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Palliative Care

Emergencies LAURA BARNFIELD

What might constitute an

emergency in Palliative Care?

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Palliative Care Emergencies

Major haemorrhage

Metastatic Spinal Cord Compression

(MSCC)

Superior Vena Cava Obstruction (SVCO)

Hypercalcaemia

Not…

Cardiac Arrest

Anaphylaxis

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Major Haemorrhage

Major Haemorrhage

Which patients might be at risk? Head and neck cancers

GI tract cancers

Lung cancer

Any cancer encroaching on

vessels

Any patient with clotting problems

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Major Haemorrhage (cont.)

How might we manage this? Non-medical

Planning ahead with patient and family

Dark towels

Stay with patient

Keep them calm and warm

Support patient and family

Medical

5-10mg Midazolam SC, repeated as necessary

Metastatic Spinal Cord

Compression (MSCC)

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MSCC

Metastatic deposits push on the spinal cord, leading to neurological

compromise at and below the area affected

Can be a first presentation of cancer

5-10% of all cancer patients affected (4000 cases/year in England

and Wales)

Most common cancers to cause spinal metastases are:

Prostate

Lung

Breast

Myeloma

MSCC symptoms

Can be vague – ‘off legs’

Back pain – often band-like, progressive and/or unremitting, worse

on coughing/straining, nocturnal

Weakness of limbs

Tingling/numbness or feeling that legs don’t belong to them

Difficulty passing urine, faecal incontinence – LATE SIGNS

Consider in any patient with previous or current cancer – and those

with no known diagnosis

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MSCC signs

Localised tenderness to spine

Weakness

Altered sensation – ‘sensory level’

Reflexes can be absent or increased, extensor plantars, clonus

Examine upper and lower limbs when assessing for MSCC

MSCC management

Consider immobilisation (lie flat, log rolling and spinal board for

transfer) if concerns instability

Discussion with Christie Hotline 0161 446 3658

Urgent MRI whole spine

Steroids – high dose Dexamethasone 16mg daily – start immediately

if high index suspicion (check blood sugars)

Surgery

Radiotherapy

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Community Nurse

suspects MSCC

GP/OOH GP

suspects MSCC

AHP / CNS

suspect MSCC

Informs

Definite MSCC signs

Uncertain MSCC signs

Arrange urgent admission

for assessment via A&E or MAU

(local arrangements apply,

transfer patient flat and log roll)

Contact MSCC

Co-ordinator (in hours)

or Christie Hotline

for advice

MSCC likely

Urgent MR scan within 24 hrs in

patient’s local hospital.

Commence 16 mg Dxm + PPI

(see pathway document on

MSCC webpage)

Patient flat and log roll

(Inform Acute Oncology team)

MR scan

confirms MSCC

Low level of suspicion:

GP to review. If symptoms

persist, discuss with

Oncology team for possible

imaging within 7 days

(see Impending Pathway).

Ensure adequate pain

management

Yes

No

Inform GP / responsible team.

If symptoms persist or

worsen review patient urgently

Referring clinician informs MSCC

Co-ordinator. AO team liaise with

GP, local Medical or Oncology

team. If symptoms worsen

review patient urgently (see

Impending Pathway)

Refer to local

Rehab team /

AHP lead

Urgent clinical triage takes place by the Network MSCC Co-ordinator (9 - 5),

Christie Hotline (out of hours) in discussion with the on-call Clinical Oncology

Specialty Trainee (SpR)

Telephone number: 0161 446 3658 - (Bleep 12616 for internal Christie referrals)

Agrees

Informs

MSCC Pathway Greater Manchester Cancer

Services (part of Manchester Cancer)

Low level of suspicion:

GP to review. If symptoms

persist, discuss with

Oncology team for possible

imaging within 7 days

(see Impending Pathway).

Ensure adequate pain

management

NB

. S

pin

al sta

bil

ity d

iscu

ssed

an

d d

ocu

men

ted

th

rou

gh

ou

t p

ath

way

A&E, hospice and

secondary care

(possibly patient

with no previous

cancer diagnosis)

Christie patients

with high suspicion

of MSCC

All ‘at risk’ patients

Receive Patient

Information leaflet:

Spinal Cord

Compression ‘What

You need to know’

Patient Information given:

Spinal Cord Compression:

“What it means and

how it can be treated”

MSCC

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MSCC aims of management

Maximisation of recovery of neurological function – if unable to walk

at time of diagnosis 67% recover no function at 1 month, if able to

walk at diagnosis 81% can still walk at 1 month

Pain control

Tumour control

Improve stability of spine

Good nursing care

Pressure area care

Psychological support

Bladder/bowel management

Superior Vena Cava Obstruction

(SVCO)

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SVCO

Compression of superior vena

cava due to tumour or nodes in

mediastinum

Common with lung cancer,

possible with lymphoma

SVCO

Symptoms

Swelling of face, neck, arms

Headache

Dizziness

Breathlessness

Prominent dilated veins to neck

and arms

Hoarse voice

Stridor

Management

Sit up

Oxygen

High dose steroids

(Dexamethasone 16mg daily)

Discussion with oncology

?radiotherapy, chemotherapy or

stent

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SVCO

Hypercalcaemia

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Hypercalcaemia

Raised calcium in bloodstream

Common in cancer (10-20% patients) – traditionally if bony

metastases, but can occur without bone disease

Can develop over time or rapidly – symptoms often dependent on

rate of rise

Used to be a terminal event

Hypercalcaemia symptoms

’Bones, abdominal moans and psychic groans’

General

Dehydration

Polydipsia

Polyuria

Pruritus

Malaise

Arrythmias/conduction defects

Gastrointestinal

Anorexia

Weight loss

Nausea

Vomiting

Constipation

Ileus

Neurological

Fatigue

Confusion

Myopathy

Hyporeflexia

Seizures

Psychosis

Coma

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Hypercalcaemia management

Check bloods – Ca, U&Es

Review medications for any that impact on renal function or

calcium/Vit D supplements

Correct dehydration

IV bisphosphonates- dose according to calcium level

Recheck 5-10 days

Likely to recur within 2-4 weeks – make a plan for longer-term

management

Summary

Major Haemorrhage

MSCC

SVCO

Hypercalcaemia

If concerns please flag them up!

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Questions?

References

Palliativedrugs.com

Pain and Symptom Control Guidelines, Greater Manchester &

Cheshire Cancer Network November 2013

Christie.nhs.uk MSCC guidance

Palliative Care MRCPuk.org

NICE CKS Hypercalcaemia December 2014

Metastatic spinal cord compression in adults: diagnosis and

management, NICE 2008

Macmillan.org.uk

Cancerresearchuk.org