PALLIATIVE CARE EMERGENCIES

PALLIATIVE CAREEMERGENCIESPalliative nurses study groupApril 2006Dr Fiona M Crow MD

To heal often,

To cure sometimes,

To comfort always

• Treat the symptom• Treat the patient and family• Treat the problem, if possible andreasonable.

• If comfort care onlyReduce agitationTreat pain/dyspnea etc..Keep warm if bp low.support family, friends, and staff….yes,YOUOccasionally this will mean some treatmentof underlying problem eg CHF

Things we don’t want to miss!!• Spinal cord compression• Superior Vena CavaSyndrome• Hemorrhage• Hypercalcaemia• Pathologic fracture• Drug toxicity/side efffects

Also be aware of these urgent and potentiallyreversible emergencies.Recognizing them and treating them can improvecomfort and reduce stress even if prognosis is notchanged.Decisions to treat should be made with patient andfamily, if permitted.Consider distress treatment may cause.If difficult to decide if treatment will succeedplan to re evaluate with patient/ family after fewhours to a couple of days

Obstructive nephropathyCardiac tamponadeTumor lysisFebrile neutropeniaHyperviscosityIncreased intracranial pressureSIADHHypoglycaemia

SPINAL CORD COMPRESSION• Compression of thevasculature withengorgement andedema• Direct compressiondue to: Vertebralmetastases Paraspinal mass

• Time is of the essence- the risk of neurologicaldamage is reduced by fast diagnosis andtreatment. Delay reduces mobility therebyquality of life and life expectancy.

Common causes of malignant SCC• Prostate• Breast• Lung• Myeloma• Kidney

Signs and symptomsIncreasing neck or back pain will havebeen the presenting feature in 90% ofSCCWeakness of extremitiesSensory loss, light touch, pain andtemperatureSphincter dysfunction / urinary retention

Assessment• Altered reflexes• Pain with straight leg raising• Tingling in arms with flexing neck• Weakness maybe unilateral at times• Lax sphincter tone• Reassess if suspicion high based onsymptoms

InvestigateMRI is the preferred if availableCT myelogram

Treatment If suspicion is high should start immediatelywith Dexamethasone, at least 10mg IV/SQ statthen 4mg po/iv/sq qid. Treat pain , if not resolving look at drugs, review diagnosis Radiation single dose or more commonly over5 sessions Decompressive surgery Chemotherapy Regional anaesthethic blockade

Superior Vena Cava Syndrome• Extrinsic – tumor ornode• Intraluminal thrombus• Direct invasion• Complication ofcentral line

Common cancers causing SVCO• Lung• Lymphoma• Metastatic breast, esophagus, colorectal,

Signs and Symptoms• Distended vessels in neck, chest, arms• Headache, somnolence, dizziness• Swelling and rubor of face and eyes conjunctivainjected• Head fullness and headache• Dysphagia,• Chest pain , stridor, , cough, dyspnea• Swollen arms• Facial cyanosis,

Assess and Investigate• Clinical exam• CXR• CT or MRI

Treatment• Dexamethasone 10 mg IV / sq STAT followed by4mg qid• Radiation• Chemotherapy• Stenting ( per Radiology)• Supportive care while symptomatic Bed position, should not lie flat. Sedation Pain management Oxygen Soft diet

HEMORRHAGE• Bleeding may be caused by trauma,ulceration, inflammation, or a growththat erodes through a blood vessel• Bleeding can be external or internal.• Bleeding can be exacerbated by thecoagulopathy associated with thedisease or drugs.

Investigate and Treatment• Investigate, in earlier stages workup may bewarranted to identify site, bleedingdiathesis.• Treatment• Radiotherapy bleeding skin mets• hemoptysis• bowelSystematic Tranexamic acid 500 mg qid• Sulfacrate po / pr• Systematic

CATASTROPHIC BLEED Know who is at risk and prepare the familyand patient Have parenteral opioids and sedatives on hand,and/or fentanyl sl Have dark towels and bedding available Massive hematemesis may require NG tube,cover the suction bottle Who is at risk:FUNGATING TUMOURS AROUND MAJOR BLOODVESSELSPELVIC TUMOURS ESPECIALLY IF FISTULAE INTOVAGINA OR RECTUM.HEAD AND NECK TUMOURSMAJOR BLEEDING DISORDER

HYPERCALCAEMIA• Suspect with certain cancersMultiple MyelomaLungProstateRenal cellBreast

Assess and Investigate• Presents with confusion and drowsiness,constipation, dehydration, non specific pain• Lab corrected calcium > 2.6, also measurerenal function

Treatment• Review with patient and / or family to treat or notto treat• Hydration and diuresis• Bisphosphonates Pamidronate 60 – 90 mg IV in 500 cc N Salineover about 4 hours may need to repeat in 4weeks Clodrinate 1500 mg SQ in 500 cc N saline over4 – 6 hrs Zolendrenate( ( if refractory to above)• Calcitonin quick onset but short term relief

Pain crises / Respiratory crises• Pathologic fracture• GI bleed• Ischaemic bowel• Obstructed bowel• Collapsed lung

Drug toxicity/side effect• Respiratory depression caused by Opioids….. treat with naloxone. Benzodiazepine…. . treat with Flumanzil• Opioid toxicity Hydrate Rotate opioid Manage agitation with neuroleptics Manage myoclonus with benzodiazepine

Case studyMr. F. has widespread bone mets fromhormone resistant prostate cancer. He getsup to the bathroom, and collapses. Heexperiences severe pain in his left thigh, andcan no longer weight bear.

Treat the symptom• Fentanyl sl/ iv is the fastest. Rapiddose escalation with careful monitoringof respiratory rate. Base frequency ofadministering on pharmacokinetics,double the dose until effective painrelief is found.Convert to regular dosing once pain iscontrolled.• IV morphine or Dilaudid can be usedinstead of Fentanyl.

Treat the patient and family• Educate re potential problem• Warn of inherent risks• Relieve symptom with analgesia• May require some mild sedation• Investigate

Treat the underlying problem• Maintain analgesia• Surgery• Splinting/ traction• Bisphosphonates if appropriate• Radiate if appropriate• Rehab as appropriate

Remember• Treat the symptom• Treat the patient and family• Treat the underlying problemIf and when the crises is resolved it is a goodopportunity to review with the patient and familywhat to expect in future and to consider options invarious scenarios