Download 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
Palliative Care Emergencies
Hypercalcaemia
 Superior Vena Cava Obstruction (SVCO)
 Spinal Cord Compression
 Haemorrhage / Bleeding
 Seizures / Fitting

General Principles

Anticipate
 Who is at risk?

Plan
 Communication
 Preparation

Avoid
 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
‫‪ ‬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.‬‬
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
Diagnosis
 Check renal function and corrected calcium
( need to know albumin concentration)


Corrected ca = measured Ca+(n ALBmALB)x0.8
Hypercalcemia
Treatment
Consider the goals
 Hydration and saline diuresis
 Bisphosphonates
 Steroids?
 FolIow 3-5 days
 prevention

C. Woelk MD
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫גב' זלץ בטיפולך בהוספיס בית בשל ‪ RCC‬מפושט‪.‬‬
‫ידוע על מחלה גרורתית מפושטת לוריד החלול ‪,‬‬
‫בבלטות רטרופריטונאליות ובעמ"ש טורקלי (‪(D6-‬‬
‫‪ , 9‬באגן ובירך ימין‪.‬‬
‫גב' זלץ קוראת לך בשל החמרה בכאב הגב ונימול‬
‫הקורן ל ‪ 2‬הרגליים יותר לשמאל‪.‬‬
‫לדבריה מתקשה ללכת לשירותים גם בעזרת‬
‫ההליכון‪.‬‬
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
Compression of
Vasculature

Direct Compression

Vertebral Mets 
Paraspinal mass 
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 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

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
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
Superior Venacaval Syndrome
.
Superior Venacaval Syndrome
Extrinsic tumour or
Node
Direct Invasion
Intraluminal Thrombus
Complication of Central
Line




Superior Vena Cava Syndrome
Incidence and Etiology





C. Woelk MD
Usually associated with malignancies
Often the initial presentation of cancer
Bronchogenic carcinoma (80%)
Lymphoma (15%)
Metastatic disease (5%)
Superior Vena Cava Syndrome
Presentation

Symptoms:
 Dyspnea
 Facial and neck swelling
 Fullness in head
 Cough
 Arm swelling
 Chest pain
 Dysphagia
C. Woelk MD
63%
50%
50%
24%
18%
15%
9%
Superior Vena Cava Syndrome
Presentation

Signs:
 Venous distention of neck
 Venous distention of chest wall
 Facial edema
 Cyanosis
 Edema of the arms
 Plethora of the face
 Vocal cord paralysis
 Horner’s syndrome
66%
54%
46%
20%
14%
10%
3%
3%
Superior Vena Cava Syndrome
Management



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
Superior Vena Cava Syndrome
Management






C. Woelk MD
Chemotherapy – SCLC, NHL
Radiation - NSCLC
Bed rest with head elevated
Oxygen
Diuretics
Steroids- medium to high dose
Severe hemorrhage
Etiology


Epistaxis
GI bleeding:






Hematemesis,Hematochezia,Melena
Hemoptysis
Hematuria
Internal Bleeding
Bleeding from fungating tumours
Hemolysis
C. Woelk MD
Severe hemorrhage
Important 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
GI Bleeding
Incidence 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
GI Bleeding
Management




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
GI Bleeding
Management
Massive Bleeding in the Terminal
Phase:
•
•
•
C. Woelk MD
Keep patient warm
Consider sedation
Green and black towels and sheets
Hemoptysis
Incidence 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
Massive Hemoptysis
Management
Trendelenburg position
 Consider sedation
 Green and black towels

C. Woelk MD
Wound Bleeding
Incidence 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
Wound Bleeding
Management





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
Wound Bleeding
Management

If bleeding is possible, discuss this with the
patient and 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
Severe Hemorrhage
Systemic Interventions






C. Woelk MD
D/C antiplatelet and anti-thrombotic agents
Vitamin K
Transfusion of blood or platelets
Antifibrinolytic Medication
 Tranexamic acid
 Aminocaproic acid
Desmopressin
Octreotide (somatostatin analog)
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 150300 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
Severe Hemorrhage
Management
C. Woelk MD

Remember the goals of care

Keep patient, family, staff informed of
progress and prognosis
Seizures
Incidence:

1% of patients with advanced cancer
Seizures
Etiology


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
Seizures
Education

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)
Seizures
Management





C. Woelk MD
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
Status epilepticus
Management
C. Woelk MD

Protect airway

Administer Oxygen

Consider SC or IV
Status epilepticus
Medications

IV available:


Lorazepam 2-4 mg over 2-4 minutes
Phenytoin load: 20 mg/kg at 25 mg/min



Phenobarb 20 mg/kg at 100 mg/min
IV unavailable

Diazepam 10 mg solution PR



C. Woelk MD
May need to go as high as 30 mg/kg
May be repeated q10minutes
Midazolam SC infusion 1-3 mg / hour
Consider steroids
Multifocal Myoclonus
C. Woelk MD

Jerking, involuntary movements of
arms and legs

May start as subtle movements, and
then become bothersome and
disturbing
Multifocal Myoclonus
Etiology

Very often associated with delirium and
related to opioid toxicity

May be a pre-terminal event

Important to consider the differences
C. Woelk MD
Opioid Neurotoxicity






C. Woelk MD
Cognitive Dysfunction
Myoclonus
Hyperalgesia
Allodynia
Perceptual Disturbance
Seizures
Multifocal Myoclonus
Management





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
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.