Emergencies in Palliative Medicine

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Emergencies in Palliative Medicine

• Hazel Pearse
• Spr Palliative Medicine

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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

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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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Palliative Care Emergencies

• Hypercalcaemia
• Superior Vena Cava Obstruction (SVCO)
• Spinal Cord Compression
• Haemorrhage / Bleeding
• Seizures / Fitting

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General Principles

• Anticipate
• Who is at risk?
• Plan
• Communication
• Preparation

• Avoid
• Correct the correctable
• Prophylaxis

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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

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Hypercalcaemia

• Commonest life threatening metabolic disorder
  encountered in patients with cancer
• Consider non-malignant causes such as
  hyperparathyroidism

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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

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Hypercalcaemia

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

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Hypercalcaemia

• What causes high calcium in malignancy?
• Skeletal metastases
• Production of osteoclastic factors
• PTH related protein secretion
• Ectopic PTH secretion (rare)

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Hypercalcaemia

• Diagnosis
• Check renal function and corrected calcium( need
  to know albumin concentration)
• Corrected ca measured Ca(40-almumin)x0.02

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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

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Prevention of Recurrence

• Consider disease modifying treatments
• Consider maintenance treatment
• Monitor at 3 weekly intervals or when symptomatic

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Hypercalcaemia

• Prognosis
• Hypercalcaemia is a sign of tumour progression
• Survival is less than 3 months with treatment
• Calcium level gt4 leads to renal failure, cardiac
  arrhythmias and fits

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Superior Vena Cava Obstruction (SVCO)

• External compression
• Intraluminal thrombosis
• Direct invasion of the vessel wall

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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

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SVCO Features

• Symptoms
• Breathlessness
• Choking
• Headache
• Swelling facial, neck, trunk and arms

• Signs
• Venous distension
• Plethora
• Stridor
• Coma / Death

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SVCO Diagnosis

• Doppler ultrasound
• Angiography

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Management

• Can be a presenting feature of malignancy
• Need histology
• Treatment tailored to type of malignancy

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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

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Bleeding

• Likely sources
• Surface bleeding
• Epistaxis
• Haemoptysis
• Haematemesis / Melaena

• Rectal
• Vaginal
• Haematuria
• Erosion of an artery

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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

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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

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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

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Bleeding risks

• Vitamin K deficiency
• Malnutrition
• Fat malabsorption
• Prolonged antibiotic therapy
• Hepatic impairment
• Renal impairment

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Bleeding management

• Treat the cause
• Treat the site
• Stop any medications making the problem worse

• Topical
• Systemic

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Bleeding management

• Topical therapy
• Pressure
• Adrenaline
• Tranexamic acid
• Silver nitrate
• Sucrulfate paste

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Bleeding Management

• Systemic therapy
• Tranexamic acid (oral)
• Etamsylate
• Desmopressin

• Localised therapy
• Radiotherapy
• Cryotherapy
• LASER
• Embolization
• Surgery

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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?

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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

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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

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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

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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

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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

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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

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Spinal Cord Compression

• Poor prognostic indicators
• Paraplegia
• Loss of sphincter function
• Rapid onset (infarction)

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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

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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

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Seizures / Fitting

• What increases the risk?
• Epilepsy
• Stroke
• Brain tumour
• Biochemical disturbance
• Drugs

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Seizures / Fitting

• Management physical
• Generalised seizure
• Diazepam pr / iv
• Midazolam buccal / sc / iv
• Phenobarbital sc / iv

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Summary

• General Principles
• Anticipate
• Discuss and highlight potential problems
• Weigh up the benefits and burdens of treatment
• Advance Care Planning