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Palliative Care Emergencies Consultant Palliative MedicineEmergencies in Palliative Care ● What are they? ● How do we recognise them? ● What action is needed?Which emergencies occur in Palliative Care? ● Spinal cord compression ● SVC obstruction ● Major haemorrhage ● Malignant hypercalcaemiaSpinal Cord CompressionSpinal Cord Compression Incidence: • All cancer patients 5% • Patients with vertebral metastases 10% Most common malignant causes: - Breast ca - Renal ca - Prostate ca - Myeloma - Lung ca - LymphomaPathophysiology ● Spinal cord oedema ● Ischaemia ● Direct pressureSites ● Thoracic 70% ● Lumbar 20% ● Cervical 10% ● Multiple 20% Early diagnosis crucial to prognosis ● Some patients experience significant delays from the time when they first develop symptoms to referral ● Nearly half of all patients with MSCC are unable to walk at the time of diagnosis ● Early detection, treatment and care can reduce the risk of developing avoidable disability and premature death HIGH INDEX SUSPICION (CLINICIANS/PATIENTS)NICE Guideline, 2023Symptoms or signs of SCC (Box 1) ● Bladder or bowel dysfunction ● Gait disturbance or difficulty walking ● Limb weakness ● Neurological signs of spinal cord or cauda equnia compression ● Numbness, paraesthesia or sensory loss ● Radicular painClinical Features Lesions above L1 Lesions below L1 (Upper motor neurone signs) (Cauda equina syndrome/Lower motor signs) ● Back pain (90%) – Increased on coughing ● Sciatic pain – Localised/radicular ● Saddle anaesthesia ● Muscle weakness ● Reduced tone (check ● Sensory loss anus) ● Increased tone ● Plantars absent/ ● Abnormal reflexes (upper downgoing motor pattern) ● Urinary retention ● Sphincter dysfunction (late)NICE Guidance ● Treat as an emergency and contact MSCC coordinator when available (currently oncology registrar on call) ● Start immobilisation if syms/signs of spinal instability ● Start Dexamethasone 16mg daily ● Assess pain and ensure analgesics prescribed ● Carry out MRI within 24 hours (or CT if MRI contraindicated)Spinal Stability ● Consider specialised CT imaging to assess spinal stability if surgery planned ● Consider use of validated scoring system for spinal stability as part of the full holistic clinical assessment ● Immobilise patients with suspected/confirmed SCC + neurological syms or signs suggesting spinal instability and seek specialist advice ● Consider immobilising patients with suspected/confirmed SCC + moderate to severe pain on movement and seek specialist adviceManagement ● XRT – - aim deliver within 24 hrs unless lost all power >2 wks and pain free or prognosis very poor ● Surgical decompression (may offer better outcome if pt suitable) ▪ - If diagnosis required – - Prognosis longer 3 months – - Not tetraplegic/paraplegia more than 24 hours – - Fit and willing for surgery ● External spinal support if symptoms of spinal instability (eg: halo vest)Symptom Management ● Pain management – (including Bisphsphonates (breast cancer & myeloma) & Denosumab (solid tumors with bone mets but not prostate cancer)) ● Bowel management ● Depends on level of involvement ● Above L1 local reflex preserved so keeping stool soft/firm plus regular PR ● intervention Below L1 may have atonic bowel with loss of local reflex. Manual evacuation may be necessary ● Maintaining dignity of patient is a priority ● Psychological Support Rehabilitation ● Physiotherapy/Occupational therapy –Key role to maximise potential in function and independence ● Social worker –Increase care package incl. respite –Psychological support pt/familyWhy important for Physio / OT? ● Referrals received for: – Stair assessments – Mobility assessments – Transfers – Pain / weakness / sensory problems – Continence issues – Pressure care problems – Might be first professional involved Why is this important for SW? ● Prevention! Report new symptoms/concerns to MDT ● Resource implications - New care package for new physical needs - Significant increase to existing care package - Permanent placement if unable to stay at home - Liaison with/referral to other professionals, services ● Other SW intervention Support with major changes/losses: - client and family - practical, financial, preparation, emotional, family issues etc - negotiating systems, advocacy etc - pre-bereavement/bereavement support/resourcesOutcome – Less than 50% are able to walk at time of diagnosis ● 67% of these pts will see no functional improvement even with treatment – 81% of those walking at time of diagnosis are walking at 1 month with a significantly better overall survival – Loss of sphincter control is a bad prognostic indicator Early detection=better outcomePlace of care • - Home if function allows – - Nursing home esp if paraplegic – - Hospice if specialist physical/psychological needs – - Major life change with poor prognosis so needs good liason with inpt/comm. servicesSurvival ● Median survival is 7-10 months ● Less than 30% survival at 1 yearWhat does that mean for me? High index of suspicion Clinically assess syms/signs esp neurological signs and spinal stability If positive findings: Start steroids Treat pain Arranging urgent admission through Emergency Department for investigation (may need to consider spinal precautions depending on clinical findings)Superior Vena Cava ObstructionSuperior vena caval obstruction ● 50% first presentation ● Aetiology –Ca bronchus 70% –Lymphoma 8% –Other ca 10% – Benign 12% (goitre, AA) ● Need accurate histological diagnosis prior to treatmentClinical features Symptoms ● Signs SOB (tracheal oedema) ● Tachypnoea ● Headache (cerebral ● Periorbital/hand/arm oedema) oedema ● Visual changes ● ● Dilated collateral sup. Dizziness./syncope chest veins ● Facial/periorbital ● Cyanosis puffiness ● Neck/arm/hand ● Non-pulsatile distension of neck swelling veinsInvestigations ● CXR ● CT SCAN ● Specialist referral if tissue diagnosis requiredManagement ● Symptomatic management and support ●Upright position ● Oxygen ●Analgesia ●Anxiolytics ● Corticosteroids: Dexamethasone 16mg ● Oncology opinion ?radiotherapy/chemotherapy ● Balloon venoplasty and SVC stenting provides rapid relief of symptomsWhat does that mean for me? ● Clinically assess syms/signs ● If positive findings: ● Start steroids ● Treat symptoms ● Arranging urgent admission through Emergency Department for investigationPalliative Management of Major Haemorrhage in advanced cancerCauses – Erosion main vessel (carotid artery) – Direct from tumour (lung/gastric/sarcoma) – Bleeding tendency ●Low plt ●DIC ●Uraemia ●AnticoagulantsManagement of non-major haemorrhage May be treated by oncological, systemic, and local measures ● Palliative radiotherapy ● Oral tranexamic acid 1g tds ● Other measures: ● Sucralfate ● 1:1000 adrenaline soaks ● dressings KEEP CALM and ACTIVATE THE MAJOR HAEMORRHAGE PROTOCOLWhat does that mean for me? ● Palliative Management plan appropriate when lead clinician and MPT clear that resuscitation and acute, active management not appropriate. ● Takes into account – Stage of illness – Treatment options available – Patient choicePreparation for Major Haemorrhage ● Sensitive communication with patient and family ● Liason with OOH services/NIAS ● Equipment (gloves/PPE/waste bags/dark towels) ● Medication –Buccal/IM Midazolam –AnalgesiaAwareness/Preparation “A” ● Engage in sensitive discussion with pt/family and agree plan of care (ACP) ● Document and communicate individualised management plan to all relevant care providers (primary care team/ NIAS/OOH) ● Prescribe Midazolam crisis dose and inform pt/family and relevant healthcare providers ● Prepare pts environment (dark towels/PPE/ clinical waste bags)Be the“ B” DO NOT LEAVE THE PATIENT ALONECalm/Comfort “C” ● Call for help ● Use dark dressings or towels ● Position patient as appropriate and use suction if available/ appropriate ● If trained HCP present can administer IM Midazolam 10mg every 15 mins as required (maximum 30mg) ● Buccal Midazolam may be an alternative if family comfortable/ trained and if appropriate (Buccal Midazolam 5-10mg every 15 mins if required with maximum 30mg) ● Use clinical waste bags for used towels/dressingsAfter a Major Hae“D”rhage Debriefing: ● Disposal of waste ● Immediate support for family ● Immediate support for professionals ● Psychological support/bereavement counsellingMalignant Hypercalcaemia Commonly associated with: • Squamous carcinoma (bronchus, ENT , etc) • Breast, prostate, renal tract malignancies • Multiple myeloma • LymphomaManagement ● Fluid replacement ● Bisphosphonates (caution with renal failure) C.Ca 2+ levels decline after 48hrs and continue to fall for ~ 7 days ● Resistance can be treated with repeat dose of bisphosphonate or Denosumab (seek advice on dose/ interval) 80% OF PATIENTS WITH MALIGNANT HYPERCALCAEMIA DIE WITHIN ONE YEAR What does that mean for me? ● High index of suspicion if patient confused or nauseated. ● Check U&E and Corrected Calcium ● Will usually need IV fluids and IV bisphosphonate (red list) so usually inpatient treatment but sometimes managed at homeANY QUESTIONS?