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?

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

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

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

Treat the site

Stop any medications making the problem worse

Topical

Systemic

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 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

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