1. Emergencies in Palliative Care

2. Objectives Manage palliative care emergencies
Have a basic knowledge of appropriate treatments
Know where to get help and advice
Plan Ahead / Be prepared
Understand importance of communication
Know what supplies might be needed
Advance care planning

3. Palliative Care Emergencies
Hypercalcaemia
Superior Vena Cava Obstruction (SVCO)
Spinal Cord Compression
Haemorrhage / Bleeding
Seizures / Fitting

4. General Principles Anticipate Who is at risk? Plan Communication
Preparation
Avoid
Correct the correctable
Prophylaxis
Who to tell and what to tell- patient carers etc

5. Factors to consider What is the emergency Can it be reversed
General physical status of the patient
Prognosis
Burdens of treatment
Patients and carers wishes

6. מר לוי סובל מסרטן ראה NSCC .
אתמול בגלל הדרדרות במצבו , חולשה ניכרת קושי בעמידה, החמרה בעצירות בצרבת ובכאב, בדקת אותו וביקשת מהאחות לשלוח בדיקת דם. מה תבקש?
אשתו מתקשרת אליך בשל החמרה במצבו: לא מסוגל לצאת מהמיטה, נראה מעט מבולבל וגונח מכאב.

7. Hypercalcaemia Who is at risk?
10-20% of all patients with malignant disease
50% of patients with myeloma
20% of breast and non small cell lung cancer patients
Also commonly seen in oesophagus, thyroid, prostate, lymphoma, and renal cell carcinoma

8. Hypercalcaemia Features Confusion Drowsiness Nausea and vomiting
Constipation
Polyuria and polydipsia
Can mimic deterioration due to progressive malignancy

9. Hypercalcaemia Diagnosis Check renal function and corrected calcium
( need to know albumin concentration)
Corrected ca = measured Ca+(n ALB-mALB)x0.8

10. Hypercalcemia Treatment
Consider the goals
Hydration and saline diuresis
Bisphosphonates
Steroids?
FolIow 3-5 days
prevention
C. Woelk MD

11. גב' זלץ בטיפולך בהוספיס בית בשל RCC מפושט.
ידוע על מחלה גרורתית מפושטת לוריד החלול , בבלטות רטרופריטונאליות ובעמ"ש טורקלי ((D6-9 , באגן ובירך ימין.
גב' זלץ קוראת לך בשל החמרה בכאב הגב ונימול הקורן ל 2 הרגליים יותר לשמאל.
לדבריה מתקשה ללכת לשירותים גם בעזרת ההליכון.

12. Spinal Cord Compression (SCC)
Occurs in advanced malignancy
Main problem is lack of recognition
Up to 5% of patients with cancer develop SCC
There is a 30% 1 year survival
Malignancies which commonly cause SCC include; prostate, breast, lung, myeloma, lymphoma and renal

13. Spinal Cord Compression
Compression of Vasculature
Direct Compression
Vertebral Mets
Paraspinal mass

14. Spinal Cord Compression (SCC)
Most commonly affects thoracic level (70%)
Signs and symptoms depend on the area of the cord affected
Signs can be subtle to gross
More than one level can be affected
Compression below L2 affects the cauda equina
Lumbar spine 20% and Cervical spine 10%

15. Spinal Cord Compression
Causes
Vertebral metastases and collapse 85%
Extravertebral tumour (extension into epidural space)
Intramedullary tumour (from spinal cord)
Intradural tumour (from meninges)
Epidural metastases

16. Spinal Cord Compression
Features
Pain (earliest symptom)
Weakness
Sensory changes and a sensory level tingling and numbness
Sphincter dysfunction / perianal numbness
Altered reflexes
Can have resolution of the pain
Examination
Demarcated sensory loss
Brisk or abscent reflexes
Earliest pain- vertebral on lying flat and coughing

17. Spinal Cord Compression
Diagnosis
Urgent MRI or CT
Important early diagnosis!
70% have substantial weakness by the time of scanning
70% who can walk before treatment maintain mobility
35% of those with weakness regain function
Only 5% completley paraplegic do so
Plain x ray of spine can be helpful in suggesting bone involvement
Surgery (vertebral body resection with anterior spinal stabilisation) only if:-
progression despite steroids and RDXT
solitary vertebral metastasis
uncertain diagnosis

18. Management of SCC Oral dex 16mg (EMERG MNG IV 100MG )
Radiotherapy ( no spinal instability)20GR 5 #
Surgery and radiotherapy ( spinal instability such as fracture
Surgery alone relapse at previously irradiated site
Chemotherapy
Steroids alone

19. Superior Vena Cava Syndrome
The clinical manifestation of superior vena cava (SVC) obstruction, with severe reduction in venous return from the head, neck and upper extremities
C. Woelk MD

20. Superior Venacaval Syndrome.

21. Superior Venacaval Syndrome
Extrinsic tumour or Node
Direct Invasion
Intraluminal Thrombus
Complication of Central Line

22. Superior Vena Cava Syndrome Incidence and Etiology
Usually associated with malignancies
Often the initial presentation of cancer
Bronchogenic carcinoma (80%)
Lymphoma (15%)
Metastatic disease (5%)
C. Woelk MD

23. Superior Vena Cava Syndrome Presentation
Symptoms:
Dyspnea 63%
Facial and neck swelling %
Fullness in head 50%
Cough %
Arm swelling 18%
Chest pain 15%
Dysphagia %
C. Woelk MD

24. Superior Vena Cava Syndrome Presentation
Signs:
Venous distention of neck 66%
Venous distention of chest wall 54%
Facial edema 46%
Cyanosis %
Edema of the arms 14%
Plethora of the face 10%
Vocal cord paralysis 3%
Horner’s syndrome 3%

25. Superior Vena Cava Syndrome Management
Does not usually imply immediate threat to life, except when trachea or pericardium is compromised
Important is to establish a diagnosis
Emergency treatment indicated if:
Compromised airway
Decreased cardiac output
Cerebral dysfunction
C. Woelk MD

26. Superior Vena Cava Syndrome Management
Chemotherapy – SCLC, NHL
Radiation - NSCLC
Bed rest with head elevated
Oxygen
Diuretics
Steroids- medium to high dose
C. Woelk MD

27. Severe hemorrhage Etiology
Epistaxis
GI bleeding:
Hematemesis,Hematochezia,Melena
Hemoptysis
Hematuria
Internal Bleeding
Bleeding from fungating tumours
Hemolysis
C. Woelk MD

28. Severe hemorrhage Important General Questions
Is treatment of the underlying condition possible in the context of the bleeding?
Is it possible to keep up with the loss of blood, and for how long?
These may need to be addressed early, with the patient, family and caregivers.
C. Woelk MD

29. GI Bleeding Incidence and Etiology
80% of GI bleeding in cancer patients is from benign sources – good prognosis
Massive hemorrhage is unusual
ESOPHAGUS
STOMACH
SMALL INTESTINE
COLORECTUM
C. Woelk MD

30. GI Bleeding Management
Consider gastroscopy / colonoscopy / surgery if life expectancy reasonable.
Avoid surgery if life expectancy < 2 months
Stop potentially offending agents: e.g. NSAIDs
Consider IV fluids, PPI
C. Woelk MD

31. GI Bleeding Management
Massive Bleeding in the Terminal Phase:
Keep patient warm
Consider sedation
Green and black towels and sheets
C. Woelk MD

32. Hemoptysis Incidence and Etiology
Present in 30-50% of primary lung neoplasms at the time of presentation
10 % of patients admitted to hospice
Massive hemoptysis uncommon:
Pulmonary embolism
Bronchial bleeding due to tumour erosion
Epistaxis
C. Woelk MD

33. Massive Hemoptysis Management
Trendelenburg position
Consider sedation
Green and black towels
C. Woelk MD

34. Wound Bleeding Incidence and Etiology
Bleeding is a common problem with malignant wounds
May involve oozing from microvascular fragmentation to frank bleeding if vessels are involved
C. Woelk MD

35. Wound Bleeding Management
For patients with malignant wounds, it will not be possible to heal the wound, unless one can treat the underlying cancer.
Avoid adherent dressings.
Keep the wound moist.
Direct pressure, if actively bleeding
Medicated dressing possibilities:
Topical aminocaproic acid
Topical dilute silver nitrate solutions
C. Woelk MD

36. Wound Bleeding Management
If bleeding is possible, discuss this with the patient and family and staff
If bleeding is catastrophic, dark towels may reduce anxiety of all involved
If the patient is distressed, consider sedation
C. Woelk MD

37. Severe Hemorrhage Systemic Interventions
D/C antiplatelet and anti-thrombotic agents
Vitamin K
Transfusion of blood or platelets
Antifibrinolytic Medication
Tranexamic acid
Aminocaproic acid
Desmopressin
Octreotide (somatostatin analog)
C. Woelk MD

38. Severe Hemorrhage - Management
Desmopressin (DDAVP)
An analog of the posterior pituitary hormone: vasopressin
Extensively used in Type 1 von Willebrand Disease
mcg/kg IV over 20 minutes OR mcg nasal inhalation
Has been used successfully in acquired defects of platelet function – e.g. uremia, cirrhosis, ASA – and in variceal bleeding
Avoid excessive fluid administration

39. Severe Hemorrhage Management
Remember the goals of care
Keep patient, family, staff informed of progress and prognosis
C. Woelk MD

40. Seizures Incidence:
1% of patients with advanced cancer

41. Primary or metastatic brain tumours CVA / Stroke
Seizures Etiology
Most common:
Primary or metastatic brain tumours
CVA / Stroke
Pre-existing seizure disorder
Less common:
Hypoxemia
Metabolic: uremia, hypoglycemia, hyponatremia
Sepsis
Drug or alcohol withdrawal

42. What to do if a seizure happens: Help avoid harm / trauma
Seizures Education
What to do if a seizure happens:
Help avoid harm / trauma
Do not restrain
Do not attempt to insert anything orally
Recovery position after the seizure
Expect drowsiness for a while after
Call for help if seizure lasts more than 5 minutes (it will feel like 30)

43. Investigate as appropriate, based on patient’s status and course
Seizures Management
Investigate as appropriate, based on patient’s status and course
Generally felt unnecessary to give routine prophylaxis for seizures
Grand Mal Seizures: Phenytoin is first drug of choice
Focal Seizures: Carbamazepine is first drug of choice
Other anticonvulsants may be needed
C. Woelk MD

44. Status epilepticus Management
Protect airway
Administer Oxygen
Consider SC or IV
C. Woelk MD

45. Status epilepticus Medications
IV available:
Lorazepam 2-4 mg over 2-4 minutes
Phenytoin load: 20 mg/kg at 25 mg/min
May need to go as high as 30 mg/kg
Phenobarb 20 mg/kg at 100 mg/min
IV unavailable
Diazepam 10 mg solution PR
May be repeated q10minutes
Midazolam SC infusion 1-3 mg / hour
Consider steroids
C. Woelk MD

46. Multifocal Myoclonus Jerking, involuntary movements of arms and legs
May start as subtle movements, and then become bothersome and disturbing
C. Woelk MD

47. Multifocal Myoclonus Etiology
Very often associated with delirium and related to opioid toxicity
May be a pre-terminal event
Important to consider the differences
C. Woelk MD

48. Opioid Neurotoxicity Cognitive Dysfunction Myoclonus Hyperalgesia
Allodynia
Perceptual Disturbance
Seizures
C. Woelk MD

49. Multifocal Myoclonus Management
Stop the current opioid and rotate to a different one at 50-75% of the equivalent dose.
Allow for adequate breakthrough doses
Consider careful hydration
Expect resistance from family / staff
Interpreting the myoclonus and associated symptoms / signs as pain, and increasing the original opioid will eventually result in more myoclonus and delirium
C. Woelk MD

50. Summary Emergencies happen, even in dying individuals.
Emergencies may be treated differently in the palliative population, with much more of an emphasis on symptom management than on attempts at reversing the disease process.
Communication with the patient and family is extremely important for dealing with emergencies.