Emergencies in palliative care

Question 1

Pathophysiology of SVCO

Answer 1

Extrinsic compression by tumour/mets

Direct invasion by tumour

Thrombus formation

Question 2

Tumours commonly contributing to SVCO

Answer 2

Bronchus (esp small cell, squamous) - 75%

Lymphoma - 15%

Other: breast, testicular

Question 3

Presentation of SVCO

Answer 3

Symptoms: Dyspnoea, face/neck/arm tightness/swelling, visual changes, headache

Signs: Neck/thoracic vein distension, facial plethora/edema (e.g. periorbital), tachypnoea

Often insidious!

Question 4

Management of SVCO

Answer 4

16mg STAT dexamethasone IV (reduce oedema) + PPI

Opioid/benzo for breathlessness + distress

Radiotherapy/chemotherapy for underlying tumour

SVCO stent insertion + anticoagulation

Question 5

Contraindication to dexamethasone for SVCO

Answer 5

First diagnosis of suspected lymphoma –> biopsy first

Question 6

Risk factors for severe haemmorhage

Answer 6

Herald bleed (24-48h after catastrophic haemmorhage)

Tumour pulsation/near blood vessel

Tumour infection

Recent radiotherapy

Clotting disorders

NB: STILL RARE EVENT!

Question 7

Anticipatory planning for catastrophic haemmorhage

Answer 7

Warn pt + family

Document resuscitation status

Dark towels

Preloaded sedative drugs (crisis pack)

Blankets for cold from hypotension

Question 8

Management of severe haemmorhage

Answer 8

Conservative: Presence, dark towels, blankets

Pharma: 10mg midazolam (any route), fluids/blood products/TXA if appropriate

Question 9

Aetiology of spinal cord compression

Answer 9

Malignant compression - myeloma, prostate, breast, bronchus

Disc protrusion

Degenerative - e.g. arthritis

CIDP/AIDP

Infectious causes incl. abscess

Question 10

Pathophysiology of spinal cord compression

Answer 10

Venous stasis –> oedema –> compromise blood supply –> infarction

Question 11

Presentation of malignant spinal cord compression

Answer 11

Pain (earliest sign, 90% of patients)

Weakness - esp with stairs, may be sudden. Differentiate from fatigue (e.g. asymmetry)

Bladder/bowel/sexual dysfunction (late sign, poor prognosis)

Altered sensation

Question 12

Features of pain in spinal cord compression

Answer 12

Band-like

Worse on straining/coughing

Lhermitte’s sign

Shooting down thigh

Suspect in all cancer patients with back pain

Question 13

Initial management of malignant spinal cord compression

Answer 13

16mg dexamethasone + gastroprotection

Whole-spine MRI

SINS score for stability

Full neuro exam - document baseline

Activate MSCC via contact with patient’s cancer care centre

Question 14

Indications for surgical management of MSCC

Answer 14

Solitary lesion

Radioresistant/raiotherapy ineffective

Unknown origin - need for histology

Unstable spine/cervical lesion

Question 15

Indications for radiotherapy for MSCC

Answer 15

1-week course

If pt unfit for surgery (e.g. multiple lesions)

Radiosensitive tumour

Prognosis >6-8 weeks (time taken for effect)

Question 16

Prognosis for malignant spinal cord compression

Answer 16

70% mortality within 1 year, better if ambulant prior to treatment

No recovery after treatment –> median survival 1-3 months

Question 17

Aetiology of malignant hypercalcaemia

Answer 17

Cancer with or without bony mets (may be presentation of bony mets)

Breast, myeloma, bronchus, kidney, cervix

10-20% of cancer patients

Related to bony mets or PTHrP secretion

Question 18

Presentation of hypercalcaemia

Answer 18

Severity related to rate of rise in Ca

Bones (bony pain)

Groans (GI symptoms - N+V, constipation, dehydration)

Stones (renal stones, polyuria, polydipsia, failure)

Psychiatric overtones (lethargy, mental dullness, fatigue)

Question 19

Ca level in malignant hypercalcaemia

Answer 19

Corrected Ca >2.6 is hypercalcaemic

>3 is emergency, to be treated fast even i asymptomatic

Question 20

Management of hypercalcaemia

Answer 20

Fluids - promote calciuresis + maintain renal function

Laxatives/low-dose haloperidol - for symptom management

Zoledronic acid 4mg (bisphosphonate) - check (and recheck!) eGFR and recheck Ca 3 days later (time to effect)

Caution if recurrent - poor prognostic indicator (will pt benefit?)