Palliative Medicine Flashcards
What is the PAM index?
Pre-arrest morbidity - looks at whether CPR will work (clinical team’s decision when deciding the efficacy of CPR in DNACPR decision)
(Common Pain syndromes)
Mx of Bone Pain?
- NSAIDs (e.g. diclofenac)
- Radiotherapy
- Bisphosphonates (e.g. pamidronate infusion)
(Common Pain syndromes)
What is Visceral pain?
Dull, deep-seated, poorly localised pain. May be tender over particular organ. Some visceral pain is spasmodic such as bladder spasm/ bowel colic.
(Common Pain syndromes)
Mx of different types of visceral pain?
- Constant pain: follow analgesic ladder
- Visceral stretch (e.g. liver capsule pain): NSAIDs/ corticosteroids (reduce inflam)
- Colic pain: anticholinergic drugs e.g Hyoscine butylbromide for bowel colic, or Oxybutunin for bladder spasm.
(Common pain syndromes)
Management of neuropathic pain?
- Antidepressants (amitriptyline)
- Anticonvulsants (gabapentin/ pregablin)
- Corticosteroids if compression of nerve
What is the 2nd stage on the Analgesic Ladder? (after paracetamol)
Codeine (240mg max)
Co-codamol (8/500, 15/500, 30/500)
Tramadol (not well tolerated in elderly, causes delirium
In pain mx, what must you always prescribe in?
mg !!!!
e.g. Oramorph 10mg/5ml, or 100mg/5ml
Example of Oral Morphine- quick release?
How do you work out the dose? What is the max dose?
How do you prescribe it?
Oramorph liquid/ Sevredol tablets.
-Takes effect in 15-30mins, lasts 4hrs.
Should be 1/6th total daily dose of regular opiate. Max top-up pain is 6 doses in 24hrs!
Prescribing:
- ‘hrly’ in frequency box.
- ‘6doses max’ in extra info box.
Example of Oral Morphine- modified/ slow-release?
Morphine Sulphate Tablets (MST)/ Zomorph capsules
MST is prescribed 12 hourly!!!
Lasts up to 12 hours.
What is the starting dose of MST?
20mg BD (if pt on max strength co-codamol)
Remember- always check the pain is opioid sensitive.
How much more potent than oral morphine is:
a) Parenteral morphine
b) Parenteral diamorphine
a) 2x more potent than oral
b) 3x more potent than oral
How can you administer Diamorphine/ Morphine Sulphate for injection?
Both can be given subcut either as required or as a continuous SC infusion via a syringe driver.
(n.b. the total 24hr SC infusion diamorphine dose should be 1/3 of total 24hr oral morphine)
Duration of action of Fentanyl transdermal patch?
72 hours
Mainly suitable for pts with severe chronic pain already stabilised on other opioids.
Example of a syringe driver, and what are they used for?
McKinley T34
Portable, delivering a continuous infusion of drugs usually via subcut route.
(usually indicated if: cannot swallow, persistent N&V, intestinal obstruction, malabsorption)
Drugs suitable for subcut infusion via a syringe driver? (avoid mixing >3 compatible drugs)
- Diamorphine/morphine sulphate
- Cyclizine (may cause skin irritation)
- Haloperidol
- Metoclopramide (useful prokinetic, avoid if colic)
- Levomepromazine (can cause skin irritation)
- Hyoscine hydrobromide (may cause sedation/ agitation)
- Hyoscine butylbromide (doesn’t cross BBB)
- Midazolam
Drugs NOT suitable for subcut infusion (as they are too irritant)?
- Diazepam
- Chlorpromazine
- Prochlorperazine
What types of mouth problems are there in palliative care?
- Dry mouth (xerostomia): RT to head+neck can cause severe dry mouth. Results in loss of taste, anorexia, halitosis, dysphagia + oral infection.
- Oral thrush (candidosis)
Management of Anorexia in Palliative care?
- Always try find any reversible cause (oral thrush, nausea, pain, constipation + depression
- Drugs that may help: dexamethasone (effect wears off), or megestrol acetate (lasts longer, may cause fluid retention).
4 reasons for Nausea+Vomiting in palliative care and their different presentations?
- Gastric stasis/ irritation: early satiety, epigastric fullness, heartburn, often minimal nausea between vomits.
- ‘Toxic’: persistent/intermittent nausea, small vomits, retching.
- Cerebral: Raised ICP (early morning headache), or Anxiety/anticipatory (may have certain precipitants)
- Vestibular: may be associated with movement, hearing loss, vertigo or tinnitus.
What are some ‘toxic’ causes of N&V, and what is the best management?
- Drugs (opioids, digoxin, antiepileptics)
- Hypercalcaemia
- Ureaemia
- Infections
Best mx: Haloperidol!
What is the best mx for N&V caused by gastric statis/irritation?
Metoclopramide! (this is pro-kinetic so causes diarrhoea)
Stop any causative drugs if poss.
Consider PPI if gastric irritation
What is best mx for N&V caused by Vestibular problems?
Cyclizine, hyoscine or cinnarizine.
What are 4 types of laxatives for constipation?
- Bulk forming (e.g. Fybogel- rarely appropriate in palliative pts)
- Stool softeners (e.g. Lactulose, Sodium docusate)
- Stimulants (e.g. Senna, Dantron. Avoid if pt has colic)
- Combination (e.g. Co-danthrusate, Movicol/Laxido)- for opioid-induced constipation.
What is lactulose?
Stool softener.
Osmotic, so can cause bloating/ flatulence.
What are some sx of intestinal obstruction?
High incidence in pts with ovarian + bowel cancer.
Sx vary: N&V, colicky pain, abdo distention, dull ache, diarrhoea/constipation
How do you manage collicky pain?
Stop stimulant laxatives + prokinetic drugs (metoclopramide). Prescribe antispasmodics (hyoscine butylbromide- Buscopan!).
What can Midazolam be used for?
Short-acting sedative/ anxiolytic/ muscle relaxant.
Can be used for terminal restlessness, once have explored any reversible causes such as pain, urinary retention, faecal impaction.
When is a death reported to a Coroner?
- Cause of death unknown/ any doubt
- Decreased not seen by a dr during last illness, or within 14days of death
- Death due to operation/or as a consequence of/ related to anaesthetic
- Detained under MHA
- Death may have been caused by the actions of decreased (e.g. drugs)
- Due to/contributed to by industrial disease/ poisoning/ occupational injury
- Due to/contributed to by a fall/fracture
