do for nutrition and hydration?

A

Look at flow charts in ‘terminal care’ lecture
Mouth care- prevent feeling of thirst, support oral food and drink for as someone wants it and is able
Regularly review for symptoms related to reduced fluid intake

31
Q

Things to do if a decision is made to use fluids?

A

Basic care with oral fluids and regular mouth care, regularly re-assess fluid status
Agree an aim- understand patient and family view, trying to prevent dehydration/ tx dehydration-related symptoms
Agree when you will review and when you would stop- review at least daily, symptoms not improving or developing complications from fluids
Decide on a route and volume- SC not for fluid resus- 1 to 2 litres per 24 hours, SC= an effective route to manage dehydration, you may have good IV access, if you lose access what would you do(forward planning)

32
Q

3 Human rights involved in Ethics and the Law?

A

The right to life, the prohibition of torture or inhuman or degrading treatment or punishment, the right to respect for private and family life

33
Q

3 parts to the Civil Contigencies act of 2004? Describes what 2 types of responder?

A

1) Defines the obligations of certain organisations to prepare for various types of emergencies
2) Provides additional powers for the government to use in the event of a large scale emergency
3) Provides supplementary legislation in support of the first 2 parts
NHS, Police, Fire services, local authorities and more…
Mostly utilities and transport organisations

34
Q

What does the CCA Act (2004) define an emergency as? It requires organisations to do what?

A

Event/ situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK or war or terrorism which threatens serious damage to the security of the UK
Maintain arrangements to warn the public, and to provide information and advice to the public, if an emergency is likely to occur or has occurred
Assess the risk of emergencies occurring and use this to inform contingency planning
Put in place emergency plans, business continuity management arrangements, arrangements to make information available to the public about civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency
Share info with other local responders to enhance coordination
Cooperate with other local responders to enhance coordination and efficiency

35
Q

3 levels of incident classification?

A

Major e.g. terrorist attack
Critical e.g. power outage at a hospital
Business continuity incident e.g. flood within a NHS property

36
Q

What are national incidents supported by? Function of ICCs?

A

Incident Coordination Centre based in London, National one is supported by 7 regional ones
Coordinate action, manage information, provide a clear focal point for the response and expert advice and guidance

37
Q

The Joint Emergency Services Interoperability Programme(JESIP) is covered by what 5 blocks?

A

Gather information and intelligence, assess risks and develop a working strategy, consider powers, policies and procedures, identify options and contigencies, take action and review what happened

38
Q

What is an incident? Reputational management?

A

Declared as per the CCA (2004)- an event/ issue that comes from within an organisation and prevents all or some core services or functions from running normally
External event that causes a significant increase in demand for services and/ or prevents them from operating normally
Not declared- event that while not impacting the day to day running of your organisation risks long-term viability through significant damage to reputation

39
Q

5 steps in how crisis comms are managed?

A

Signal detection, probing and prevention, damage containment, recovery, learning and evaluation

40
Q

What is a single point of contact?

A

Useful in the management and response to critical incidents- applicable in broader medical practice- ensures responded to in appropriate timescale, allows for monitoring of response times and logging of all requests and information provided, prevents time being spent on duplicate work, establishes trust and reliability during rapidly evolving and uncertain situation

41
Q

What is major trauma?

A

Serious and often multiple injuries where there is a strong possibility of death or disability

42
Q

Key principles in major trauma primary survey?

A

Control catastrophic haemorrhage, airway with C-spine protection, breathing with ventilation, circulation with haemorrhage control, neurological status, exposure/ environment (CABCDE)

43
Q

Difference between primary, secondary, tertiary and quaternary blast injuries? Commonest causes of preventable or potentially preventable death? Priorities are what?

A

Blast disrupts gas filled structure, impact airborne debris, transmission of body, all other forces
Bleeding, multiple organ dysfunction syndrome, CR arrest
Prevent hypoxia, acidaemia, traumatic cardiac arrest, or tx correctly

44
Q

ATMIST in relation to major trauma?

A

Age, time, mechanism, injuries, signs(observations,) treatments

45
Q

Tx of catastrophic haemorrhage?

A

Clear any clots obscuring bleeding source, direct pressure, more direct pressure, indirect pressure, tourniquet, haemostatic agents i.e. ceelox

46
Q

How to apply tourniquet for haemorrhage? Expected time frame for securing an airway in major trauma?

A

Above as high as possible, twist rod until bleeding stops, ensure stopped and no distal pulse, add 2nd one above first if cannot stop
45 minutes

47
Q

Absolute indications for intubation?

A

Inability to maintain and protect own airway regardless of conscious level, to maintain adequate oxygenation with less invasive manoeuvres (PaO2<10kPa,) inability to maintain normocapnia- spontaneous PaCO2<4.0kPa or >6.0kPa, deteriorating conscious level>/= 2 points on motor scale, significant facial injuries, seizures

48
Q

In the presence of burns or a blast injury, consider what? Early intubation considered in the presence of what?

A

Whether or not the airway is compromised or at risk of compromise
Hypoxaemia or hypercapnia, deep facial burns, full thickness neck burns

49
Q

Relative indications for intubation?

A

Haemorrhagic shock- particularly with evolving metabolic acidosis, early and repeat blood gas analysis will aid in this decision making, agitated- hypoxia and hypovolaemia cause agitation, multiple painful injuries, transfer to another area of hospital/ expected clinical course e.g. vascular angio/ theatres/ GITU