emergencies in palliative care. objectives manage palliative care emergencies manage palliative care...

Emergencies Emergencies inin

Palliative CarePalliative Care

ObjectivesObjectives

Manage palliative care emergenciesManage palliative care emergencies Have a basic knowledge of Have a basic knowledge of

appropriate treatmentsappropriate treatments Know where to get help and adviceKnow where to get help and advice

Plan Ahead / Be preparedPlan Ahead / Be prepared Understand importance of Understand importance of

communication communication Know what supplies might be neededKnow what supplies might be needed Advance care planningAdvance care planning

Palliative Care Palliative Care EmergenciesEmergencies

HypercalcaemiaHypercalcaemia Superior Vena Cava Obstruction Superior Vena Cava Obstruction

(SVCO)(SVCO) Spinal Cord CompressionSpinal Cord Compression Haemorrhage / BleedingHaemorrhage / Bleeding Seizures / FittingSeizures / Fitting

General PrinciplesGeneral Principles

AnticipateAnticipate Who is at risk?Who is at risk?

PlanPlan CommunicatioCommunicatio

nn PreparationPreparation

AvoidAvoid Correct the Correct the

correctablecorrectable Prophylaxis Prophylaxis

Factors to considerFactors to consider

What is the emergencyWhat is the emergency Can it be reversedCan it be reversed General physical status of the General physical status of the

patientpatient PrognosisPrognosis Burdens of treatmentBurdens of treatment Patients and carers wishesPatients and carers wishes

מר לוי סובל מסרטן ראה מר לוי סובל מסרטן ראהNSCCNSCC . .

אתמול בגלל הדרדרות במצבו , חולשה ניכרת אתמול בגלל הדרדרות במצבו , חולשה ניכרת קושי בעמידה, החמרה בעצירות בצרבת קושי בעמידה, החמרה בעצירות בצרבת

ובכאב, בדקת אותו וביקשת מהאחות לשלוח ובכאב, בדקת אותו וביקשת מהאחות לשלוח בדיקת דם. מה תבקש? בדיקת דם. מה תבקש?

אשתו מתקשרת אליך בשל החמרה במצבו: לא אשתו מתקשרת אליך בשל החמרה במצבו: לא מסוגל לצאת מהמיטה, נראה מעט מבולבל מסוגל לצאת מהמיטה, נראה מעט מבולבל

וגונח מכאב. וגונח מכאב.

HypercalcaemiaHypercalcaemia

Who is at risk?Who is at risk? 10-20% of all patients with malignant 10-20% of all patients with malignant

diseasedisease 50% of patients with myeloma50% of patients with myeloma 20% of breast and non small cell lung 20% of breast and non small cell lung

cancer patientscancer patients Also commonly seen in oesophagus, Also commonly seen in oesophagus,

thyroid, prostate, lymphoma, and thyroid, prostate, lymphoma, and renal cell carcinomarenal cell carcinoma


FeaturesFeatures ConfusionConfusion DrowsinessDrowsiness Nausea and vomitingNausea and vomiting ConstipationConstipation Polyuria and polydipsiaPolyuria and polydipsia

Can mimic deterioration due to Can mimic deterioration due to progressive malignancyprogressive malignancy


DiagnosisDiagnosis Check renal function and corrected Check renal function and corrected

calciumcalcium

( need to know albumin concentration)( need to know albumin concentration)

Corrected ca = measured Ca+(n Corrected ca = measured Ca+(n ALB-mALB)x0.8ALB-mALB)x0.8

Hypercalcemia TreatmentHypercalcemia Treatment

Consider the goalsConsider the goals Hydration and saline Hydration and saline

diuresisdiuresis BisphosphonatesBisphosphonates Steroids?Steroids? FolIow 3-5 daysFolIow 3-5 days preventionprevention

C. Woelk MD

גב' זלץ בטיפולך בהוספיס בית בשל גב' זלץ בטיפולך בהוספיס בית בשלRCCRCC מפושט.מפושט.

ידוע על מחלה גרורתית מפושטת לוריד החלול ידוע על מחלה גרורתית מפושטת לוריד החלול, בבלטות רטרופריטונאליות ובעמ"ש טורקלי , בבלטות רטרופריטונאליות ובעמ"ש טורקלי

((((D6-9D6-9 .באגן ובירך ימין. , באגן ובירך ימין , גב' זלץ קוראת לך בשל החמרה בכאב הגב גב' זלץ קוראת לך בשל החמרה בכאב הגב

הרגליים יותר לשמאל. הרגליים יותר לשמאל. 22ונימול הקורן ל ונימול הקורן ל לדבריה מתקשה ללכת לשירותים גם בעזרת לדבריה מתקשה ללכת לשירותים גם בעזרת

ההליכון. ההליכון.

Spinal Cord Compression Spinal Cord Compression (SCC)(SCC)

Occurs in advanced malignancyOccurs in advanced malignancy Main problem is lack of recognitionMain problem is lack of recognition Up to 5% of patients with cancer Up to 5% of patients with cancer

develop SCCdevelop SCC There is a 30% 1 year survivalThere is a 30% 1 year survival Malignancies which commonly cause Malignancies which commonly cause

SCC include; SCC include; prostate, breast, lung, prostate, breast, lung, myeloma, lymphoma and renalmyeloma, lymphoma and renal

Spinal Cord CompressionSpinal Cord Compression

Compression of Compression of VasculatureVasculature

Direct Direct CompressionCompression

Vertebral MetsVertebral MetsParaspinal massParaspinal mass

Spinal Cord Compression Spinal Cord Compression (SCC)(SCC)

Most commonly affects thoracic level Most commonly affects thoracic level (70%)(70%)

Signs and symptoms depend on the Signs and symptoms depend on the area of the cord affectedarea of the cord affected

Signs can be subtle to grossSigns can be subtle to gross More than one level can be affectedMore than one level can be affected Compression below L2 affects the Compression below L2 affects the

cauda equinacauda equina


CausesCauses Vertebral metastases and collapse Vertebral metastases and collapse

85%85% Extravertebral tumour (extension into Extravertebral tumour (extension into

epidural space)epidural space) Intramedullary tumour (from spinal Intramedullary tumour (from spinal

cord)cord) Intradural tumour (from meninges)Intradural tumour (from meninges) Epidural metastasesEpidural metastases

Spinal Cord CompressionSpinal Cord Compression FeaturesFeatures

Pain (earliest Pain (earliest symptom)symptom)

WeaknessWeakness Sensory changes and Sensory changes and

a sensory level a sensory level tingling and tingling and numbnessnumbness

Sphincter dysfunction Sphincter dysfunction / perianal numbness/ perianal numbness

Altered reflexesAltered reflexes Can have resolution Can have resolution

of the painof the pain

ExaminationExamination Demarcated Demarcated

sensory losssensory loss Brisk or abscent Brisk or abscent

reflexesreflexes


DiagnosisDiagnosis Urgent Urgent MRI or CTMRI or CT Important early diagnosis!Important early diagnosis! 70% have substantial weakness by the 70% have substantial weakness by the

time of scanningtime of scanning 70% who can walk before treatment 70% who can walk before treatment

maintain mobilitymaintain mobility 35% of those with weakness regain 35% of those with weakness regain

function function Only 5% completley paraplegic do soOnly 5% completley paraplegic do so

Management of SCCManagement of SCC

Oral dex 16mg (EMERG MNG IV 100MG )Oral dex 16mg (EMERG MNG IV 100MG ) Radiotherapy ( no spinal instability)20GR Radiotherapy ( no spinal instability)20GR

5 #5 # Surgery and radiotherapy ( spinal Surgery and radiotherapy ( spinal

instability such as fractureinstability such as fracture Surgery alone relapse at previously Surgery alone relapse at previously

irradiated siteirradiated site ChemotherapyChemotherapy Steroids alone Steroids alone

Superior Vena Cava Superior Vena Cava SyndromeSyndrome

The clinical manifestation The clinical manifestation of superior vena cava of superior vena cava

(SVC) obstruction, with (SVC) obstruction, with severe reduction in severe reduction in

venous return from the venous return from the head, neck and upper head, neck and upper

extremitiesextremities

C. Woelk MD

Superior Venacaval Superior Venacaval SyndromeSyndrome

. .

Superior Venacaval Superior Venacaval SyndromeSyndrome

Extrinsic tumour Extrinsic tumour or Nodeor Node

Direct InvasionDirect InvasionIntraluminal Intraluminal

ThrombusThrombusComplication of Complication of

Central LineCentral Line

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

Incidence and EtiologyIncidence and Etiology

Usually associated with Usually associated with malignanciesmalignancies

Often the initial presentation of Often the initial presentation of cancercancer

Bronchogenic carcinoma (80%)Bronchogenic carcinoma (80%) Lymphoma (15%)Lymphoma (15%) Metastatic disease (5%)Metastatic disease (5%)

C. Woelk MD


PresentationPresentation

Symptoms:Symptoms: DyspneaDyspnea 63%63% Facial and neck swellingFacial and neck swelling 50% 50% Fullness in headFullness in head 50%50% CoughCough 24%24% Arm swellingArm swelling 18%18% Chest painChest pain 15%15% Dysphagia Dysphagia 9% 9%

C. Woelk MD


PresentationPresentation

Signs:Signs: Venous distention of neckVenous distention of neck 66%66% Venous distention of chest wallVenous distention of chest wall 54%54% Facial edemaFacial edema 46%46% CyanosisCyanosis 20%20% Edema of the armsEdema of the arms 14%14% Plethora of the facePlethora of the face 10%10% Vocal cord paralysisVocal cord paralysis 3% 3% HornerHorner’’s syndromes syndrome 3% 3%


ManagementManagement

Does not usually imply immediate Does not usually imply immediate threat to life, except when trachea threat to life, except when trachea or pericardium is compromisedor pericardium is compromised

Important is to establish a diagnosisImportant is to establish a diagnosis Emergency treatment indicated if:Emergency treatment indicated if:

Compromised airwayCompromised airway Decreased cardiac outputDecreased cardiac output Cerebral dysfunctionCerebral dysfunction

C. Woelk MD



Chemotherapy Chemotherapy –– SCLC, NHL SCLC, NHL Radiation - NSCLCRadiation - NSCLC

Bed rest with head elevatedBed rest with head elevated OxygenOxygen Diuretics Diuretics Steroids- medium to high doseSteroids- medium to high dose

C. Woelk MD

Severe hemorrhageSevere hemorrhageEtiologyEtiology

EpistaxisEpistaxis GI bleeding: GI bleeding:

Hematemesis,Hematochezia,MelenaHematemesis,Hematochezia,Melena HemoptysisHemoptysis HematuriaHematuria Internal BleedingInternal Bleeding Bleeding from fungating Bleeding from fungating

tumourstumours HemolysisHemolysis

C. Woelk MD

Severe hemorrhageSevere hemorrhage

Important General Important General QuestionsQuestions

Is treatment of the underlying condition Is treatment of the underlying condition possible in the context of the bleeding?possible in the context of the bleeding?

Is it possible to keep up with the loss of Is it possible to keep up with the loss of blood, and for how long?blood, and for how long?

These may need to be addressed early, These may need to be addressed early, with the patient, family and caregivers.with the patient, family and caregivers.

C. Woelk MD

GI BleedingGI Bleeding

Incidence and EtiologyIncidence and Etiology

80% of GI bleeding in cancer 80% of GI bleeding in cancer patients is from benign sources patients is from benign sources –– good prognosisgood prognosis

Massive hemorrhage is unusualMassive hemorrhage is unusual

ESOPHAGUSESOPHAGUSSTOMACH STOMACH SMALL INTESTINESMALL INTESTINECOLORECTUM COLORECTUM

C. Woelk MD



Consider gastroscopy / colonoscopy / Consider gastroscopy / colonoscopy / surgery if life expectancy reasonable.surgery if life expectancy reasonable.

Avoid surgery if life expectancy < 2 Avoid surgery if life expectancy < 2 monthsmonths

Stop potentially offending agents: Stop potentially offending agents: e.g. NSAIDse.g. NSAIDs

Consider IV fluids, PPIConsider IV fluids, PPI

C. Woelk MD



Massive Bleeding in the Massive Bleeding in the Terminal PhaseTerminal Phase::

• Keep patient warmKeep patient warm• Consider sedationConsider sedation• GreenGreen and black and black towels and towels and

sheetssheets

C. Woelk MD

HemoptysisHemoptysisIncidence and EtiologyIncidence and Etiology

Present in 30-50% of primary lung Present in 30-50% of primary lung neoplasms at the time of presentationneoplasms at the time of presentation

10 % of patients admitted to hospice10 % of patients admitted to hospice

Massive hemoptysis uncommon:Massive hemoptysis uncommon: Pulmonary embolismPulmonary embolism Bronchial bleeding due to tumour Bronchial bleeding due to tumour

erosionerosion EpistaxisEpistaxis

C. Woelk MD

Massive HemoptysisMassive HemoptysisManagementManagement

Trendelenburg positionTrendelenburg position Consider sedationConsider sedation Green and black towelsGreen and black towels

C. Woelk MD

Wound BleedingWound BleedingIncidence and EtiologyIncidence and Etiology

Bleeding is a common Bleeding is a common problem with malignant problem with malignant woundswounds

May involve oozing from May involve oozing from microvascular fragmentation microvascular fragmentation to frank bleeding if vessels to frank bleeding if vessels are involvedare involved

C. Woelk MD

Wound BleedingWound Bleeding


For patients with malignant wounds, it For patients with malignant wounds, it will not be possible to heal the wound, will not be possible to heal the wound, unless one can treat the underlying unless one can treat the underlying cancer.cancer.

Avoid adherent dressings.Avoid adherent dressings. Keep the wound moist.Keep the wound moist. Direct pressure, if actively bleedingDirect pressure, if actively bleeding Medicated dressing possibilities: Medicated dressing possibilities:

Topical aminocaproic acidTopical aminocaproic acid Topical dilute silver nitrate solutionsTopical dilute silver nitrate solutions

C. Woelk MD

Wound BleedingWound Bleeding


If bleeding is possible, discuss this If bleeding is possible, discuss this with the patientwith the patient and family and staffand family and staff

If bleeding is catastrophic, dark If bleeding is catastrophic, dark towels may reduce anxiety of all towels may reduce anxiety of all involvedinvolved

If the patient is distressed, consider If the patient is distressed, consider sedationsedation

C. Woelk MD

Severe HemorrhageSevere Hemorrhage

Systemic InterventionsSystemic Interventions

D/C antiplatelet and anti-thrombotic D/C antiplatelet and anti-thrombotic agentsagents

Vitamin KVitamin K Transfusion of blood or plateletsTransfusion of blood or platelets Antifibrinolytic MedicationAntifibrinolytic Medication

Tranexamic acidTranexamic acid Aminocaproic acidAminocaproic acid

DesmopressinDesmopressin Octreotide (somatostatin analog)Octreotide (somatostatin analog)

C. Woelk MD

Severe Hemorrhage - ManagementSevere Hemorrhage - Management

Desmopressin (DDAVP)Desmopressin (DDAVP) An analog of the posterior pituitary An analog of the posterior pituitary

hormone: vasopressinhormone: vasopressin Extensively used in Type 1 von Extensively used in Type 1 von

Willebrand DiseaseWillebrand Disease 0.3-0.4 mcg/kg IV over 20 minutes OR 0.3-0.4 mcg/kg IV over 20 minutes OR

150-300 mcg nasal inhalation150-300 mcg nasal inhalation Has been used successfully in acquired Has been used successfully in acquired

defects of platelet function defects of platelet function –– e.g. uremia, e.g. uremia, cirrhosis, ASA cirrhosis, ASA –– and in variceal bleeding and in variceal bleeding

Avoid excessive fluid administrationAvoid excessive fluid administration

Severe HemorrhageSevere Hemorrhage


Remember the goals of careRemember the goals of care

Keep patient, family, staff Keep patient, family, staff informed of progress and informed of progress and prognosisprognosis

C. Woelk MD

SeizuresSeizuresIncidenceIncidence::

1% of patients with advanced 1% of patients with advanced cancercancer

SeizuresSeizures

EtiologyEtiology Most common:Most common:

Primary or metastatic brain tumoursPrimary or metastatic brain tumours CVA / StrokeCVA / Stroke Pre-existing seizure disorderPre-existing seizure disorder

Less common:Less common: HypoxemiaHypoxemia Metabolic: uremia, hypoglycemia, Metabolic: uremia, hypoglycemia,

hyponatremiahyponatremia SepsisSepsis Drug or alcohol withdrawalDrug or alcohol withdrawal

SeizuresSeizures

EducationEducation

What to do if a seizure happens:What to do if a seizure happens: Help avoid harm / traumaHelp avoid harm / trauma Do not restrainDo not restrain Do not attempt to insert anything Do not attempt to insert anything

orallyorally Recovery position after the seizureRecovery position after the seizure Expect drowsiness for a while afterExpect drowsiness for a while after Call for help if seizure lasts more than Call for help if seizure lasts more than

5 minutes (it will feel like 30)5 minutes (it will feel like 30)

SeizuresSeizures


Investigate as appropriate, based on Investigate as appropriate, based on patientpatient’’s status and courses status and course

Generally felt unnecessary to give Generally felt unnecessary to give routine prophylaxis for seizuresroutine prophylaxis for seizures

Grand Mal Seizures: Phenytoin is Grand Mal Seizures: Phenytoin is first drug of choicefirst drug of choice

Focal Seizures: Carbamazepine is Focal Seizures: Carbamazepine is first drug of choicefirst drug of choice

Other anticonvulsants may be Other anticonvulsants may be neededneeded

C. Woelk MD

Status epilepticusStatus epilepticusManagementManagement

Protect airwayProtect airway

Administer Administer OxygenOxygen

Consider SC or IV Consider SC or IV

C. Woelk MD

Status epilepticusStatus epilepticus

MedicationsMedications

IV available:IV available: Lorazepam 2-4 mg over 2-4 minutesLorazepam 2-4 mg over 2-4 minutes Phenytoin load: 20 mg/kg at 25 Phenytoin load: 20 mg/kg at 25

mg/minmg/min May need to go as high as 30 mg/kgMay need to go as high as 30 mg/kg

Phenobarb 20 mg/kg at 100 mg/minPhenobarb 20 mg/kg at 100 mg/min

IV unavailableIV unavailable Diazepam 10 mg solution PR Diazepam 10 mg solution PR

May be repeated q10minutesMay be repeated q10minutes Midazolam SC infusion 1-3 mg / hourMidazolam SC infusion 1-3 mg / hour

Consider steroidsConsider steroidsC. Woelk MD

Multifocal MyoclonusMultifocal Myoclonus

Jerking, involuntary Jerking, involuntary movements of arms and legsmovements of arms and legs

May start as subtle May start as subtle movements, and then movements, and then become bothersome and become bothersome and disturbingdisturbing

C. Woelk MD


EtiologyEtiology

Very often associated with delirium Very often associated with delirium and related to opioid toxicity and related to opioid toxicity

May be a pre-terminal eventMay be a pre-terminal event

Important to consider the Important to consider the differencesdifferences

C. Woelk MD

Opioid NeurotoxicityOpioid Neurotoxicity

Cognitive DysfunctionCognitive Dysfunction MyoclonusMyoclonus HyperalgesiaHyperalgesia AllodyniaAllodynia Perceptual DisturbancePerceptual Disturbance SeizuresSeizures

C. Woelk MD



Stop the current opioid and rotate to a Stop the current opioid and rotate to a different one at 50-75% of the equivalent different one at 50-75% of the equivalent dose.dose.

Allow for adequate breakthrough dosesAllow for adequate breakthrough doses Consider careful hydrationConsider careful hydration Expect resistance from family / staffExpect resistance from family / staff Interpreting the myoclonus and associated Interpreting the myoclonus and associated

symptoms / signs as pain, and increasing symptoms / signs as pain, and increasing the original opioid will eventually result in the original opioid will eventually result in more myoclonus and delirium more myoclonus and delirium

C. Woelk MD

SummarySummary

Emergencies happen, even in dying Emergencies happen, even in dying individuals.individuals.

Emergencies may be treated differently Emergencies may be treated differently in the palliative population, with much in the palliative population, with much more of an emphasis on symptom more of an emphasis on symptom management than on attempts at management than on attempts at reversing the disease process.reversing the disease process.

Communication with the patient and Communication with the patient and family is extremely important for family is extremely important for dealing with emergencies.dealing with emergencies.

emergencies in palliative care. objectives manage palliative care emergencies manage palliative care...

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