(W5/6a) Palliative Emergencies Flashcards
What are the 7 main palliative emergencies?
1) Acute Pain Crisis
2) Stridor
3) Bleeding in cancer
4) Seizures
5) Malignant Spinal Compression
6) Superior Vena Cava Obstruction (SVCO)
7) Hypercalcemia
What is acute pain crisis?
- Severe and uncontrolled pain
- Causes immense distress to the patient
- > 7 in pain scale
- Requires immediate intervention
How to carry out pain assessment?
- Hx taking (COLDPSA)
~ Intensity
~ Nature
~ Cause
~ New pain or
~ Exacerbation of existing pain - Exclude reversible factors
What are the principles of pain management?
- Use strong opioids for rapid titration
~ Take into account presence of liver/renal impairment
~ IV/SC
~ eg Morphine, Fentanyl, Oxynorm - After pain is controlled, start continuous infusion of the opioid
- Have breakthrough doses ready
- Monitor for signs of opioid toxicity
What is a breakthrough dose?
For people on long-acting pain medications (like opioids), a breakthrough dose is a short-acting pain reliever given when pain “breaks through” the regular pain control regimen.
IMPT:
What are signs of opioid toxicity?
- Low RR
- Excessive sedation
- Myoclonic jerks
- Hallucinations
What is stridor and its causes?
- Abnormal, high-pitched breath sounds
~ Usually inspiratory - Due to narrowed airway
~ Tumour of upper airway
~ External compression
~ Recurrent laryngeal nerve palsy
Management of stridor?
- Tracheostomy
- Bronchoscopic interventions (intraluminal stenting)
- Chemotherapy/radiotherapy (if tumour)
- Dexamethasone (to decrease peritumour edema)
- Opioids (for breathlessness)
- Midazolam/sedation
- Keep fluids to a minimum
~ Secretions may further block the already narrowed airway
Management for bleeding?
- Resuscitative support
- Embolization/surgery to stop the bleeding
- Palliative sedation if bleeding is catastrophic
- Use dark green or brown towels
- Use Adrenaline or Tranexamic acid to reduce the bleeding
- Hemostatic pressure packing for surface bleeding
- Keep family members outside
- Debrief to screen for distress
What are the topical treatments for bleeding?
1) Tranexamic acid
- Crush 4 500mg tablets and mix with 60g base of paraffin
- or Soak undiluted ampoule 5ml in gauze and apply pressure for 10 mins, then leave in with dressing
2) Adrenaline
- Soak undiluted Adrenaline (1:1000) in gauze and apply pressure for 10 min, then leave in with dressing
- No long-term use
~ Can cause ischemic necrosis and rebound vasodilation
What is a systemic treatment for bleeding?
1) Tranexamic acid
- PO/IV 500mg-1000mg
- Max 1500mg tds
- NOT to be used when there is hematuria
~ Higher risk of clot formation -> Urinary retention
- NOT to be used in px with renal impairment and hx of thromboembolism
What is status epilepticus?
Continuous seizure activity that lasts >30 mins
Management of seizures?
- Turn px lateral left
- Provide supplemental oxygen
- Consider Dexamethasone if there is brain tumour (to reduce cerebral edema)
- Consider long-term epileptics (Keppra, Phenytoin)
- Rectal Diazepam
- Parental Midazolam
~ Every 15 mins until seizure is aborted
~ Can change to continuous infusion if85 seizures persist
What is malignant spinal cord compression?
- Growth of a tumour that compresses the spinal cord
- Highly suspected in cancer px who present with sudden back pain
- Can present acutely (within hours) or subacutely (within weeks to months)
- Usually from metastases
How to assess for malignant spinal cord compression?
- Back pain
- Neurological impairment
~ Weakness, sensory impairment and bladder/bowel dysfunction - Lax anal tone
- MRI spine to confirm
