Session 3a Flashcards
(31 cards)
Acute pain crisis often score
7 or more in the Numeric Rating Scale
Acute Pain crisis Assessment
The pain assessment and management usually occurs simultaneously.
- A focused history-taking is needed.
- The important aspects in the pain assessment include:
- Intensity
- Nature
- Cause
- Elicit if this a new pain or an exacerbation of an existing pain
- Exclude reversible factors (e.g. acute retention of urine)
Principles of Management of acute pain crisis
Keep calm and reassuring manner.
Seek help from senior members in the team.
Use strong opioids for rapid titration:
1. Select the opioid based on pain assessment, patient’s response to opioids, and if
there is renal/liver impairment.
2. Use parenteral route (IV/SC) for rapid onset of analgesia.
3. Commonly used opioids locally include Morphine, Fentanyl or Oxynorm.
- After pain is controlled, start a continuous infusion of the opioid.
- Breakthrough doses should be available for breakthrough pain.
- Start a pain chart if available.
- Revisit the pain history in greater detail when the patient is more comfortable.
- Monitor for signs of opioid toxicity (e.g. low respiratory rate, excessive sedation,
myoclonic jerks and hallucinations).
Stridor
an abnormal, high-pitched breath sound (usually inspiratory) that is produced by turbulent airflow through a narrowed airway.
Once stridor is heard, the airway passage is often less than 5mm.
Onset may be gradual or sudden. It can be very distressing to the patient or anyone who witnesses it.
Causes of stridor
- Tumour of the upper airway (eg: laryngeal or nasopharyngeal).
- Intraluminal obstruction of the trachea due to lung or oesophageal
cancers. - External compression by tumour, metastasis or mediastinal
lymphadenopathy. - Recurrent laryngeal nerve palsy (from stroke/metastasis from lung
cancer)
Management of stridor
Important to recognize and manage early because of risk of eventual
total obstruction and asphyxiation.
If aligned with the patient’s goals of care, airway may be secured via
* Tracheostomy
* Bronchoscopic interventions (e.g. intraluminal stenting, laser)
Chemotherapy or radiotherapy may be considered subsequently if the
obstruction is caused by a tumour that is responsive to these treatment
modalities. An elective tracheostomy may be required before
radiotherapy.
- Palliative pharmacological management includes:
- PO/IV/SC Dexamethasone 16-24mg/day to decrease peritumour
oedema - PO/IV/SC opioids for breathlessness
- If agitated, may need sedation (e.g. with Midazolam)
- Keep fluids to minimum, otherwise airway secretions may
compromise an already narrowed airway
Good communication and education of patients and family members
about what to expect and treatment plans is essential.
Causes of bleeding in cancer
include vascular tumours, tumour invasion
into vascular structures, or systemic processes like disseminated
intravascular coagulopathy or thrombocytopenia
Assessment and Management of bleeding in cancer
Underlying cause of bleed
* Patient’s prognosis
* Patient’s resuscitation status and goals of care
* Likelihood of reversing the underlying cause
* Balance of benefit VS burden ratio of interventions
Topical treatments for bleeding in cancer eg
Topical agents may be used if the site of bleeding is exposed. The following are common drugs used for surface bleeding
Tranexamic Acid (antifibrinolytic)
Adrenaline
General
Measures of bleeding in cancer
If appropriate, consider:
- Resuscitative support
- Interventions (e.g. embolization) to stop the bleed
- All medications that can worsen bleeding should be discontinued.
- If bleeding is catastrophic (e.g. carotid blow out), efforts to stop the bleeding may not even be possible in such dire circumstances. Consider palliative sedation and supportive measures as below:
- Use dark green or brown towels
- Consider Adrenaline or Tranexamic acid packs
- Hemostatic pressure packing with gauze or ‘Kaltostat’ dressings for surface bleeding
- Use curtains to screen patient
- Provide a calm and reassuring presence
- Family members may be encouraged to ‘remain outside’ till the situation is under control.
- Reassure family that will be done to keep patient comfortable.
- Involve medical social worker or nurse to support family
- After the incident, a debrief should be held to screen for distress amongst the involved team members
How to prepare tranexamic acid
Crush four 500mg tablets to a fine powder in a 60g base (e.g. soft paraffin)
OR
Soak undiluted Tranexamic acid ampoule
(500mg/5ml, 10%) into gauze and apply pressure for 10mins, then leave in with dressings
How to prepare Adrenaline
Soak undiluted Adrenaline (1:1000) in gauze
and apply pressure for 10min, then leave in
with dressings.
Do not use long-term as it can
cause ischemic necrosis and
rebound vasodilation.
Systemic treatments in bleeding in cancer
Besides blood products to correct the coagulation profile,
Tranexamic acid can be used systemically for bleeding.
Tranexamic Acid caution
Do not use for hematuria as it will
cause clots to form (hence, risk of
urinary retention)
Caution:Renal impairment, history of
thromboembolism
Seizures
Result of abnormal electrical conductions in the brain causing the
sudden onset of transient neurological symptoms.
Continuous seizure activity that lasts longer than 30 minutes is
termed as ‘status epilepticus’.
Causes of seizuree
Brain metastasis or primary brain tumour
Hypoglycaemia, hyponatremia, uraemia
Hepatic encephalopathy
Hypoxic encephalopathy/ hypercarbia
Stroke/Scar epilepsy
Infection
Medications
(Hum et, al., 2022)
Management of seizure
Turn patient to lateral position (preferably left)
Ensure safe environment
Provide supplemental oxygen
Correct reversible causes if appropriate
Provide a calm and reassuring presence to the patient
and family members
Consider Dexamethasone (16-24mg/day) if underlying
cause is brain tumours especially if there is cerebral
oedema.
Consider long-term antiepileptics (e.g. Levetiracetam (Keppra), Phenytoin), however, may not be necessary if patient is imminently dying.
Pharmacological Management of seizure
Rectal Diazepam 10mg can be given if immediately available
Parenteral Midazolam 1-2.5mg can be given every 15 minutes until
the seizure is aborted.
If seizures persist, a parenteral (IV/SC) Midazolam continuous infusion (range from 0.5-3mg/hr) can be started OR consider
intravenous antiepileptics (e.g. Phenytoin, Levetiracetam or
Phenobarbitone)
For persistent seizures, urgent referral to a neurologist or specialist
palliative care team should be considered
Malignant Spinal
Cord Compression underlying cause
The underlying cause can be from intramedullary, intradural, or
extradural metastases.
Assessment Malignant Spinal
Cord Compression
- Back pain is the most common symptom.
- Neurological impairment such as weakness, sensory impairment,
and bladder and bowel dysfunction may develop. - Physical examination should include a full neurological examination
including looking for lax anal tone.
Management of Malignant Spinal
Cord Compression
Confirm with MRI spine (unless patient refuses further treatments).
Assess if more than one level is involved.
Start Dexamethasone 16mg/day with gastric protection
Assess extent of neurological deficits.
Superior Vena Cava
Obstruction (SVCO)
SVCO is the obstruction of blood flow in the superior vena cava.
Most SVCOs are caused by primary or secondary lung tumours.
Many patients present with an insidious onset of symptoms rather
than acutely.
In the event of rapid onset of SVCO, it may be life-threatening.
Symptoms of SVCO
Breathlessness
*Headache
*Visual changes
*Dizziness
*Feeling of pressure in the head
and face
Signs of SVCO (6)
Tachypnea
Engorged conjunctivae
Periorbital oedema
Cyanosis
Dilated neck veins and collateral
veins in arms and chest
Papilloedema (late feature)
