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Year 4 CCC > Palliative Medicine > Flashcards

Palliative Medicine Flashcards

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1
Q

What is the PAM index?

A

Pre-arrest morbidity - looks at whether CPR will work (clinical team’s decision when deciding the efficacy of CPR in DNACPR decision)

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2
Q

(Common Pain syndromes)

Mx of Bone Pain?

A
  • NSAIDs (e.g. diclofenac)
  • Radiotherapy
  • Bisphosphonates (e.g. pamidronate infusion)
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3
Q

(Common Pain syndromes)

What is Visceral pain?

A

Dull, deep-seated, poorly localised pain. May be tender over particular organ. Some visceral pain is spasmodic such as bladder spasm/ bowel colic.

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4
Q

(Common Pain syndromes)

Mx of different types of visceral pain?

A
  1. Constant pain: follow analgesic ladder
  2. Visceral stretch (e.g. liver capsule pain): NSAIDs/ corticosteroids (reduce inflam)
  3. Colic pain: anticholinergic drugs e.g Hyoscine butylbromide for bowel colic, or Oxybutunin for bladder spasm.
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5
Q

(Common pain syndromes)

Management of neuropathic pain?

A
  • Antidepressants (amitriptyline)
  • Anticonvulsants (gabapentin/ pregablin)
  • Corticosteroids if compression of nerve
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6
Q

What is the 2nd stage on the Analgesic Ladder? (after paracetamol)

A

Codeine (240mg max)
Co-codamol (8/500, 15/500, 30/500)
Tramadol (not well tolerated in elderly, causes delirium

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7
Q

In pain mx, what must you always prescribe in?

A

mg !!!!

e.g. Oramorph 10mg/5ml, or 100mg/5ml

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8
Q

Example of Oral Morphine- quick release?

How do you work out the dose? What is the max dose?

How do you prescribe it?

A

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.
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9
Q

Example of Oral Morphine- modified/ slow-release?

A

Morphine Sulphate Tablets (MST)/ Zomorph capsules

MST is prescribed 12 hourly!!!
Lasts up to 12 hours.

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10
Q

What is the starting dose of MST?

A

20mg BD (if pt on max strength co-codamol)

Remember- always check the pain is opioid sensitive.

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11
Q

How much more potent than oral morphine is:

a) Parenteral morphine
b) Parenteral diamorphine

A

a) 2x more potent than oral

b) 3x more potent than oral

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12
Q

How can you administer Diamorphine/ Morphine Sulphate for injection?

A

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)

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13
Q

Duration of action of Fentanyl transdermal patch?

A

72 hours

Mainly suitable for pts with severe chronic pain already stabilised on other opioids.

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14
Q

Example of a syringe driver, and what are they used for?

A

McKinley T34
Portable, delivering a continuous infusion of drugs usually via subcut route.
(usually indicated if: cannot swallow, persistent N&V, intestinal obstruction, malabsorption)

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15
Q

Drugs suitable for subcut infusion via a syringe driver? (avoid mixing >3 compatible drugs)

A
  • 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
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16
Q

Drugs NOT suitable for subcut infusion (as they are too irritant)?

A
  • Diazepam
  • Chlorpromazine
  • Prochlorperazine
17
Q

What types of mouth problems are there in palliative care?

A
  • 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)
18
Q

Management of Anorexia in Palliative care?

A
  • 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).
19
Q

4 reasons for Nausea+Vomiting in palliative care and their different presentations?

A
  1. Gastric stasis/ irritation: early satiety, epigastric fullness, heartburn, often minimal nausea between vomits.
  2. ‘Toxic’: persistent/intermittent nausea, small vomits, retching.
  3. Cerebral: Raised ICP (early morning headache), or Anxiety/anticipatory (may have certain precipitants)
  4. Vestibular: may be associated with movement, hearing loss, vertigo or tinnitus.
20
Q

What are some ‘toxic’ causes of N&V, and what is the best management?

A
  • Drugs (opioids, digoxin, antiepileptics)
  • Hypercalcaemia
  • Ureaemia
  • Infections

Best mx: Haloperidol!

21
Q

What is the best mx for N&V caused by gastric statis/irritation?

A

Metoclopramide! (this is pro-kinetic so causes diarrhoea)

Stop any causative drugs if poss.

Consider PPI if gastric irritation

22
Q

What is best mx for N&V caused by Vestibular problems?

A

Cyclizine, hyoscine or cinnarizine.

23
Q

What are 4 types of laxatives for constipation?

A
  1. Bulk forming (e.g. Fybogel- rarely appropriate in palliative pts)
  2. Stool softeners (e.g. Lactulose, Sodium docusate)
  3. Stimulants (e.g. Senna, Dantron. Avoid if pt has colic)
  4. Combination (e.g. Co-danthrusate, Movicol/Laxido)- for opioid-induced constipation.
24
Q

What is lactulose?

A

Stool softener.

Osmotic, so can cause bloating/ flatulence.

25
Q

What are some sx of intestinal obstruction?

A

High incidence in pts with ovarian + bowel cancer.

Sx vary: N&V, colicky pain, abdo distention, dull ache, diarrhoea/constipation

26
Q

How do you manage collicky pain?

A 
Stop stimulant laxatives + prokinetic drugs (metoclopramide).
Prescribe antispasmodics (hyoscine butylbromide- Buscopan!).
27
Q

What can Midazolam be used for?

A

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.

28
Q

When is a death reported to a Coroner?

A
  • 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

Year 4 CCC (2 decks)

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