Transcript Emergencies in Palliative Medicine

Emergencies in
Palliative Medicine
Hazel Pearse
Spr Palliative Medicine
Objectives
Recognise palliative care emergencies
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Be aware of their existence
Recognise signs and symptoms of common
emergencies
Anticipate occurrence of emergencies
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Understand who is at risk
Be able to minimise the risk
Objectives
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Manage palliative care emergencies
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Have a basic knowledge of appropriate
treatments
Know where to get help and advice
Plan Ahead / Be prepared
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Understand importance of communication
Know what supplies might be needed
Advance care planning
Palliative Care Emergencies
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Hypercalcaemia
Superior Vena Cava Obstruction (SVCO)
Spinal Cord Compression
Haemorrhage / Bleeding
Seizures / Fitting
General Principles
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Anticipate
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Who is at risk?
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Avoid
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Plan
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Communication
Preparation
Correct the correctable
Prophylaxis
Factors to consider
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What is the emergency
Can it be reversed
General physical status of the patient
Prognosis
Burdens of treatment
Patients and carers wishes
Hypercalcaemia
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Commonest life threatening metabolic
disorder encountered in patients with cancer
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Consider non-malignant causes such as
hyperparathyroidism
Hypercalcaemia
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Who is at risk?
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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
Hypercalcaemia
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Features
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Confusion
Drowsiness
Nausea and vomiting
Constipation
Polyuria and polydipsia
Can mimic deterioration due to progressive
malignancy
Hypercalcaemia
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What causes high calcium in malignancy?
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Skeletal metastases
Production of osteoclastic factors
PTH related protein secretion
Ectopic PTH secretion (rare)
Hypercalcaemia
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Diagnosis
Check renal function and corrected calcium(
need to know albumin concentration)
Corrected ca = measured Ca+(40almumin)x0.02
Management
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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
Prevention of Recurrence
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Consider disease modifying treatments
Consider maintenance treatment
Monitor at 3 weekly intervals or when
symptomatic
Hypercalcaemia
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Prognosis
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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
Superior Vena Cava
Obstruction (SVCO)
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External compression
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Intraluminal thrombosis
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Direct invasion of the vessel wall
Who is at risk
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Mostly tumours / nodes within the
mediastinum
75% primary bronchial carcinomas
Lymphoma
Breast cancer patients
Seminoma
Occurs in 3% of thoses with ca bronchus
SVCO: Features
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Symptoms
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Breathlessness
Choking
Headache
Swelling; facial, neck,
trunk and arms
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Signs
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Venous distension
Plethora
Stridor
Coma / Death
SVCO: Diagnosis
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Doppler ultrasound
Angiography
Management
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Can be a presenting feature of malignancy
Need histology
Treatment tailored to type of malignancy
SVCO: Management in
advanced disease
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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
Bleeding
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Likely sources
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Surface bleeding
Epistaxis
Haemoptysis
Haematemesis /
Melaena
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Rectal
Vaginal
Haematuria
Erosion of an artery
Bleeding
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Who is at risk?
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Metastatic malignancy increases the risk of
bleeding and thrombosis
20% of patients with cancer have bleeds
In 5% of patients bleeding contributes to death
Bleeding; risks
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The malignancy itself
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Site of tumour or secondaries; skin, bowel,
bladder, lung etc.
Nature of tumour; risk of erosion of near by
vessels
Bleeding; risks
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Thrombocytopenia
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Marrow infiltration
Drugs, chemotherapy
Blood transfusion
Disseminated
intravascular coagulation
(DIC)
Hypersplenism
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Impaired function
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Drugs eg. NSAID
Myeloma /
paraproteinaemias
Myeloproliferative
disorders
Renal and hepatic failure
Bleeding; risks
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Vitamin K deficiency
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Malnutrition
Fat malabsorption
Prolonged antibiotic therapy
Hepatic impairment
Renal impairment
Bleeding; management
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Treat the cause
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Topical
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Treat the site
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Systemic
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Stop any medications
making the problem
worse
Bleeding; management
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Topical therapy
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Pressure
Adrenaline
Tranexamic acid
Silver nitrate
Sucrulfate paste
Bleeding Management
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Systemic therapy
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Tranexamic acid (oral)
Etamsylate
Desmopressin
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Localised therapy
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Radiotherapy
Cryotherapy
LASER
Embolization
Surgery
Severe Haemorrhage as a
Terminal Event
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Preparation/ Advance Care Planning
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Practical
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reduce risks
have drugs and equipment at hand
Psychological
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be aware of the risk
Inform other care workers of the risk
Discuss with patient / carers?
Severe Haemorrhage as a
Terminal Event
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Reduce impact of a bleed
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Support patient and carers
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Green towels
Stay with the patient
Sedation
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10mg midazolam intramuscularly or buccal
Spinal Cord Compression
(SCC)
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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
(SCC)
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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 Compression
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Causes
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Vertebral metastases and collapse 85%
Extravertebral tumour (extension into epidural
space)
Intramedullary tumour (from spinal cord)
Intradural tumour (from meninges)
Epidural metastases
Spinal Cord Compression
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Features
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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
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Examination
Demarcated sensory
loss
Brisk or abscent
reflexes
Spinal Cord Compression
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Diagnosis
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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
Spinal Cord Compression
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Poor prognostic indicators
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Paraplegia
Loss of sphincter function
Rapid onset (infarction)
Management of SCC
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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
Seizures / Fitting
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What is a fit?
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Usually referring to a generalised tonic clonic
seizure
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Fall with loss of consciousness
Urinary or faecal incontinence
Convulsions / jerking / frothing at mouth
Self limiting (usually)
Post ictal drowsiness and confusion
Seizures / Fitting
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What increases the risk?
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Epilepsy
Stroke
Brain tumour
Biochemical disturbance
Drugs
Seizures / Fitting
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Management: physical
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Generalised seizure
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Diazepam pr / iv
Midazolam buccal / sc / iv
Phenobarbital sc / iv
Summary
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General Principles
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Anticipate
Discuss and highlight potential problems
Weigh up the benefits and burdens of treatment
Advance Care Planning