Emergencies in Palliative Medicine

1. Emergencies in Palliative Medicine Hazel Pearse Spr Palliative Medicine

2. Objectives • Recognise palliative care emergencies • Be aware of their existence • Recognise signs and symptoms of common emergencies • Anticipate occurrence of emergencies • Understand who is at risk • Be able to minimise the risk

3. 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

4. Palliative Care Emergencies • Hypercalcaemia • Superior Vena Cava Obstruction (SVCO) • Spinal Cord Compression • Haemorrhage / Bleeding • Seizures / Fitting

5. Anticipate Who is at risk? Plan Communication Preparation Avoid Correct the correctable Prophylaxis General Principles

6. 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

7. Hypercalcaemia • Commonest life threatening metabolic disorder encountered in patients with cancer • Consider non-malignant causes such as hyperparathyroidism

8. 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

9. Hypercalcaemia • Features • Confusion • Drowsiness • Nausea and vomiting • Constipation • Polyuria and polydipsia • Can mimic deterioration due to progressive malignancy

10. Hypercalcaemia • What causes high calcium in malignancy? • Skeletal metastases • Production of osteoclastic factors • PTH related protein secretion • Ectopic PTH secretion (rare)

11. Hypercalcaemia • Diagnosis • Check renal function and corrected calcium( need to know albumin concentration) • Corrected ca = measured Ca+(40-almumin)x0.02

12. Management • Is it appropriate to treat • Can be effective symptom management even in the final stages • Rehydrate with normal saline • Bisphosphonate treatment • Calcium takes 3-5 days to normalise

13. Prevention of Recurrence • Consider disease modifying treatments • Consider maintenance treatment • Monitor at 3 weekly intervals or when symptomatic

14. Hypercalcaemia • Prognosis • Hypercalcaemia is a sign of tumour progression • Survival is less than 3 months with treatment • Calcium level >4 leads to renal failure, cardiac arrhythmias and fits

15. Superior Vena Cava Obstruction (SVCO) • External compression • Intraluminal thrombosis • Direct invasion of the vessel wall

16. Who is at risk • Mostly tumours / nodes within the mediastinum • 75% primary bronchial carcinomas • Lymphoma • Breast cancer patients • Seminoma • Occurs in 3% of thoses with ca bronchus

17. Symptoms Breathlessness Choking Headache Swelling; facial, neck, trunk and arms Signs Venous distension Plethora Stridor Coma / Death SVCO: Features

18. SVCO: Diagnosis • Doppler ultrasound • Angiography

19. Management • Can be a presenting feature of malignancy • Need histology • Treatment tailored to type of malignancy

20. SVCO: Management in advanced disease • High dose corticosteroids • Radiotherapy to the mediastinum • Stenting of the SVCO • In Non small cell lung cancer palliative radiotherapy gives relief in 70% • Important to give symptomatic treatments for SOB etc • Review steroids after 5 days

21. Likely sources Surface bleeding Epistaxis Haemoptysis Haematemesis / Melaena Rectal Vaginal Haematuria Erosion of an artery Bleeding

22. Bleeding • Who is at risk? • Metastatic malignancy increases the risk of bleeding and thrombosis • 20% of patients with cancer have bleeds • In 5% of patients bleeding contributes to death

23. Bleeding; risks • The malignancy itself • Site of tumour or secondaries; skin, bowel, bladder, lung etc. • Nature of tumour; risk of erosion of near by vessels

24. Thrombocytopenia Marrow infiltration Drugs, chemotherapy Blood transfusion Disseminated intravascular coagulation (DIC) Hypersplenism Impaired function Drugs eg. NSAID Myeloma / paraproteinaemias Myeloproliferative disorders Renal and hepatic failure Bleeding; risks

25. Bleeding; risks • Vitamin K deficiency • Malnutrition • Fat malabsorption • Prolonged antibiotic therapy • Hepatic impairment • Renal impairment

26. Treat the cause Treat the site Stop any medications making the problem worse Topical Systemic Bleeding; management

27. Bleeding; management • Topical therapy • Pressure • Adrenaline • Tranexamic acid • Silver nitrate • Sucrulfate paste

28. Systemic therapy Tranexamic acid (oral) Etamsylate Desmopressin Localised therapy Radiotherapy Cryotherapy LASER Embolization Surgery Bleeding Management

29. Severe Haemorrhage as a Terminal Event • Preparation/ Advance Care Planning • Practical • reduce risks • have drugs and equipment at hand • Psychological • be aware of the risk • Inform other care workers of the risk • Discuss with patient / carers?

30. Severe Haemorrhage as a Terminal Event • Reduce impact of a bleed • Green towels • Support patient and carers • Stay with the patient • Sedation • 10mg midazolam intramuscularly or buccal

31. 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

32. 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

33. 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

34. 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

35. Spinal Cord Compression • Diagnosis • Urgent MRI • 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

36. Spinal Cord Compression • Poor prognostic indicators • Paraplegia • Loss of sphincter function • Rapid onset (infarction)

37. Management of SCC • Oral dex 16mg • MDT approach • Radiotherapy ( no spinal instability)20GR 5 # • Surgery and radiotherapy ( spinal instability such as fracture • Surgery alone relapse at previously irradiated site • Chemotherapy • Steroids alone

38. Seizures / Fitting • What is a fit? • Usually referring to a generalised tonic clonic seizure • Fall with loss of consciousness • Urinary or faecal incontinence • Convulsions / jerking / frothing at mouth • Self limiting (usually) • Post ictal drowsiness and confusion

39. Seizures / Fitting • What increases the risk? • Epilepsy • Stroke • Brain tumour • Biochemical disturbance • Drugs

40. Seizures / Fitting • Management: physical • Generalised seizure • Diazepam pr / iv • Midazolam buccal / sc / iv • Phenobarbital sc / iv

41. Summary • General Principles • Anticipate • Discuss and highlight potential problems • Weigh up the benefits and burdens of treatment • Advance Care Planning