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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 General Principles Anticipate Who is at risk? Avoid Plan Communication Preparation Correct the correctable Prophylaxis 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+(40almumin)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 SVCO: Features Symptoms Breathlessness Choking Headache Swelling; facial, neck, trunk and arms Signs Venous distension Plethora Stridor Coma / Death 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 Bleeding Likely sources Surface bleeding Epistaxis Haemoptysis Haematemesis / Melaena Rectal Vaginal Haematuria Erosion of an artery 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 Bleeding; risks 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 Vitamin K deficiency Malnutrition Fat malabsorption Prolonged antibiotic therapy Hepatic impairment Renal impairment Bleeding; management Treat the cause Topical Treat the site Systemic Stop any medications making the problem worse Bleeding; management Topical therapy Pressure Adrenaline Tranexamic acid Silver nitrate Sucrulfate paste Bleeding Management Systemic therapy Tranexamic acid (oral) Etamsylate Desmopressin Localised therapy Radiotherapy Cryotherapy LASER Embolization Surgery 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 Support patient and carers Green towels 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 Spinal Cord Compression 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 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