Palliative Care Flashcards
Pall Care: emergencies x 5
Emergencies:
- superior vena cava syndrome
- malignant hypercalcaemia
- metastatic spinal cord compression
- neutrosepsis
- catastrophic events; terminal haemorrhage & acute/complete airway obstruction
Pall Care: Superior vena cava syndrome x 4 points
SVC vulnerable to expanding tumours in upper thorax; non-small cell lung CAs, bronchial carcinomas, lymphomas, mets occurring in the mediastinum
When central venous lines are used for chemo, SVC thrombosis can occur
Abrupt onset: over 2/52
Slow onset: over longer period
SVCS may be life-threatening & req urg* intervention
eg; laryngeal or cerebral oedema
Pall Care: SVCS S&S x 8, Ass x 6, man* x 4
Signs & symptoms:
- facial swelling/plethora
- distended neck & chest veins
- arm swelling
- dyspnoea & cough; worsening due to tracheal oedema & sensation of drowning
- dizziness & syncope
- headache (‘fullness’ on bending or lying), confusion, seizures, coma
- hoarseness, stridor
- dysphagia, epistaxis & haemoptysis
Assessment may reveal:
- periorbital oedema w swelling of face, neck & arms
- non-pulsation dilated veins of neck, dilated veins of forehead
- dilated collateral vessels coursing over the upper anterior chest
- tachypnoea, cyanosis
- suffused conjunctivae - redness not involving inflammatory exudates
- Pemberton’s sign; positive when bilateral arm elevated causes facial plethora
Management:
- airway management
- symptom management/relief (pain man, posture, O2)
- dexamethasone - to reduce tumour mass & assoc inflammation (alt* hydrocortisone)
- prompt specialist referral; radiotherapy, endovascular stent, chemo, etc
Pall Care: malignant hypercalcaemia; x 4 points
One of he most common life-threatening metabolic disorders in CA pts, assoc* w; breast CA, non-small cell lung CA, & multiple myeloma
Usually occurs w advanced & widespread malignancy & causes a number of distressing symptoms
Development of this is poor prognostic indicator
Characterised by abnormally high serum calcium levels
Pall Care: Malignant hypercalcaemia; S&S x 4, ass x 1, & man* x 2
Signs & symptoms:
- anorexia, nausea, vomiting, constipation
- malaise, lethargy, confusion, delirium
- thirst, dehydration
- hypotension, renal failure, cardiac dysrhythmias & eventually Code 2
Assessment:
- bloods: to confirm; test at risk Pts
Management:
- focus on rehydration
- Tx for biophospohates; even in advanced CA states (for symptom control)
Pall Care: metastatic SC comp* x 5 points
Involves spinal cord compression secondary to CA Dx (mostly 60% thoracic) extension of CA into epidural space
Occurs in approx 5% of Pts w advanced CA ( mostly; lung, breast, renal, prostate & lymphoma)
Diagnosed by MRI in Pts w high index of suspicion; effective Rx can limit loss of function & maintain QoL
Needs to be suspected/excluded in any CA Pt w back pain or difficult walking
Rapidity of symptom development implies worse prognosis
Pall Care: Malignant SC comp; red flags x 4
Red flags:
- pain - a painful back problem
- new onset or exacerbation of old; radiating circumferentially around chest of abdo, aggravated w movement/coughing
- most common initial presenting symptom 90% of cases
- autonomic dysfunction - an evacuation problem
- bowel/bladder dysfunction
- abdo pain/distension
- dizziness/syncope due to hypotension
- cold, shivering, drowsy due to hypothermia
- usually a Late consequence - motor deficits - a movement problem
- weakness of legs of feet, difficulty mobilising - sensory deficits - a feeling problem
- weakness, tingling or numbness to legs or feet, or circumferential boundary
- perianal numbness
- less common
Pall Care: malignant SC comp; man x 4, ongoing Rx x 4, & refer
Management:
- assess for any changes in; reflexes, anal tone, motor weakness & any sensory loss
- posture per spinal injury
- pain management - as per normal
- corticosteroids: first dose may be given even without imaging confirmation [dexamethasone 16mg PO/IV, SC across separate injection sites (alt* hydrocortisone)]
Ongoing Rx:
- continuing w corticosteroids
- radiotherapy
- chemotherapy
- surgical decompression
Refer:
- for Urgent MRI - avoid delays in reducing damage
Pall Care: neutropenic sepsis x 3 points
Defined as; temp >38C measured x 2 over 1 hr, in a neutropenic Pt (<1.0 x 109/L)
Usually occurs 5-10days post chemo & lasts 2-4 wks
CA Pts on anti-CA home Rx, with or without fever, should be assessed at ED
Pall Care: terminal haemorrhage Rx options
If active Rx: O2 therapy, fluid resus, & reverse coagulopathy
If bleeding catastrophic: likely a terminal event STAY w PT!!
Common plans for Fam: use dark towels to hide colouring & volume
Opioid/benzo use should have been pre-approved & documented in plan (if not, use yr brain!)
Pall Care: acute/complete airway obstruction Rx options
Individualised approach: only if Pt agrees & even if not, managing anxiety & distress important
Reversible factors: mucous plug, mechanical blockage or kinking of tracheostomy tube, etc. Manage according to Pt preferences
Acute Rx: dexamethasone or hydrocortisone
Acute severe dyspnoea when stridor present: nebulised adrenaline may offer temp relief
Pre-terminal event: single dose of opioid & benzo advised (see Pt plan or consult!!)
Pall Care: specific symptoms seen x 9
Symptoms:
- pain
- fatigue
- GIT symptoms; dry mouth, anorexia, nausea & vomiting, constipation & diarrhoea
- Resp symptoms; dyspnoea, cough, hiccups
- Neurological & neuromuscular symptoms; seizures
- Psych symptoms; anxiety, depression & delirium
- Dermatological symptoms; itch & sweating
- bleeding
- GU symptoms
Pall Care: Clin* Ass elements x 6
Determine if symptom due to:
- expected manifestation of Dx
- unexpected manifestation of Dx
- temporary relapse, which may be reversible
- exacerbation of an intercurrent problem
- new, acute intercurrent illness, which may be treatable
- deterioration due to irreversible Dx progression or the terminal phase
Pall Care: acute severe pain
First focus on prompt relief & then confier underlying cause;
- aim to maintain comfort & enable their QoL
- reassure Pt U will get pain under control & stay until U succeed
- administer meds; opioids, hyoscine for smooth muscle spasms
- attempt to relieve source of pain; ? Catheter to relive urinary retention
- continue to observe & manage Pt
- consult w specialist support
Pall Care: opioids
- consider equivalent doses elements
- consider age & comorbidities
- new pain, even exacerbation of existing pain, may require sig* higher doses
- use SC/IV/IN as appropriate
- Morphine; 2.5-5mg IV @ 5 min intervals OR SC @ 10 min intervals to effect
- OR Fentanyl; 25-50mcg IV @ 5 min intervals OR SC @ 10 min intervals OR IN as a single divided dose @ 5 min intervals
- with any Opioid; if ineffective at Third dose = consult
- other strategies; different SCIP options for management; ketamine, ketoralac, lignocaine, methadone, dexamethasone etc… dependent upon service scope
- equianalgensic calculations must be done in consultation with GP, Pall Care Consultant, or AMB Medical Advisor
Breakthrough pain:
- only given hourly, as it takes that long to reach peak effect
- if inadequate after 3 consecutive doses = consult for meds review of dose
