palliative care emergencies additional module if needed
TRANSCRIPT
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Palliative Care Emergencies
Additional module if needed
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Learning objectives
Understand emergency /urgent / important Describe common emergencies in PC Explore principles of essential management Outline management for specific common
emergencies in PC
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Questions
■ In any given situation we must use■ knowledge
■ know what we could do■ skill
■ know what we should do■ attitude
■ know how we should do ■ diplomacy
■ know what the patient wants us to do / not do■ judgement
■ make an active/ negotiated decision
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Emergencies
severe pain confusion spinal cord compression fractures metabolic - hypercalcaemia seizures haemorrhage superior vena cava obstruction respiratory obstruction
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Total Pain
PHYSICAL
SOCIAL
EMOTIONAL
SPIRITUAL
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Confusion
■ confusion■ up to 75% patients advanced illness■ often fluctuates■ terminal restlessness (mild)■ terminal delerium (severe)
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Confusion
Causes biochemical / drugs pain cerebral irritation infection constipation / retention hypoxia / respiratory distress anxiety / spiritual distress
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Confusion
Management■ treat reversible causes
■ stop medications / insert catheter / start antibiotics / treat constipation
■ adjust environment■ familiar voices, music, soft lighting, avoid loud
noise / don’t use restraints■ explain / support
■ family needs■ pharmacological intervention
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Confusion
Management■ use sedatives■ symptom relief
■ neuroleptics - anxiolyic /antipsychotic■ haloperidol / olanzepine / chlorpromazine
■ haloperidol 5mg po/sc as required and repeat ■ benzodiazepines - anxiolytic / sedative■ midazolam / lorazepam / diazepam
■ midazolam 2.5mg sc / diazepam 5mg od
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Spinal Cord Compression
Incidence■ 3% patients advanced cancer■ > one level 20%■ common
■ breast■ bronchus■ prostate
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Spinal Cord Compression
Mechanism■ metastatic spread to bone 85%
■ direct tumour extension 10%
■ intramedullary primary 4%
■ haematogenous spread
to epidural space 1%
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Spinal Cord Compression
Presentation pain >90% weakness >75% sensory level >50% sphincter dysfunction >40%
nb. pain usually predates other symptoms
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Spinal Cord Compression
Diagnosis history and clinical findings plain x-ray ?bone scan ?MRI ?CT / myelogram
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Spinal Cord Compression
Management■ corticosteroids
■ dexamethasone 16-32mg
■ radiotherapy■ as soon as possible
■ surgery
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Spinal Cord Compression
Outcome■ poor prognosis
■ loss of sphincter control■ rapid onset■ complete paraplegia
■ better prognosis■ early detection and treatment■ cauda equina lesion■ incompete paraplegia
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Fracture
■ common with metastatic bone disease■ may be terminal event■ management
■ anticipate■ radiotherapy■ surgery■ neuraxial therapies
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Hypercalcaemia
■ commonest metabolic complication■ rate of rise determines emergency■ common
■ up to 50% breast and myeloma■ lung / renal / cervix / head and neck
■ diagnosis■ thirst / polyuria / confusion / pain / nausea and
vomiing / constipation / dehydration / coma
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Hypercalcaemia
■ investigation■ serum calcium / albumin / renal function
■ management■ rehydrate■ bisphosphonates
■ pamidronate 60mg ■ treat underlying disease
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Seizures
Causes cerebral metastases cerebral infection / oedema cerebral haemorrhage biochemical derangement premorbid epilepsy
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Seizures
Treatment■ emergency■ maintain airway■ pharmacology
■ diazepam 10mg pr■ midazolam 5-10mg sc/iv■ phenobarbitol 100mg sc or in 100mls saline
over 30mins■ consider steroids
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Haemorrhage
■ fear often worse than reality■ more common
■ GI / lung / pelvic / head and neck
■ management■ radiotherapy■ surgery
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Haemorrhage
Management■ topical
■ mild oozing■ topical sucralfate
■ moderate oozing■ dilute hemloc (adrenaline 1:1000 soaked
swab)
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Haemorrhage
Management■ oral
■ ethamsylate 500mg QID (tranexamic acid) ■ sucralfate 1g bd-qds
■ 1% alum bladder irrigation
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Massive Haemorrhage
Management■ anticipate■ prevent (if possible)■ keep calm■ skilled person (if available) ■ sedation (if possible)
■ benzodiazepine / morphine
■ vaginal pack / local measures / surgery
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SVCO
Superior venal cava obstruction■ 75% SVCO is in lung carcinoma■ extrinsic compression / mediastinum■ symptoms/signs
■ depend on extent and speed of development■ symptoms worse on lying flat■ facial +/- arm swelling■ engorged neck and chest wall veins
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SVCO
Management stat iv dexamethasone 8-16mg then po ?urgent referral for radiotherapy stent ?chemotherapy
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Respiratory Obstruction
■ acute■ reversible or irreversible ?■ relieve symptoms regardless of cause
Pharmacological■ parenteral morphine■ s/l lorazepam 0.5- 2.0 mg PRN / parenteral
midazolam■ ?steroids - dexamethasone
Non-pharmacological■ fan, presence
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Stridor
acute stridor is very rare iv dexamethasone stat iv midazolam, if severe agitation ? referral for stent /DXT
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can be physical, social, spiritual, psychological
can cause team tension challenge opportunity bridges specialties teamwork
Conclusions
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These resources are developed as part of the THET multi-country project whose goal is to strengthen and integrate palliative care into national health systems through a public health primary care approach– Acknowledgement given to Cairdeas International
Palliative Care Trust and MPCU for their preparation and adaptation
– part of the teaching materials for the Palliative Care Toolkit training with modules as per the Training Manual
– can be used as basic PC presentations when facilitators are encouraged to adapt and make contextual