Palliative Care/ Oncology Flashcards
What is terminal agitation?
Agitation occurring in the last few days of life
How is neutropenic sepsis diagnosed? Presentation? Time to administer antibiotics to treat?
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)
Medications can cause neutropenic sepsis? Tx?
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
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?
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)
Causes of malignant spinal cord compression? Presentation? Ix?
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
Management of malignant spinal cord compression? Prognosis?
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
Who is hypercalcaemia common in? Symptoms? Often ass w/ what? How is it diagnosed?
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
Tx of hypercalcaemia?
IV fluids- manage AKI, IV bisphosphonates- zolendronate, pamidronate(can take days to work), denosumab if resistant to bisphosphonates
Level for mild hypercalcaemia? Moderate? Severe? Causes?
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
Acute treatment for malignant hypercalcaemia? Persistent or relapsed hypercalcaemia of malignancy?
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
Causes and signs of SVC obstruction?
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
Ix and tx for SVC obstruction?
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)
Other oncological emergencies?
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
General SEs of chemo? Immunotherapy? Radiotherapy?
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
What is stridor usually due to? Signs? Ix? Tx? Management?
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
Who is massive haemorrhage common in? S+S?
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
Tx massive haemorrhage?
Stop anticoagulation, if palliative- dark towels, remain w/ patient, midazolam 10mg stat, DEBRIEF W/ SENIOR
S+S of opioid overdose? Ix? Tx?
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)
Pitfalls in opioid overdose?
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