Emergencies in palliative care
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Emergencies in Palliative Care. Objectives. Manage palliative care emergencies Have a basic knowledge of appropriate treatments Know where to get help and advice Plan Ahead / Be prepared Understand importance of communication Know what supplies might be needed Advance care planning.

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Emergencies in palliative care

Emergencies inPalliative Care


Objectives
Objectives

  • Manage palliative care emergencies

    • Have a basic knowledge of appropriate treatments

    • Know where to get help and advice

  • Plan Ahead / Be prepared

    • Understand importance of communication

    • Know what supplies might be needed

    • Advance care planning


Palliative care emergencies
Palliative Care Emergencies

  • Hypercalcaemia

  • Superior Vena Cava Obstruction (SVCO)

  • Spinal Cord Compression

  • Haemorrhage / Bleeding

  • Seizures / Fitting


General principles

Anticipate

Who is at risk?

Plan

Communication

Preparation

Avoid

Correct the correctable

Prophylaxis

General Principles


Factors to consider
Factors to consider

  • What is the emergency

  • Can it be reversed

  • General physical status of the patient

  • Prognosis

  • Burdens of treatment

  • Patients and carers wishes


מר לוי סובל מסרטן ראה NSCC .

אתמול בגלל הדרדרות במצבו , חולשה ניכרת קושי בעמידה, החמרה בעצירות בצרבת ובכאב, בדקת אותו וביקשת מהאחות לשלוח בדיקת דם. מה תבקש?

אשתו מתקשרת אליך בשל החמרה במצבו: לא מסוגל לצאת מהמיטה, נראה מעט מבולבל וגונח מכאב.


Hypercalcaemia
Hypercalcaemia

  • Who is at risk?

    • 10-20% of all patients with malignant disease

    • 50% of patients with myeloma

    • 20% of breast and non small cell lung cancer patients

    • Also commonly seen in oesophagus, thyroid, prostate, lymphoma, and renal cell carcinoma


Hypercalcaemia1
Hypercalcaemia

  • Features

    • Confusion

    • Drowsiness

    • Nausea and vomiting

    • Constipation

    • Polyuria and polydipsia

  • Can mimic deterioration due to progressive malignancy


Hypercalcaemia2
Hypercalcaemia

  • Diagnosis

  • Check renal function and corrected calcium

    ( need to know albumin concentration)

  • Corrected ca = measured Ca+(n ALB-mALB)x0.8


Hypercalcemia treatment
Hypercalcemia Treatment

Consider the goals

Hydration and saline diuresis

Bisphosphonates

Steroids?

FolIow 3-5 days

prevention

C. Woelk MD


גב' זלץ בטיפולך בהוספיס בית בשל RCC מפושט.

ידוע על מחלה גרורתית מפושטת לוריד החלול , בבלטות רטרופריטונאליותובעמ"שטורקלי ((D6-9 , באגן ובירך ימין.

גב' זלץ קוראת לך בשל החמרה בכאב הגב ונימול הקורן ל 2 הרגליים יותר לשמאל.

לדבריה מתקשה ללכת לשירותים גם בעזרת ההליכון.


Spinal cord compression scc
Spinal Cord Compression (SCC)

  • Occurs in advanced malignancy

  • Main problem is lack of recognition

  • Up to 5% of patients with cancer develop SCC

  • There is a 30% 1 year survival

  • Malignancies which commonly cause SCC include; prostate, breast, lung, myeloma, lymphoma and renal


Spinal cord compression

Compression of Vasculature

Direct Compression

Vertebral Mets

Paraspinal mass

Spinal Cord Compression


Spinal cord compression scc1
Spinal Cord Compression (SCC)

  • Most commonly affects thoracic level (70%)

  • Signs and symptoms depend on the area of the cord affected

  • Signs can be subtle to gross

  • More than one level can be affected

  • Compression below L2 affects the cauda equina


Spinal cord compression1
Spinal Cord Compression

  • Causes

    • Vertebral metastases and collapse 85%

    • Extravertebral tumour (extension into epidural space)

    • Intramedullary tumour (from spinal cord)

    • Intradural tumour (from meninges)

    • Epidural metastases


Spinal cord compression2

Features

Pain (earliest symptom)

Weakness

Sensory changes and a sensory level tingling and numbness

Sphincter dysfunction / perianal numbness

Altered reflexes

Can have resolution of the pain

Examination

Demarcated sensory loss

Brisk or abscent reflexes

Spinal Cord Compression


Spinal cord compression3
Spinal Cord Compression

  • Diagnosis

    • Urgent MRI or CT

    • Important early diagnosis!

    • 70% have substantial weakness by the time of scanning

    • 70% who can walk before treatment maintain mobility

    • 35% of those with weakness regain function

    • Only 5% completley paraplegic do so


Management of scc
Management of SCC

  • Oral dex 16mg (EMERG MNG IV 100MG )

  • Radiotherapy ( no spinal instability)20GR 5 #

  • Surgery and radiotherapy ( spinal instability such as fracture

  • Surgery alone relapse at previously irradiated site

  • Chemotherapy

  • Steroids alone


Superior vena cava syndrome
Superior Vena Cava Syndrome

The clinical manifestation of superior vena cava (SVC) obstruction, with severe reduction in venous return from the head, neck and upper extremities

C. Woelk MD



Superior venacaval syndrome1

Extrinsic tumour or Node

Direct Invasion

Intraluminal Thrombus

Complication of Central Line

Superior Venacaval Syndrome


Superior vena cava syndrome incidence and etiology
Superior Vena Cava SyndromeIncidence and Etiology

Usually associated with malignancies

Often the initial presentation of cancer

Bronchogenic carcinoma (80%)

Lymphoma (15%)

Metastatic disease (5%)

C. Woelk MD


Superior vena cava syndrome presentation
Superior Vena Cava SyndromePresentation

  • Symptoms:

    • Dyspnea 63%

    • Facial and neck swelling 50%

    • Fullness in head 50%

    • Cough 24%

    • Arm swelling 18%

    • Chest pain 15%

    • Dysphagia 9%

C. Woelk MD


Superior vena cava syndrome presentation1
Superior Vena Cava SyndromePresentation

  • Signs:

    • Venous distention of neck 66%

    • Venous distention of chest wall 54%

    • Facial edema 46%

    • Cyanosis 20%

    • Edema of the arms 14%

    • Plethora of the face 10%

    • Vocal cord paralysis 3%

    • Horner’s syndrome 3%


Superior vena cava syndrome management
Superior Vena Cava SyndromeManagement

  • Does not usually imply immediate threat to life, except when trachea or pericardium is compromised

  • Important is to establish a diagnosis

  • Emergency treatment indicated if:

    • Compromised airway

    • Decreased cardiac output

    • Cerebral dysfunction

C. Woelk MD


Superior vena cava syndrome management1
Superior Vena Cava SyndromeManagement

Chemotherapy – SCLC, NHL

Radiation - NSCLC

Bed rest with head elevated

Oxygen

Diuretics

Steroids- medium to high dose

C. Woelk MD


Severe hemorrhage etiology
Severe hemorrhageEtiology

  • Epistaxis

  • GI bleeding:

    • Hematemesis,Hematochezia,Melena

  • Hemoptysis

  • Hematuria

  • Internal Bleeding

  • Bleeding from fungating tumours

  • Hemolysis

C. Woelk MD


Severe hemorrhage important general questions
Severe hemorrhageImportant General Questions

Is treatment of the underlying condition possible in the context of the bleeding?

Is it possible to keep up with the loss of blood, and for how long?

These may need to be addressed early, with the patient, family and caregivers.

C. Woelk MD


Gi bleeding incidence and etiology
GI BleedingIncidence and Etiology

  • 80% of GI bleeding in cancer patients is from benign sources – good prognosis

  • Massive hemorrhage is unusual

    ESOPHAGUS

    STOMACH

    SMALL INTESTINE

    COLORECTUM

C. Woelk MD


Gi bleeding management
GI BleedingManagement

Consider gastroscopy / colonoscopy / surgery if life expectancy reasonable.

Avoid surgery if life expectancy < 2 months

Stop potentially offending agents: e.g. NSAIDs

Consider IV fluids, PPI

C. Woelk MD


Gi bleeding management1
GI BleedingManagement

Massive Bleeding in the Terminal Phase:

  • Keep patient warm

  • Consider sedation

  • Green and black towels and sheets

C. Woelk MD


Hemoptysis incidence and etiology
HemoptysisIncidence and Etiology

  • Present in 30-50% of primary lung neoplasms at the time of presentation

  • 10 % of patients admitted to hospice

  • Massive hemoptysis uncommon:

    • Pulmonary embolism

    • Bronchial bleeding due to tumour erosion

    • Epistaxis

C. Woelk MD


Massive hemoptysis management
Massive HemoptysisManagement

Trendelenburg position

Consider sedation

Green and black towels

C. Woelk MD


Wound bleeding incidence and etiology
Wound BleedingIncidence and Etiology

Bleeding is a common problem with malignant wounds

May involve oozing from microvascular fragmentation to frank bleeding if vessels are involved

C. Woelk MD


Wound bleeding management
Wound BleedingManagement

  • For patients with malignant wounds, it will not be possible to heal the wound, unless one can treat the underlying cancer.

  • Avoid adherent dressings.

  • Keep the wound moist.

  • Direct pressure, if actively bleeding

  • Medicated dressing possibilities:

    • Topical aminocaproic acid

    • Topical dilute silver nitrate solutions

C. Woelk MD


Wound bleeding management1
Wound BleedingManagement

If bleeding is possible, discuss this with the patientand family and staff

If bleeding is catastrophic, dark towels may reduce anxiety of all involved

If the patient is distressed, consider sedation

C. Woelk MD


Severe hemorrhage systemic interventions
Severe HemorrhageSystemic Interventions

  • D/C antiplatelet and anti-thrombotic agents

  • Vitamin K

  • Transfusion of blood or platelets

  • Antifibrinolytic Medication

    • Tranexamic acid

    • Aminocaproic acid

  • Desmopressin

  • Octreotide (somatostatin analog)

C. Woelk MD


Severe hemorrhage management
Severe Hemorrhage - Management

  • Desmopressin (DDAVP)

    • An analog of the posterior pituitary hormone: vasopressin

    • Extensively used in Type 1 von Willebrand Disease

    • 0.3-0.4 mcg/kg IV over 20 minutes OR 150-300 mcg nasal inhalation

    • Has been used successfully in acquired defects of platelet function – e.g. uremia, cirrhosis, ASA – and in variceal bleeding

    • Avoid excessive fluid administration


Severe hemorrhage management1
Severe HemorrhageManagement

Remember the goals of care

Keep patient, family, staff informed of progress and prognosis

C. Woelk MD


Seizures incidence
SeizuresIncidence:

1% of patients with advanced cancer


Seizures etiology
SeizuresEtiology

  • Most common:

    • Primary or metastatic brain tumours

    • CVA / Stroke

    • Pre-existing seizure disorder

  • Less common:

    • Hypoxemia

    • Metabolic: uremia, hypoglycemia, hyponatremia

    • Sepsis

    • Drug or alcohol withdrawal


Seizures education
SeizuresEducation

  • What to do if a seizure happens:

    • Help avoid harm / trauma

    • Do not restrain

    • Do not attempt to insert anything orally

    • Recovery position after the seizure

    • Expect drowsiness for a while after

    • Call for help if seizure lasts more than 5 minutes (it will feel like 30)


Seizures management
SeizuresManagement

Investigate as appropriate, based on patient’s status and course

Generally felt unnecessary to give routine prophylaxis for seizures

Grand Mal Seizures: Phenytoin is first drug of choice

Focal Seizures: Carbamazepine is first drug of choice

Other anticonvulsants may be needed

C. Woelk MD


Status epilepticus management
Status epilepticusManagement

Protect airway

Administer Oxygen

Consider SC or IV

C. Woelk MD


Status epilepticus medications
Status epilepticusMedications

  • IV available:

    • Lorazepam 2-4 mg over 2-4 minutes

    • Phenytoin load: 20 mg/kg at 25 mg/min

      • May need to go as high as 30 mg/kg

    • Phenobarb 20 mg/kg at 100 mg/min

  • IV unavailable

    • Diazepam 10 mg solution PR

      • May be repeated q10minutes

    • Midazolam SC infusion 1-3 mg / hour

  • Consider steroids

C. Woelk MD


Multifocal myoclonus
Multifocal Myoclonus

Jerking, involuntary movements of arms and legs

May start as subtle movements, and then become bothersome and disturbing

C. Woelk MD


Multifocal myoclonus etiology
Multifocal MyoclonusEtiology

Very often associated with delirium and related to opioid toxicity

May be a pre-terminal event

Important to consider the differences

C. Woelk MD


Opioid neurotoxicity
Opioid Neurotoxicity

Cognitive Dysfunction

Myoclonus

Hyperalgesia

Allodynia

Perceptual Disturbance

Seizures

C. Woelk MD


Multifocal myoclonus management
Multifocal MyoclonusManagement

Stop the current opioid and rotate to a different one at 50-75% of the equivalent dose.

Allow for adequate breakthrough doses

Consider careful hydration

Expect resistance from family / staff

Interpreting the myoclonus and associated symptoms / signs as pain, and increasing the original opioid will eventually result in more myoclonus and delirium

C. Woelk MD


Summary
Summary

Emergencies happen, even in dying individuals.

Emergencies may be treated differently in the palliative population, with much more of an emphasis on symptom management than on attempts at reversing the disease process.

Communication with the patient and family is extremely important for dealing with emergencies.


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