palliative emergencies (13 Nov) Flashcards
What is an acute pain crisis?
Severe and uncontrolled, causing immense distress to patient and loved ones.
May be acute in onset or worsening gradually to an intolerable level which requires immediate intervention.
7 or more in pain scale.
What are the important aspects of the pain assessment?
Intensity
Nature
Cause
Elicit if this is a new pain or an exacerbation of an existing pain
Exclude reversible factors (eg. acute retention of urine)
What are the principles of management for acute pain crises?
Keep calm and be reassuring.
Seek help from senior members of the team.
Use strong opioids for rapid transition (use IV/SC for rapid onset of analgesia, usually morphine, fentanyl or oxynorm)
MONITOR FOR SIGNS OF TOXICITY^
After pain is controlled -> continuous infusion of opioid.
Start pain chart.
What is stridor?
Abnormal, high-pitched breath sound that is produced by turbulent airflow through a narrowed airway.
Airway passage is often <5mm.
May be gradual or sudden, can be very distressing
What are the causes of stridor?
Tumour of the upper airway
Intraluminal obstruction of the trachea due to lung or esophageal cancers
External compression by tumour, metastasis or mediastinal lymphadenopathy
Recurrent laryngeal nerve palsy (from stroke/metastasis from lung cancer)
What is the non-pharmacological management of stridor?
IMPT TO RECOGNISE & MANAGE EARLY
airway may be secured via tracheostomy or bronchoscopic interventions
Chemo or radiotherapy if the cause is a tumour that is responsive
Good communication and education of patients and family members about what to expect and treatment plans is essential
What are the pharmacological interventions for stridor?
PO/IV/SC dexamethasone 16-24mg/day to decrease peritumour oedema
PO/IV/SC opioids for breathlessness - reduces secretions
if agitated, may need sedation (eg. midazolam)
keep fluids to minimum, airway secretions may compromise an already narrowed airway
What can be the causes of bleeding in cancers?
Vascular tumours
Tumour invasion into vascular structures
Systemic processes like disseminated intravascular coagulopathy or thrombocytopenia
What to assess and manage for bleeding in cancers?
- Underlying cause of bleed
- Patient’s prognosis
- Patient’s resuscitation status and goals of care
- Likelihood of reversing the underlying cause
- Balance of benefit vs burden ratio of intervention
What are the general measures for bleeding in cancers?
All medications that can worsen bleeding should be discontinued.
Topical treatments !!
Systemic treatments !!
Provide a calm and reassuring presence - encourage family members to stay outside until situation is under control
Involve MSW to support family
If bleeding in cancer is catastrophic (eg. carotid blow out), what do we do?
Consider palliative sedation and supportive measures ->
- Use dark green or brown towels
- Consider adrenaline or tranexemic acid packs
- Hemostatic pressure packing with gauze or ‘Kaltostat’ dressings for surface bleeding
- Use curtains to screen patient
What are the topical treatments for bleeding in cancer?
Tranexamic Acid (antifibrolytic)
- Crush 4 500mg tablets to a fine powder (or according to institution policy)
- 60g base (eg. soft parrafin)
OR
- Soak undiluted tranexamic acid ampoule (500mg/5ml, 10%) into gauze and apply pressure for 10 mins, leave in with dressings
Adrenaline
- Soak undiluted adrenaline (1:1000) in gauze and apply pressure for 10 min, then leave in with dressings
! Do not use long term - can cause ischemic necrosis and rebound vasolidation
What are the systemic treatments for bleeding in cancer?
Tranexamic acid
- PO/IV 500-1000mg TDS
! Do not use for hematuria as it will cause clots to form (risk of urinary retention)
! Caution: renal impairment, history of thromboembolism
What are seizures?
Result of abnormal electrical conductions in the brain causing the sudden onset of transient neurological symptoms
Continuous seizure activity that lasts longer than 30 minutes is termed as ‘status epilepticus’
What are the causes of seizures?
- Brain metastasis or primary brain tumour
- Hypoglycemia, hyponatremia, uraemia
- Hepatic encephalopathy
- Hypoxic encephalopathy/hypercarbia
- Stroke/scar epilepsy
- Infection
- Medications
What are the managements for seizures?
- Turn patient to lateral position (preferably left)
- Ensure safe environment
- Provide supplemental oxygen
- Correct reversible causes if appropriate
- Provide a calm and reassuring presence to the patient and family members
- Consider dexamethasone (16-24mg/day) if underlying cause is brain tumours especially if there is cerebral edema
- Consider long-term antiepileptics (eg. levetiracetam (keppra), phenytoin) - may not be necessary if patient is imminently dying
What are the pharmacological management for seizures?
- Rectal diazepam 10mg can be given if immediately available
- Parenteral midazolam 1-2.5mg can be given every 15 min until the seizure if aborted
- If seizures persist, parenteral (IV/SC) midazolam continuous infusion (0.5-3mg/hr) can be started OR consider IV antiepileptics (phenytoin, levetiracetam or phenobarbitone)
- for persistent seizures, urgent referral to a neurologist or specialist palliative care team should be considered
What is the significance of spinal cord compression?
SCC requires early identification and immediate treatment to prevent permanent neurological impairment.
Patients can present acutely (within hours) or subacutely (weeks to months)
When should you suspect spinal cord compression in patients?
There should be a high index of suspicion in cancer patients who present with back pain or sudden worsening of previously well controlled back pain, especially with known spinal metastases
If in doubt, consider an early MRI of the spine.
The underlying cause can be from intramedullary, intradural, or extradural metastases.
What to assess for spinal cord compression?
Back pain is the most common symptom.
Neurological impairment - weakness, sensory impairment, bladder and bowel dysfunction
Physical examination should include a full neurological examination including looking for lax anal tone
What is the management for SCC?
Confirm with MRI spine (unless patient refuses further treatment) - assess if more than one level is involved
Start dexamethasone 16mg/day with gastric protection
Assess extent of neurological deficits
What is superior vena cava obstruction (SVCO)?
Obstruction of blood flow in the superior vena cava
Mose SVCOs are caused by primary or secondary lung tumours
Usually insidious onset of symptoms rather than acutely - if rapid, it may be life threatening
Assessment of SVCO (signs and symtoms)
Symptoms:
Breathlessness
Headache
Visual changes
Dizziness
Feeling of pressure in the head and face
Signs:
Tachypnea
Engorged conjunctivae
Periorbital oedema
Cyanosis
Dilated neck veins and collateral veins in arms and chest
Pappiloedema (late feature)
What is the investigation for SVCO?
CT thorax to define level and degree of venous blockage
Identify the cause of SVCO
What is the management of SVCO?
If patient is acutely symptomatic with stridor, consider the possibility of tracheal compression which may need emergency tracheostomy
Immediate treatment:
- Position patient with head raised to decrease hydrostatic pressure
- Provide O2 if no contraindication
- Start IV/PO dexamethasone, particularly for patient with laryngeal oedema
What is hypercalcemia?
A common metabolic disorder affecting up to 1/3 of cancer patients
Poor prognostic indicator in malignant disease.
What is the assessment for hypercalcemia?
Usually insidious, acute symptoms occur with rapidly rising calcium levels.
Symptoms:
Fatigue
N&V
Anorexia
Abdominal pain
Constipation
General aches and pains
Polydipsia/polyuria
Signs:
Drowsiness
Delirium
Seizure
Arrythmia
Postural hypotension
Renal stones
What is the investigation for hypercalcemia?
Corrected calcium
>2.6mmol/L = hypercalcemia
>3.0mmol/L requires urdent intervention
Urea and electrolytes
- dehydration and electrolyte imbalance is common in hypercalcemia
Plasma PTH (parathyroid hormone)
- if suspicious of non-malignant causes of hypercalcemia
- plasma PTH is suppressed in malignant hypercalcemia
ECG
- arrythmia
- shortened ST segment
What is the management for hypercalcemia?
Rehydration
- the MOST IMPT
- helps to restore renal function and increase calcium excretion
- most pts have fluid deficits of 4-6L, hydrate with 2-3L of IV fluids per day if there are no contraindications
Medications:
- Biphosphonates
- Calcitonin
- Denosumab
