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Emergencies in Palliative Care

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

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  1. Emergencies inPalliative Care

  2. 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

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

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

  5. 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

  6. 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.

  7. 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

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

  9. Hypercalcaemia • Diagnosis • Check renal function and corrected calcium ( need to know albumin concentration) • Corrected ca = measured Ca+(n ALB-mALB)x0.8

  10. Hypercalcemia Treatment Consider the goals Hydration and saline diuresis Bisphosphonates Steroids? FolIow 3-5 days prevention C. Woelk MD

  11. 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.

  12. 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

  13. Compression of Vasculature Direct Compression Vertebral Mets Paraspinal mass Spinal Cord Compression

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Superior Venacaval Syndrome .

  21. Extrinsic tumour or Node Direct Invasion Intraluminal Thrombus Complication of Central Line Superior Venacaval Syndrome

  22. 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

  23. 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

  24. 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%

  25. 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

  26. Superior Vena Cava SyndromeManagement Chemotherapy – SCLC, NHL Radiation - NSCLC Bed rest with head elevated Oxygen Diuretics Steroids- medium to high dose C. Woelk MD

  27. Severe hemorrhageEtiology • Epistaxis • GI bleeding: • Hematemesis,Hematochezia,Melena • Hemoptysis • Hematuria • Internal Bleeding • Bleeding from fungating tumours • Hemolysis C. Woelk MD

  28. 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

  29. 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

  30. 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

  31. GI BleedingManagement Massive Bleeding in the Terminal Phase: • Keep patient warm • Consider sedation • Green and black towels and sheets C. Woelk MD

  32. 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

  33. Massive HemoptysisManagement Trendelenburg position Consider sedation Green and black towels C. Woelk MD

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. Severe HemorrhageManagement Remember the goals of care Keep patient, family, staff informed of progress and prognosis C. Woelk MD

  40. SeizuresIncidence: 1% of patients with advanced cancer

  41. 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

  42. 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)

  43. 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

  44. Status epilepticusManagement Protect airway Administer Oxygen Consider SC or IV C. Woelk MD

  45. 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

  46. Multifocal Myoclonus Jerking, involuntary movements of arms and legs May start as subtle movements, and then become bothersome and disturbing C. Woelk MD

  47. 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

  48. Opioid Neurotoxicity Cognitive Dysfunction Myoclonus Hyperalgesia Allodynia Perceptual Disturbance Seizures C. Woelk MD

  49. 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

  50. 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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