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Emergencies in Palliative Medicine . Hazel Pearse Spr Palliative Medicine. 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
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Emergencies in Palliative Medicine Hazel Pearse Spr Palliative Medicine
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
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 • Hypercalcaemia • Superior Vena Cava Obstruction (SVCO) • Spinal Cord Compression • Haemorrhage / Bleeding • Seizures / Fitting
Anticipate Who is at risk? Plan Communication Preparation Avoid Correct the correctable Prophylaxis General Principles
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
Hypercalcaemia • Commonest life threatening metabolic disorder encountered in patients with cancer • Consider non-malignant causes such as hyperparathyroidism
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
Hypercalcaemia • Features • Confusion • Drowsiness • Nausea and vomiting • Constipation • Polyuria and polydipsia • Can mimic deterioration due to progressive malignancy
Hypercalcaemia • What causes high calcium in malignancy? • Skeletal metastases • Production of osteoclastic factors • PTH related protein secretion • Ectopic PTH secretion (rare)
Hypercalcaemia • Diagnosis • Check renal function and corrected calcium( need to know albumin concentration) • Corrected ca = measured Ca+(40-almumin)x0.02
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
Prevention of Recurrence • Consider disease modifying treatments • Consider maintenance treatment • Monitor at 3 weekly intervals or when symptomatic
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
Superior Vena Cava Obstruction (SVCO) • External compression • Intraluminal thrombosis • Direct invasion of the vessel wall
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
Symptoms Breathlessness Choking Headache Swelling; facial, neck, trunk and arms Signs Venous distension Plethora Stridor Coma / Death SVCO: Features
SVCO: Diagnosis • Doppler ultrasound • Angiography
Management • Can be a presenting feature of malignancy • Need histology • Treatment tailored to type of malignancy
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
Likely sources Surface bleeding Epistaxis Haemoptysis Haematemesis / Melaena Rectal Vaginal Haematuria Erosion of an artery Bleeding
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
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
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
Bleeding; risks • Vitamin K deficiency • Malnutrition • Fat malabsorption • Prolonged antibiotic therapy • Hepatic impairment • Renal impairment
Treat the cause Treat the site Stop any medications making the problem worse Topical Systemic Bleeding; management
Bleeding; management • Topical therapy • Pressure • Adrenaline • Tranexamic acid • Silver nitrate • Sucrulfate paste
Systemic therapy Tranexamic acid (oral) Etamsylate Desmopressin Localised therapy Radiotherapy Cryotherapy LASER Embolization Surgery Bleeding Management
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?
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
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 (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 Compression • Causes • Vertebral metastases and collapse 85% • Extravertebral tumour (extension into epidural space) • Intramedullary tumour (from spinal cord) • Intradural tumour (from meninges) • Epidural metastases
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 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
Spinal Cord Compression • Poor prognostic indicators • Paraplegia • Loss of sphincter function • Rapid onset (infarction)
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
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
Seizures / Fitting • What increases the risk? • Epilepsy • Stroke • Brain tumour • Biochemical disturbance • Drugs
Seizures / Fitting • Management: physical • Generalised seizure • Diazepam pr / iv • Midazolam buccal / sc / iv • Phenobarbital sc / iv
Summary • General Principles • Anticipate • Discuss and highlight potential problems • Weigh up the benefits and burdens of treatment • Advance Care Planning