Symptom control 2 Flashcards
Clinical toxicity
Ax [4]
Presentation [2]
CTZ chemical stimulation by:
- Drugs
- Carcinomatosis or chronic infection
- Metabolic
Presentation:
- persistent and severe nausea
- little relief from vomiting or retching
Clinical toxicity
Mx [4]
Rx if chemotherapy or RT related?
- Manage metabolic imbalance
- DA antagonist: metoclopramide
- Haloperidol
- Chemotherapy or RT related: ondansetron
Drugs that can cause clinical toxicity [7]
- cytotoxics
- opioids, syrupy liquids
- antidepressants
- abx
- anticonvulsants
- digoxin and cardiac drugs
- alcohol
Metabolic causes of clinical toxicity [6]
- uraemia
- hypercalcaemia
- hyponatraemia
- ketoacidosis, infection
- Addison’s
- circulating toxins
Motility disorders
Another name
Ax [5]
aka Squashed stomach syndrome Ax: gastric stasis (functional) • Autonomic neuropathy: paraneoplastic • Drugs: opioid, anticholinergic • Metabolic: hypercalcaemia • Colic caused by prokinetic agent
Motility disorders
Presentation [4]
Management [3]
- intermittent large volume vomit with temporary relief of symptoms
- early satiation
- reflux, hiccup
- little nausea prior to vomit
Management
- mx of any underlying cause (drainage and diuretics for ascites)
1. Prokinetic: e.g. METACLOPRAMIDE or DOMPERIDONE (elderly or high risk extra-pyramidal SE) -
DO NOT combine pro-kinetics with anti-cholinergic e.g. CYCLIZINE, HYOSCINE*
2. Steroids can also be tried
Intracranial disorders etiology [2]
Presentation [4]
Ax:
- raised ICP by skull base tumour or space occupying lesion
- vestibular nerve or inner ear stimulation by ototoxicity or middle ear problems
Presentation:
- Headache
- Altered GCS
- Vertigo
- Motion sickness
Intracranial disorders mx:
- Increased ICP [2]
- Movement related nausea [3]
- Increased ICP: CYCLIZINE, DEXAMETHASONE
* Movement related nausea: CYCLYZINE, HYOSCINE HYDROBROMIDE, CINNARIZINE
Oropharyngeal irritation
Presentation
Mx
Sy/Si: worse on eating, exacerbated by food or smells, reflux symptoms, retching assoc. w/ productive cough
Mx: mx of reflux and infection etc, CYCLIZINE or HYOSCINE HYDROBROMIDE
Oropharyngeal irritation
Ax [10]
Cranial nerve irritation (vagus and glossopharyngeal) by
• Tumour
• Sputum or secretion stimulating gag reflex
• Acid reflex
• Toxins
• Inflammation
• Infection: candida, HSV
• Foreign body
• Smells from wounds, stomas, food and other sources
• Poor oral hygiene
Constipation causes in palliative patients [6]
Medication Secondary effects of illness, Concurrent disease Tumour in or compressing the bowel wall Nerve damage Hypercalcemia
What medication can cause constipation [5]
What secondary effects of illness can cause infection? [4]
Medication:
- opioids, antacids, diuretics, iron, ondansetron
Secondary effects of illness:
- dehydration, immobility, poor diet, anorexia
Management of constipation [3]
Laxatives - senna +/- docusate or macrogol
Rectal treatments:
- for soft/hard loading - bisacodyl suppository
- very hard loading: arachis oil enema overnight then phosphate enema
Laxative types [4]
Stimulant
Bulk forming
Softeners
Osmotic laxatives
Stimulant laxatives
Eg [4]
MOA
Indication
- Senna, bisacodyl, docusate, glycerol
- MOA: increases volume of bowel electrolytes drawing water from bowel into mucosa
- stimulates peristalsis
- Ind: constipation, fecal impaction
Stimulant laxatives
CI [3]
SE [2]
Education
CI: GI obstruction, perforation, heart failure
SE:
- N&V, abdo pain and discomfort, diarrhoea
- clinically irrelevant red/brown urine discolouration (Senna)
Education: take a few hours to work
Bulk forming laxatives
Eg [2]
MOA [3]
Indication [4]
Ispagula hulk, normacol
MOA:
- contain indigestible polysaccharides
- which increase faecal mass
- stimulate stretch receptors in the bowel mucosa increasing peristalsis and defecation
Indication:
- Constipation especially IBD, diverticulitis, colostomies, ileostomies
Bulk forming laxatives
CI [3]
SE [4]
Education
CI:
- faecal loading
- intestinal obstruction
- reduced gut motility
- so UNSUITABLE IN PALLIATIVE PATIENTS
SE:
- flatulence
- abdo distension
- intestinal obstruction, GI impaction
Education:
- unlikely to work if already have good fluid intake and high fibre diet
Softener laxatives Eg [2] MOA Indication [2] Education [3]
Eg: decussate sodium, liquid paraffin
MOA: Soften stool and act as a lubricant
• Ind: constipation, faecal impaction
• Education: liquid paraffin not before bed, docusate takes 1-2d to work orally but only 20 mins rectally
Osmotic laxatives
Eg [2]
MOA [3]
Eg: lactulose, laxido
MOA:
- Composed of sugar that is not digested or absorbed
- so maintains water in intestinal lumen and holds it there
- to provoke peristalsis and maintain faecal bulk
Osmotic laxatives
CI [3]
SE [4]
iNTERACTIONS [1]
- CI: obstruction/perforation, paralytic ileus (laxido), galactosaemia (lactulose)
- SE: abdo discomfort, cramps, flatulence, N&V, electrolyte imbalance
- Interactions: may increase effects of warfarin
Dyspnoea in palliative patient
Differentials [8]
- Recurrent PTX or pleural effusion
- Pre-exising lung condition
- SVC obstruction, lung mets lymphangitis carcinomatosis, bronchial obstruction
- Increasing anxiety
- Anaemia
- Pericardial effusion
- Diaphragmatic splinting (ascites)
- Muscle weakness (cachexia, paraneoplastic syndrome)
Management of dyspnoea in palliative care [3]
Rx [5]
- Underlying cause
- Non pharmacological
- Pharmacological
> Opioids
> CCS
> BDZ
> O2 if SpO2 <92%
> Nebulised NaCl
Non-pharmacological methods of dyspnoea mx [4]
- self-management plan
- smoke free environment, positioning
- controlled breathing
- planning and pacing activities
