Palliative Medicine Flashcards by Luse Mwenechanya

Cancer pain occurs in what % of patients?

80%

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Bone pain is described as what type of pain?

Dull pain often worse on weight bearing/with movement

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Bone pain is treated with what?

NSAIDs
Radiotherapy
Bisphosphonates - pamidronate

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Deep seated tenderness over a particular organ can be a sign of which type of pain?

visceral

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Hyoscine butylbromide can be used to treat what type of pain?

Colicky pain - e.g. intestinal obstruction

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A dull headache worse on leaning forward is treated with what agents?

Raised ICP headache
16mg dexamathasone to reduce oedema + cyclazine
NSAIDS & paracetamol

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Pregabalin can be used to treat what type of pain?

Neuropathic

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Liver capsule pain is a type of what pain? And how is it managed?

Visceral pain

Analgesic ladder

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What is neuropathic pain?

Area of abnormal sensation - pins & needles, numbness, pallor/sweating
Abnormal pain due to damaged nerves

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What does TENS stand for? And what is it used to treat?

Transcutaneous electrical nerve stimulation

Nerve pain where amitriptyline is inappropriate

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What fraction of your 24 hour dose of morphine should the PRN dose be?

1/6

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If morphine is not tolerated or ineffective, what is the alternative opioid?

Oxycodone - 2x more potent than morphine

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How many times more potent is diamorphine SC compared to PO morphine?

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What opioids are available transdermal? And for how long does they last?

Fentanyl - 72 hours

Buprenorphine

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What should always be prescribed in conjunction with an opioid?

Laxative

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Name 3 preparations of co-codamol

8/500 2x QDS max
30/500 2x QDS max - is this doesn’t work, don’t increase codeine due to constipation
Instead move up ladder

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Which patients should amitriptyline be avoided in and why

Cardiac patients - risk of arrhythmias

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What are the strong opioids?

Morphine
Fentanyl
Oxycodone
Buprenorphine

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Which weak opioid is rarely used in treatment of cancer pain?

Tramadol

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Which antiemetic is used to counteract opioid N&V?

Haloperidol

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When does drowsiness usually occur when taking opioids & when is it abnormal?

When starting or changing dose

Should subside in 48 hours - if prolonged then this is abnormal

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If respiratory depression occurs due to opioid overdose, what is the management?

Naloxone

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What are the signs of opioid toxicity?

Persistent N&amp;V
Persistent drowsiness
Confusion
Visual hallucinations 
Myoclonic jerks
Respiratory depression - late sign

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What are the 2 types of morphine?

Immediate release

Modified/slow release

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MST & Zomorph are what type of morphine and what is the duration of action?

Modified release | Lasts up to 12 hours - therefore take BD

Oromorph is what type of morphine & what is the duration of action?

Normal/ immediate release Works within 20-30 minutes & lasts 4 hours Used as PRN

What is the normal starting dose of MST?

15-20mg

What is the maximum no. of doses you can take of PRN oromorph?

6 doses per day | Each dose = 1/6 of max dose in 24 hours

How many times more potent is parenteral MST compared to oral morphine?

2x more common | Therefore divide max dose by 2 when converting PO to SC

How can MST be delivered to someone not tolerating oral tablets?

Syringe driver over 24 hours

What step of the analgesic ladder is oxycodone?

Step 3 - 2nd line after morphine

What are the 2 preparations of oxycodone?

Oxynorm - immediate release | Oxycontin - slow release

What is the medical term for dry mouth? | What are some causes?

Xerostomia Palliative meds - antiemetics, antidepressants Reduced intake of oral fluids - e.g. due to opioid N&V Radiotherapy of head & neck

What can be used to treat anorexia caused by opiate use?

Dexamethasone 4mg OD - effect wears off after 2-3 weeks | Megestrol acetate - 160mg OD - can cause fluid retention

What are the 4 main causes of vomiting?

Toxic Gastric Cerebral Vestibular

N&V caused by ascites pressing on the stomach can be treated with which antiemetic?

Gastric cause - use metaclopramide | Or domperidone

Posseting & retching is a sign of which type of N&V? | Which antiemetic should be used to treat this?

Toxic causes Haloperidol - 1.5-5mg PO/sc nocte (at night) Or levomoperizine

Cyclamen is used to treat which type of N&V?

Raised ICP

What are the side effects of metaclopramide?

EPSEs | Prolactinaemia

Diazepam is used to treat what type of nausea? When can it occur?

Anticipatory nausea E.g. before chemo/rx Consultations/ bad news

Fybogel is what type of laxative?

Bulk forming

What are the softener laxatives?

Lactulose | Sodium docusate

What is a side effect of lactulose?

Bloating

What are the stimulant laxatives?

Senna Danton Sodium picosulphate

What are the combination laxatives?

Movicol | Co-danthramer

Which laxative causes orange urine?

Co-danthramer

Which type of cancers most commonly cause intestinal obstruction?

Ovarian & bowel

What are the symptoms of intestinal obstruction?

N&V Abdominal pain & distention Constipation/ overflow diarrhoea Colicky pain

What non-surgical treatment can be used for intestinal obstruction? How does it work?

Buscapan - hyosine butylbromide | Reduces bowel movement & pain

What can be used to treat breathlessness in palliative patients?

Opioids to reduce respiratory effort

What are common acute causes of breathlessness?

Asthma - bronchodilators Pulmonary oedema - diuretics & diamorphine PE - anticoagulants

What if someone develops SoB over several days, what may be the cause?

Pneumonia - abx COPD - abx & bronchodilators SVCO obstruction - dex + & PPI + stent Bronchial obstruction - dex + PPI +stent

Name some causes of gradual onset SoB

``` Heart failure - digoxin, diuretics, ACE-i Anaemia Pleural effusion - aspiration Ascites Lymphangitis carcinomatosis ```

What is lymphangitis carcinomatosis

Inflammation of the lymph vessels caused by malignancy | Causes gradual onset SoB

What are the 3 main causes of cough in palliative patients?

Excessive mucous production Inhaled foreign body Abnormal stimulation of bronchial receptors

How can dry cough be treated pharmacologically?

Opioids - cough suppressants | E.g. codeine linctus

What are the benefits of telling someone when they are palliative?

Reduces fear Allows them to make non-medical decisions Allows them to make preparations

What is the gold standards framework and who is it for?

Patients in last year of life Assesses current & future possible clinical needs Plans for cross-boundary care i.e. gives relevant contacts etc

What does the AMBER in amber care bundle stand for?

``` Assessment Management Best practice Engagement Recovery uncertain ```

Who is the AMBER care bundle for?

Those likely to die in the next 2 months | Aims for early conversation with carers & reduced hospital readmissions