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Good evening and welcome to our third webinar in the palliative care webinar series. Um, tonight I'm really looking forward to having Katy Sanderson joining us. Speaking about palliative care emergencies, Katie is an i m T two working in London. She's currently on an oncology job. She's had two years out of training, working in a hospice and an inpatient palliative care team. She's also done a hospice job in F two. So she's got lots of experience in palliative things, including emergencies. Um, hi. To even and Amanda. I'm hoping you can hear me. Well, someone mind just saying yes to let me know that you can hear us loud and clear. Fantastic. Thank Christina. That's great. Um, so I'm going to hand over to Katie to take us through palliative care emergencies. Um, we'll be doing a question section at the end, but if anyone does have anything pressing, they want to ask during, feel free to post in the chat, and I'll let Katie no, Um, but for now, Katie, take it away. Thanks very much. Hello, everyone. I just wondered if you might be able to put in the chat. Um, whether you're a medical student or an F one or what, your what stage you're at at the moment, just so that you can make sure that it's it's relevant to you as possible. So if you're able to do that, that would be really helpful. Um, and then we'll make a stop. I don't think I can. Everyone see the chat. Okay, great. So it's mainly nothing, all right, And And And you just if you want to stop and do questions on the way, just put that in the chat and Beth, we'll keep an eye on it. And I'm afraid I can't see the chat and my sides at the same time, So we'll have to rely on Beth for that. Um, so let's get going. So this is a talk on palliative care emergencies? Um, some of them are also sort of oncology emergency, so you might have learned about them in oncology teaching. Um, I don't think any of them are particularly sort of groundbreaking, and the medicine is not particularly complicated. But I think for patients who are known to palliative care, service is often knowing what the right thing to do in these situations is quite complex. and nuanced and not necessarily that obvious. And there isn't necessarily the right answer. So it's just going to go through a sort of approach and some of the things you might think about And then obviously, what the medical management is, Um and, yeah, you just stop along the way. If you got any questions, obviously the F one F two s would have had some experience of it and and probably had some teaching in medical school. So it would be a bit of a recap. Um, and if anything is not clear, just you stop me. So the things we'll talk about sort of general approach hemorrhages. So terminal hemorrhages and patients with less severe bleeding um, superior vena cava obstruction, um, metastatic cord compression, hypercalcemia and seizures, which I think are the kind of things that generally come up in this this topic. We'll talk a little bit sorry about fractures, about terminal agitation, about neutropenic sepsis. But I'm not going to talk a lot about that because I think there is a huge amount to say, um and then about lymphangitis carcinomatosis, which isn't typically thought of as a political emergency. But it's just something that I think is sometimes not recognized and not manage that well. And, um, people can deteriorate from very rapidly, and so it's just worth having in the back of your mind. And I think it's sometimes sort of missed or the importance of it isn't really appreciated. So I thought we just talked about that a little bit as well. Um, so just But you may well, no these resources, but in terms of sort of useful places to go for information, I think the this political adult network guidelines is a sort of free guideline. I think it's based in Wales, but if you type in Pang guidelines, p a N G and there's very, very it's free and it's very, very helpful information that's very easy to use. There's an opiate sort of conversion calculator, and I think it's a useful thing to be aware of if you're not aware of it already, Um, the PCF is you need to have a log into it or a paper copy, but obviously it's a sort of Bible and has most of the information that you would need in it. And so it's useful if you can get access to that, um, the Oxford Handbook. Charity care is very useful and quite concise. And then if you're just looking for guidelines, you don't have local guidelines. You want a quick reference? The Scottish palliative care guidelines, I think are very useful and very easy to use and accessible. And so if you're not aware of those resources, I think it's worth having you look for them. Katie, I'm so sorry to interrupt, but I just said Are you sharing your slides right now? Oh, yeah, you can. The people just I can't see them, but can the people watching? Right? Sorry. It might be that everyone else can see them, and I just can't I I think I might have done something wrong. Sorry. I can see them. Yeah. Amazing. Thank you. I'm sorry about that. Um, okay. You haven't missed much from that picture of them. Um, so, yeah, I would have a look at those if you have a note to those already, Um, I was just going to start with a scenario to sort of set the scene. And I have to think about some of the considerations when you think about political emergencies. So this is just a patient who I saw a couple of years ago. Many of you may have seen sort of similar situations. So this is a 50 year old man and you're in the hospital ward. He has a squamous cell, had an X squamous cell carcinoma, and he has been known to oncology for quite a long time. He initially had treatment with curative intent. He's had quite radical surgery, He had a radical radiotherapy and he's had some chemotherapy. He's been considered for a trial and then wasn't suitable, and he now has no further treatment options. But that's quite a recent development. Um, he was admitted with breathlessness. He was treated for a cap, and then he had some increased pain in his neck and was still quite breathless. And so routine did a CT pa and also a CT of his neck. So he hasn't got a P, but he's got progressive disease, and the radiologist rings you to say that they're very, very concerned. He's at risk of having a massive bleed because he's now got to that's encasing his external carotid artery, and at this point, you're starting sort of discharge planning for this patient. It's a very difficult situation with a very anxious family. Patient wants to go home and has two Children at home. Lives with his wife is where he's sort of approaching the end of his life. But it's sort of ambulance is still eating and drinking, and the wife is very worried about him going home. And so you, um, are left in a situation where you need to think about whether you tell this man about his what? What? You tell this man about this scan report what you tell his family about it and how you sort of proceed from here. So he's a very high risk of having a catastrophic sort of internal hemorrhage, but equally, although that would be certainly be terminal. You don't know. You may. Well, just not that may. That may never happen. And so you have to think about what to do. I just want you to have a thing for a minute about what you might do in this situation. Would you tell him? Would you not tell him what might tell him? And then how might you sort of plan for the future with him if if you were in this situation, and I'll just give you 30 seconds. Maybe you could sort of think about why you might tell him. And you might also think about why you might not tell him. Um, okay, so we'll move on. Um, So in terms of the general approach to panic or emergencies, I think the first thing is to sort of be basically competent. Know what the emergency is? Our know how to manage them, which will go through. I think the next thing is that this is really about anticipation. So most of these are emergencies. You can anticipate you know which patients are at risk, you know, from their scans from what disease they have who these are likely to happen to you. And they are. There is generally an element of predictability. So these things don't tend to happen completely out of the blue. Nobody expected them. So I think this is why palliative care is enjoyable and interesting. What what one patient might want to do who is at risk of one of these emergencies and how they might want to plan what you might want to talk to them about might be completely different to somebody else and they might choose to do something completely, completely different. So just going back to this man, you might have a patient who says I want to be at home at all costs. And if I have a catastrophic hemorrhage at home, so be it. And he you speak to his family and you send them home with some local midazolam and you send them home with the drugs that they need. You send them home with the information they need. Or you might have somebody who says The idea of having a catastrophic hemorrhage in my family home, where my Children are going to continue to live after I die is absolutely appalling and completely unacceptable to me. And I definitely don't want to go to some home somewhere where there is a 24 hour care and, um, not not those are both, you know, completely acceptable. And, um, you can help the patient to plan and prepare for for both of those scenarios. But in order to do that, you need to anticipate that this might happen and you need to know your patient and the family well and be able to talk to them about something which is pretty horrifying and help to draw out what their preferences might be. Think about what services are available where you are, how might be able to support them and be realistic about what sort of support there is and make plan about how they might deal with this if it happens, how they might deal with it. If it happens during the day, how they might deal with it happens at night. Um, one of the things I just want to make a point about, particularly for F one F two doctors. I think sometimes when patients are discharged from hospital who are in the terminal stages of the illness to go to hospice to receive terminal care, not a lot of thought goes into the discharge summaries because, I suppose reasonably, people think there's an, well, many questions here. This patient is going to go to urgent care. They're going to be in a hospice. There's going to be doctors looking after them is going to be nice. Is there all the time? So the discharge summary says this patient has progressive disease. There's no further treatment options there being discharged for terminal care, but It's very difficult then, to anticipate what sort of emergencies what might happen. And so I think it's really important to try to, um, think about what information to include. So including blood results and including scans is is really important on these discharge summaries. And I think if you can bear that in mind and try to devote a little bit of time to them and think about what information might be needed for hospice for a GP for a nursing home so that they can anticipate some of these things, that's really helpful. And if you can encourage colleagues, too, because the quality of a lot of discharge summaries for these patients is quite quite poor, and then the other thing is just about communicating with the team who's going to be looking after them. So this is really about knowing how services work in your area, what the district nursing arrangements are communicating in a timely way to the GPS. So for a patient like this, it might be worth calling their GP and then making sure nursing staff in a hospice are aware and that the patient oncology team is a wear and it's it's so often the information just that you have in the hospital just doesn't make it to the right places. And so I think you should really see that as part of your duty when a patient is changing, setting so moving from hospital to hospital or to home, or to a nursing home that that information gets there on the same day. And that should really be part of what you think about when you're just charging somebody in terms of the sort of general questions you ask yourself. I suppose you think about what the problem is and is it reversible at all? If you do try to reverse it, is it going to make any difference to the patient? So what medical do you think can be done? What does the patient want? What the carers want. And if you do treat this problem actively, are you going to maintain or improve this patient's quality of life at all? And there are lots of situations where actually investigating and treating an emergency is not going to make any difference to the overall picture, and it's completely acceptable and sensible not not to do about it, and we'll go through some of those situations. Um, so in terms of bleeding, I thought that's the first thing we could talk about. Um, it's very common in advanced cancer, so you can obviously bleed, um, externally. So from the lungs, from the gut from the skin, um, from the rectum from the bladder from the vagina, common sides. Or you can have internal bleeding and become anemic or become shocked. And it's estimated to be the immediate cause of death in up to 6% of patients with advanced cancer. I think that's quite high estimate that, you know. So you need to think about the severity, and then you need to think about the etiology, because how you manage it is going to be very different than why it's happening. So I suppose the first thing to think about is there a local vessel invasion from tumor lymph nodes, whatever it is, um or is this actually a more systemic problem that's causing this patient to bleed? So do they have D I. C, which is not at all uncommon in the late stages of cancer. So a massive kind of coagulopathy and where they got very low papers. Um, do they have my low suppression. So they got bone marrow failure either because they got bone marrow involvement from their disease or as a complication of treatment, Do they have liver failure? Do they have local infection? So sometimes people who have bladder infections, infections in their mouth and neck cancers are much more likely to bleed. So actually giving them some treatment for that can reduce bleeding. I think the next thing to consider is if you've got, for example, local vessel invasion. Do you think this patient should go to hospital being hospital and have a consideration of some sort of intervention? So I suppose the things you can think about the surgery radiotherapy, particularly for him apoptosis for hematuria, for rectal bleeding and embolization from interventional radiology, um, or endoscopic intervention. So particularly for bladder um, G I bleeding and hypothesis and radiotherapy, particularly for amoxicillin cancer can be very, very effective. So I think they think 85% of people who they who have radiotherapy, amoxicillin successful and they get hemostasis. So these things are really, really worth considering and being aware of it. And I suppose the next thing to do is think about reviewing the drug chart. So think about steroids, which make you particularly more prone to bleeding. Whether the patient actually needs to be on steroids. Are they anticoagulated Do they need to be anticoagulated? Should that be stopped? Um, are they using nonsteroidal analgesia? Could you stop that? Um and are they on anti platelets? So on an aspirin, clopidogrel. And And do those need to be stopped? And I have a really, really thorough review of the blood of the drug child. You need to think about the role of transfusion, So, um, this can be quite complex. So particularly in, um, he monk patients who become transfusion dependent. It's very resource intensive, particularly some of these, for example, needing to go to a day center to have a transfusion twice a week, which is quite common, um, needing multiple transport becoming increasingly weak, that there's a point where that's probably not in their best interest. And it's just too burdensome. And so you need to think carefully about that, obviously liaising with hematology with those patients and really starting to think about that. The risk benefit at some stage is not become unfavorable. And then, for a patient like the patient we're talking about. We need to think about planning for if this does happen. So somebody who's at risk of a huge lead thinking about their recess status and thinking about where they looked after. And I think if we talked about massive terminal images first, it's a really difficult thing to talk about. But I think in most situations you do need to discuss it. If you know that somebody is that massive risk, unless you really, really think it's going to cause psychological harm. And then I think you would definitely want to have a special Spanish care team and they're oncology team involved and for it to be a multidisciplinary decision if you really think there's any reason not to not to share that information with somebody in their family, Um, you need to think about what might happen. So do they have appropriate towels and sheets? Do they have appropriate sedative medication? Should you train the family about how to give it? What is the appropriate route? So, uh, if someone's family going to want to give an iron injection, could they give something buckle? Could they give something rectal or sublingual and You can obviously have preparations of benzos in all of those forms. Some of them are quite quite expensive, and it can be difficult to get them. But they're all possible roots, and it may be that somebody's family is not going to give them an injection. You need to think about talking to people realistically about what might happen, which is that if you have a massive hemorrhage at home, it's very unlikely that you're going to manage your contact district. Nurses and district nurses are going to come and give you a sedative medication quickly enough, so you just you just need to think realistically about what sort of situation somebody might be in, how you can help them. And do they actually want to potentially be in that situation? Or is that something they really want to avoid? And is home the right the right place? And then you should just think about if this does happen, what might happen afterwards that you need to organize some kind of debriefing? You need to think about how the waist is disposed of. Someone's had a huge hemorrhage at home, and it's obviously a very it's a very traumatic is potentially very dramatic. And you should think about whatever system you have locally for documenting. Um, advanced care plans. We have something called coordinate my care. And so that the plan you've discussed is, um, is recorded is available to the ambulance service. Um, and everybody knows what the plan is. Um, so those are the things to think about, you know, in somebody who's at risk of having a massive hemorrhage in terms of people who are bleeding, but it's not sort of catastrophic. I think it can still be very, very distressing. It can make people anemic. It can make people very symptomatic, and also some people who have been bleeding. Fungating wounds can be really, really difficult for people to manage at home and have a very significant impact on the quality of life. So, in terms of thinking about minor bleeding again, think about Is there any role for intervention might actually be better for somebody to go to hospital. Is there an option to sort this out once and for all? Could they have an immunization? Could they have radiotherapy? Could they have an endoscopic intervention if you've got people who have bleeding from their skin, and you can think about using cause. Typically, that's okay and tranexamic acid, um, or an adrenaline and that can be really useful. And it can be very, very effective, so it can be useful to think about making sure that somebody has that. If that's the problem they have. And also just about the wound management dressing Do you need district nurse input? You need a tissue viability, nurse input. And sometimes, actually, the fact that patients and their families are managing rooms very well can exacerbate bleeding. And it can make a big difference to have dressings in terms of people with nasal pharyngeal bleeding. When you think about quarter and packing involving ent and or referring to your bleeding, you can use sucralfate. You can use tranexamic acid as a mouthwash, which you just dilute to 5% and it's very easy to do yourself. You don't need to get a specific mouthwash preparation. Um, you can use adrenaline SEC cause, and sometimes people do use adrenaline NEBs, particularly if it's quite inaccessible in head neck patients. Um, basic management of hemoptysis just to revise and you need to be you can obviously be quite scary. It's very important to live somebody on the side that they bleeding from so that there are the lung, Um can work. You can put people head down. You can suction as a sort of a temporizing measure, and it's often very responsive to radiotherapy and that those are the sort of first aid measures. And it is really important not to put somebody on the wrong side because it can make them generate much more quickly. People who got the eye bleeding need to think about PPI. Yes, um, I think about oral tranexamic acid and sacral face again, people who are having a lot of bleeding from the bladder. It's very important to exclude infection, which can make it a lot worse and also to think about tranexamic acid. Um, but you can make people at risk of clot retention and make clot retention worse. So you just need to have that in mind, particularly in somebody who developed. Retention is a lot of pain. Um, do you think about using tranexamic acid, um, orally as an antifibrinolytic. So you usually start with 1 g TDs. You can use more. Some people start at a slightly lower dose. Um, it is very useful in some people. It doesn't make any difference in other people, but it's simple. It's well tolerated, and it does help a proportion of patients. And it is obviously prothrombotic. So you need to think about that and you need to assess the response. So it's something that people often end up just being sort of left on. So if you're going to do it, you need to do a trial. If it doesn't work, you can increase the dose. If the maximum dose doesn't work after I generally say 3 to 5 days, then you need to You need to stop it because it it is potentially grow from what it increases. People's risk of clots. Um, think about vitamin K, particularly patients with liver failure. And there are more specialist things like using desmopressin. You would need to speak to dermatology about that, But if you've got a patient who is having bleeding that with these kind of simple measures, it's really not improving, then that's definitely worth worth thinking about. Um and I think those are the main bits about hemorrhage, but it's really thinking about who's at risk, how you discuss it sensitively and how you, um, think about where somebody's looked after and what sort of arrangements you might make to anticipate if it does happen. Um, so the next one is SBC obstruction, which I think you probably all know something about it. But we'll just do a sort of quick recap. Um, so this is where you get compression of the superior vena cava, which is the vein that drains your head and neck and arms. And this can be from external compression, so you can have a tumor pressing on it. More lymph node. Um, it can be from direct invasion of the vein from a tumor that's grown into it. Or it could be from a cloth, and you then get reduced being this drainage from your head and neck and arms and the blood. The symptoms related to the blood pooling there because you've got low pressure in the vein after the blockage, you're very predisposed to blood clot formation, and it's very common to see a combination of some compression and some and some clot that's that's formed, Um, this occurs mostly in mediastinal tumors, and it's overwhelmingly, um, lung cancer patients. So that's who. I would have a sort of high. Um, be very careful. So 65 to 80% in lung cancer and the next sort of thing to be aware of this lymphomas, which we'll talk about in a minute. And you can get it from metastases as well. Um, so you'll have a patient. Sometimes it presents acutely, and sometimes actually it's more insidious. And it's over a period of weeks. Um, get a headache sort of fullness in the head. It could be much worse when you bend forward or lie down. Get breathlessness. Can be dizzy. Get some visual changes. Swelling can often get swelling around the eyes. And if it's left for a very long time, you can get back to the Dema. Um, you might notice that the neck veins are very distended sort of non pulse style, and you can get which you can see. This man has these sort of dilated collateral veins on your arms and on the anterior chest wall where the blood is trying to find another sort of group is not able to flow through the sec. You can get Strider because you get edema around the airway you become diagnosed and take a picnic, and you can get this very plethoric sort of red face and the man on the bottom left. I don't know if anyone remember what that's called, but this is where you put your if you put your arms above your head, your you block your thoracic outlet. And so you make this SBC obstruction much worse, and you can find that it's actually very difficult where you had some drainage of blood before you blocked off completely. And so you get this very, very red face, and I think as far as I remember, that's called Pemberton sign. And that's just a useful thing for exams, although not particularly for real life. Sometimes you find that people have had this for a little while, and they will tell you that they wake up with a very kind of puffy face. And then actually, when they get up and they've been standing up for a while and it starts to drain, that it goes down quite a lot. Um, so you to think about getting CT and the management really depends on what's causing it, how severe it is and what the patient's prognosis is so in terms of what to do in the first instance, you need to try to get the patient up, support their arms on pillows, make sure you're wearing loose clothes. Um, they may need oxygen if they're breathless. May be helpful to give them a fan. They may need, um, Benzo's or opiates for for breathlessness, and you need to manage any pain that they have. And then your next step really is to give them a high dose of steroids so usually to give 16 mg and then 8 mg twice a day, usually eight and 12 or eight and two. Um, the only sort of slight proviso is, if you've got a patient who doesn't who is presenting with this as a sort of the first presentation of cancer who doesn't have a diagnosis? You need to be a little bit careful because if you have a patient who's presenting with the lymphoma and you give them a high dose of steroids and they don't have any biopsy, you can potentially then render their biopsy totally sort of inconclusive. And it can have quite a lot of implications because you then don't have a histologic diagnosis. It's very difficult to start treatment. You've got somebody with potentially young with a potentially curable cancer, and you're then in a very difficult situation. So if you've got any suspicion that this is the first presentation of lymphoma, don't give the patient steroids speak to a senior, Um, speak to hematology speak, speak to oncology locally and just have a just pause for thought first, because it's a situation that you can potentially actually make quite a lot worse by giving. It's not common situation, but you can actually make it worse by giving them steroids and being the worst position and, uh, potentially quite significant ways to their treatment, um, into that side, given steroids and then think about involving oncology early via S or whatever the mechanism is in your hospital making. Letting their oncologist no. If they've got a clock thinking about anti coagulation and then the treatment really is, sometimes it's amenable to stenting, so interventional radiology will put in a stent. Um, often it's improved with radiotherapy, and that started as soon as possible. Um, and then, for some chemotherapy sensitives who particularly small cell lung cancer, some germ cell tumor, actually starting chemotherapy probably is the is the best treatment, so it really depends a little bit what's called What's causing it? Um, so that's the main things about SBC obstruction. Um, but do you think sometimes, you know, sometimes someone's very red in the face and they've got huge veins all over the chest, and it's very obvious. And sometimes, actually, it's someone who's just a little bit breathless and who's arms are a bit puffy and who's saying their face a bit puffy and morning and not feeling that good. And they've got a little bit new, some headaches in the morning. So do do do sort of think about symptoms can be quite vague, and it's not necessarily as obvious as the pictures you see. Um, so I think that's everything I wanted to say about that. The next one is metastatic spinal cord compression, and, um, this is obviously a really important topic because it's pretty disastrous if you miss it. The reason it matters is because if you pick it up early, you can potentially improve someone's neurological function. So somebody who's starting to have difficulty walking, sometimes you can get back to a point where they can walk, or at least stop it deteriorating. And if you don't pick it up early, you can have patients who are paralyzed who have, um, dependent on having a catheter, and it can have a really, really very significant impact on what remains of somebody's life. And so that's the reason sort of going about it all the time and just to recap what it actually is. So it's compression of your spinal cord or the cord required by um, either after logical vertebral collapse or a tumor actually directly pressing on the cord or very occasionally, um, intradural tumor. But that's not very common. So mainly it's patients who've had hematogenous spread of the cancer to the bone in their spine, and and that's what what causes the problem. And so it's most common in breast prostate lung cancer. So cancer metastasized to the bone also think about it in kidney and the thyroid, which commonly metastasized the bone and in myeloma. But more than 50% of the cases are from breast prostate. Among among patients, um, about 3 to 5% of people with cancer will develop further comments and at risk, and it's just important to think about the fact that this can be a first presentation of cancer, so there's not a huge amount of data collected about it. But in the data that has been collected about the fifth or slightly over 1/5 of patients, this is actually the first presentation of their cancer. Um, so that's just something to think about clerking people with back pain. And we'll talk about some of those sort of questions to ask in the characteristics. It's estimated to effect about 4000 patients here in England and Wales and the average age of 65. And it's becoming more common, I suppose, because there's more lines of treatment. So a lot of these patients with vertebral metastases survive longer and so have a higher risk of developing it. Um, having said that if you look at patients with who who have this diagnosis, only 30% of them will survive more than a year. So it's associated with obviously advanced cancer and having a relatively poor prognosis, and that's just something to think about when you're thinking about how to manage it. Um, so this slide is just to demonstrate to things so first of all the communist sort of level is thoracic. Um, so 60 to 80% will have a thoracic cord compression and cervical is relatively uncommon, and about 15 20% will have longer say well. And the other thing just to be aware of is that it's very common to this patient on the right, obviously, has disease. At one level, if you look at this MRI scan on the left wrist, patients got multilevel disease, and you will have about 30 to 50. Patients will have multilevel disease, so it's very important to think about that, particularly in terms of thinking about treatment and radiotherapy. And you know that somebody who has this multilevel disease, although it may not be causing the same level of compression, they probably do need to have all treated to treat one area and you leave the other area. They're very likely to then develop neurology from from the other area, so just have that in mind when you see them. Um, when you're taking history, I think the first thing to think about is pain. So you're thinking about patients who got the cord compression, and you're also trying to identify patients who are at risk of it. So most patients who develop called compression more than 95% of patients who develop called compression will have had back pain for one or two months before, and it's characteristically unremitting, getting worse. It can be associated with a narrow band of pain around the chest or abdomen. At the level of the compression, you can get a ridiculously healthy so the nerve root can be compressed. Get pain that's worse at night worth lying down with coughing, straining, sneezing and you can get bony tenderness. So that's the sort of first thing you develop, Um, and so any cancer patients who develop new back pain. That's something you need to take very seriously and need to think about the next thing to think about the next sort of thing to develop his weakness. So somebody is having difficulty walking, difficulty standing, any sort of weakness, and that's the next most common symptom. It's something that develops. Sensory disturbance can develop relatively late, so you might get numbness, tingling, altered sensation. You can get Lhermitte's sign, which some of you will know from learning about multiple sclerosis. So it's the same thing where you have a lesion in your neck, and when you flex your neck, you get sort of electric shock like symptoms down down your back. And that can be seen in called compression, when it does affect the neck and then autonomic dysfunction. So having bladder and bowel problems is something that occurs really very late. So that's an extremely bad sign. And unlike, can occur much earlier in quarter equina. So the commonest symptom is constipation and sort of 60 or 70% of the patients who have constipation. And if you have a sphincter servants that's associated with a very poor prognosis and poor recovery, you can develop urinary incontinence retention. Look for a palpable bladder. You can also have fecal incontinence, but as I said, it's most common to have constipation. Constipation is obviously a very common symptom in these patients, anyway, because of your mobility because of the medications they're on. So do be careful about about that, um, in terms of how to manage it. I just put the nice quality standards on because I think they're quite useful, and I think probably in most places they're not achieved. But I think it's good to have in your mind So adults who have spinal pain suggestive of metastases but don't have neurological impairment to have an MRI spine within a week. And adults who suspected of having core compression should have an MRI, spine and an agreed treatment within 24 hours, which is pretty ambitious if you think about somebody presenting to any but worth having in your mind. Adults with suspected MSCC should have their investigations and treatment coordinated by an MSCC coordinator. So it's basically just, well, thinking about what the arrangements are in your area. I'm working the hospital, and maybe that doesn't really have an M SEC coordinator. And so it's. It can be quite difficult to organize these investigations quickly. Um, and treatment should be started within 24 hours of confirmed diagnosis. So if you think about getting radiotherapy at the weekend, if you're a patient who's in the District General Hospital, who's going to need to be transferred? Um, it's just you need to be very sure that these patients are handed over, that people are aware of them because otherwise that's completely impossible to achieve. And in terms of how they do, the reason we've sort of touched on this. That it's so important to diagnosis early is because the strongest predictor of how you will do neurologically so whether you have any recovery, whether your neurology will be stable whether you're deteriorating, deteriorate is your neurological state when you start treatment. So if you're ambulance at the point when you start to have treatment, then 70% will improve If you're paralyzed, and particularly if you've been paralyzed for more than 24 hours before you have treatment, it's extremely unlikely you're going to get any recovery of neurological function. Um, so I would say particularly 11 or two. It could be really, really hard. You think you know about doing neurology exams, and then you actually go and see real patients and their drowsy. They're delirious, their bed bound anyway. They've got other conditions. They've got pre existing neurology. They've got a catheter anyway. Nobody knows when they open their bowels. It's not as it's not. I know it doesn't when when in real life you say, Oh, you should be able to diagnose this. It's not always very easy, but I would just really encourage you. If it's something you've got any kind of concern or suspicion about in a patient when you're on course with all the wars, whatever, um, to it just gets, you know, if you're not sure, just get someone senior to come and help you, because it is so important not to miss it. And it isn't always that clear. And the other thing, I'd say is often You don't see somebody. They have some neurology there week. It's difficult to examine them. You look through the notes is completely unclear what the neurology has been like for the last week. There's no examinations documented. You don't know if it's new. Um, just get somebody senior to help you, because these are difficult judgments to make. But there are things that can potentially make massive, massive difference to people's quality of life. And so I would never think I don't want to bother. Somebody would really encourage you to ask for help if you if you do. If you do need help, um, in terms of investigation, I suppose first things decide whether to investigate, so you don't have to investigate. You could say patients not got any pain. You don't think they're going to recover or they're dying. You think they're eminently dying in the next day or two. That's not going to be any benefit from treatment. You can speak to people, speak to their families, and you can say, actually, I am suspicious of this, But I don't think I don't think we should do anything about it, and that's fine. And but in terms of the investigation, you need to get an MRI, whole spine. So that's for the reason you've discussed, which is that you can have multilevel disease so you don't want to just scan part of somebody spine. And if you're worried about spinal stability, and you just need to think about what kind of nursing plan you need to put in place until they've had the scan and you know that their spine is stable, so do they need to be nursed flat. Do they need to be log rolled? Um, if you're worried about their C spine, should it be immobilized and so do you. Just have to think about that, Um, and so assuming you've got your MRI and this is the diagnosis, um, first thing is to give steroid, so, um, to give 60 mg of dexamethasone. Um, and then you DAPT just think about giving a PPI, trying to give it in the morning, although that is a little bit controversial. But that is sort of convention, although there is some evidence that doesn't actually make a huge difference. Um, and, um, if they're diabetic, they're risk of diabetes. Just making sure there's a plan for monitoring their blood sugars and treating it if they get steroid induced diabetes, which is obviously extremely common. And sometimes I think not that clear about communicating that that needs to be checked in terms of your treatment options, then got radiotherapy, which is the aim of it is to prevent them deteriorating anymore. See whether you can improve their neurology, and it's also very good for pain. There is very different regimes. Often, people are given 55 fractions, sometimes given 10 fractions. And you even if you think somebody has no prospect of neurological recovery, it's still worth thinking about because it can be very helpful for pain. And sometimes people can just be given one fraction, and that's very useful. Um, you need to think about whether there is a role for neurosurgery and certainly asking neurosurgeons and referring, um, so they can usually often do a laminectomy. So you're trying to decompress the spinal cord and then reconstruct and stabilize it. Treated previously. I think the trend has been to think radiotherapy is preferable because, um, it has similar sort of benefit and has fewer complications. Um, there is a bit of a move to, um, surgery because there is some evidence that surgery and radiotherapy versus just surgery sorry, surgery and radiotherapy versus just radiotherapy have better outcomes. And there was a trial. I just put a link to it below, if you're interested in it. And that was actually stopped early because the outcomes in terms of people walking is so much better with surgery and radiotherapy, and they need less steroids, less analgesia. And so that trial was actually stopped. So do you think about it? Obviously, there's patients who, because they're so frail because of the anesthetic risk because they're so near the end of their life that surgery is not going to be beneficial. Likewise, as patients, radiotherapy obviously takes weeks rather than days to work. So if somebody has a really, really poor prognosis, it may well not be appropriate, and also someone has to go for it. They have to be moved onto the table or these things. It may just be that it's too burdensome and the benefit is not is not sufficient. And then there is a role for chemotherapy just in patients who do have very chemo sensitive tumors. So sometimes in lymphomas, in jams, cells and then passing out tremors and small cell cancer. But they're all freedom for the, um, you just need to involve your local service as early as you can. Um, I think that was everything I wanted to say about this. Obviously think about managing their pain. So it's bony pain, usually, and it's got an inflammatory component. It does usually respond to steroids and thinking about your pain bladder, and also that there can be a neuropathic component to the pain and whether somebody would benefit from a adjuvent neuropathic analgesia. And so I think that's everything I want to say about that. The only other thing is just about steroids. Generally, I think we're pretty bad at documenting why people, why people on steroids, what the indication is, and we're making sure that we were making sure that the plan for weaning is communicate is communicated. So, um, just do you think about that when you're starting people on steroids that often people are discharged from hospital, maybe they've been weaned down to four or six. It's not that clear why it's not that clear when it was started. It's not that clear whether they've been beneficial. So that's something that I think there's a lot of room for improvement. Even if this patient is not suitable for radiotherapy surgery. If you start on steroids, you still need to think about. Have they got any benefit from it? And that that's just a very important thing to assess and to consider, and then to to think about weaning the steroids in a timely way. Um, Hypocalcemia, I think just to revise quickly. That's quite a lot of mechanisms, so you can have osteolytic bone lesions and cytokine. So prostaglandins Um, I'll one TNF and you can have hypercalcemia from that mechanism, and then you have a lot of them are particularly swimmers, cell tumors that secrete this parathyroid related protein, and that's the mechanism for their hypercalcemia. In some, some lymphomas secrete vitamin D. Um, and that's another potential mechanism. And then you do sometimes get a topic P. T. H. And so there are. There are various different mechanisms, and it's just useful to have a quick think about them. For example, if you're if you're doing exams, particularly part one part, too, because that's something that comes up quite a lot. Um, why is it important? So it is life threatening. It can give you arrhythmias. It's most common in myeloma and breast cancer, and it's basically got very, very vague symptoms, so some of them are just quite indistinguishable from some symptoms of advanced cancer. So, um, constipation, drowsiness can obviously have lots of causes. Think about people being very thirsty, not eating, peeing a lot. And then you can get abnormal neurology. People who are drowsy, confused, dehydrated can be asymptomatic. Um, I wouldn't necessarily treat if it's below three, but if it was above three, I would think about treating it, Um, so the treatment is basically fluid. Obviously, you need to be cautious if they've got heart failure. There's any other reason not to give them fluid quickly and bisphosphonates, um, it tends to take at least 3 to 5 days to normalize. There's no point to constantly be checking it daily because it's not necessarily going to have gone down on day one or two, and it can rise sort of transient. So I really wouldn't bother checking it for a couple of days after you've given a bisphosphonate. Um, and I think the other thing is just to be aware of is a poor prognostic market to develop hypocalcemia a malignancy so you need that can contribute to the general picture about someone's prognosis, and it's very likely to recur. So if you're seeing somebody with hypocalcemia, you think about an ongoing plan about rechecking the bone profile and do they need to be on a regular bisphosphonate? Do they need to come in in three or four weeks to have it again? You can give it orally, but it's more commonly given IV. And, um, there's obviously some GI side effects, and it's not necessarily that suitable for people who are very frail to give oral bisphosphonates. Um, so I think that's everything on hypocalcaemia. These are just the BCG. So just to show that the sort of VCG changes you get a very short Q T and Then you get these Osborne, um, waves and your QRS complex to get this kind of watch your ass complex. So just look out for that. Um, seizures is the next topic so very common? So 10 to 15% palliative care patients will have seizures and 70 patients present roughly of patients with a brain tumor. Um, will have a seizure in the course of the illness. Very common, particularly in patients with primary brain tumors in the last week of life. I always think about other causes, so particularly hypoglycemia, because that's very easy to reverse. Um, and then you're just just some considerations. So do you review people's drug chart so steroids can interact with some anti epileptics, the carbamazepine and phenytoin, Um, and some, um, drugs that are commonly used in palliative care. So particularly haloperidol and leaving the brain seen can reduce your seizure threshold. So be careful about prescribing them in people who are epileptic and then really do think about. Is there an alternative in patients who are having seizures, particularly levo, um, in terms of whether people are swallowing or not, what you need to do with their anti epileptics. If somebody is actually dying, and you think that the prognosis of hours or a day a lot of them have quite a long half life, so you don't necessarily need to do anything. And in primary brain tumors, usually you wouldn't give somebody an anti epileptic drug prophylactically, but you would usually treat them after one seizure. So it's slightly different perhaps to how you might manage epilepsy in patients who don't have brain tumors. Um, just here is a very simple algorithm for what to do, So the treatment usually inherited condition is to give midazolam so five or 10 mg and you can give it subq or I am. You can give buckle medication. You can give rectal medication, and if you have it, and then to repeat it, the seizure continues, and then you need to think about how you're going to prevent them having further seizures. So if they can swallow usually what you do is start keppra, and that doesn't have a lot of interactions, and you should start 500 B i. D. Or sometimes 250 somebody who's renal function wasn't brilliant. They're not able to swallow, and they're having seizures or they've been on anti eplectic medications for seizures and you need an alternative. Then you need to think about starting a syringe driver. And, um, the Communist thing is to give midazolam, so to give 20 or 30 mg of midazolam, which is higher than you would sometimes start for agitation to prevent seizures over 24 hours. Um, you can give keppra in a in a syringe driver, so it's got a 1 to 1 conversion. So it's the same dose, and you can give a maximum of sorry. That's supposed to 3 g 4 mg, and sometimes you need to put it in two pumps because the volume is too high. Um, and people are really concerned about drowsiness and really don't have concerns about Islam. That can be very, very useful. And you can also obviously, if you're unable to manage to just give phenobarbital, we need to do that with specialist palliative care and input. Um, new seizures. Think about whether somebody is on steroids Should they start steroids? Um, for, uh, primary or secondary, um, tumors. And so that's just another thing to consider. Um, but basically, it's a medicine called Keppra that you can get by a driver, Um, in terms of the other bits and pieces. I haven't put in a lot about nutrition and sepsis because I think you just need to follow your local guidelines. Be very aware that these patients don't necessarily mount a normal physiological response, so you need to be very suspicious, particularly in patients who are sort of 10 to 14 days post chemo. But you should consider it in. Anybody who's having a systemic anti cancer therapy who's had it in the last six weeks, who's got bone marrow failure had a bone marrow transplant. Make sure you think about line infections. Um, sending. Think about fungal impact. You are immune suppressed. So particularly doing fungal markers, thinking about extended respiratory virus panels and involving microbiology. Be familiar what your guidelines are. Um, just breathe thing about stride, or it can just be really helpful to think before that develops innovation with particularly head and neck cancers about whether they would be for a trach e or not. And I think that's just something to think about as you go about your daily life in these patients, because that is not a decision you want to be making, um, in an emergency. So somebody's got airways at risk. We think it might be at risk. It's really worth trying to have those conversations with I t u with the ent with oncology with your own team, Um, as early as possible. If you think that might be, you need to go down because it's extremely stressful to try to make those sorts of decisions in an emergency. Um, track emergencies. People's track is blocking off. Obviously, you just need to think about palliative care patients going home. What sort of plans you put in place, And can hospices look after them? Do they need extra training? Just the logistics of that earlier. If you've got a tracheostomy patient in a hospital, um, because it can take a long time to train carers, and that can cause huge delays and can mean that somebody doesn't die in their preferred place of death. And that's not uncommon. So just have that in your mind. If you got a patient who has got a tricky um, and then the last thing I was going to talk about was lymphangitis. So just in case you don't know what this is. This is when you get tumor in the lymphatics songs and you get local obstruction inflammation, and it basically presents with breathlessness so it can be sub acute. Can be quite cute, can occur over a few weeks, and it can make people get hypoxic. Give you pleuritic pain. And patients generally look quite unwell, and they don't respond to antibiotics or diuretic. So often they're treated for just infection or fluid overload. First, um, it's most common in breast and stomach and lung cancers and in adenocarcinomas, and it's very, very difficult to treat so you can give people steroids that doesn't make a huge difference, and you can give people oxygen, and that's basically it. If they got a primary that's very treatable and they haven't had treatment, sometimes it does improve if they if they have chemotherapy. But just if you got somebody who's crackles in there just aren't going away, they're not really responding to antibiotics. Um, I think maybe they felt pulmonary edema, but it's not that convincing. Do you just think about this because these patients tend to deteriorate very quickly, and, um, they need sort of planning and they need communication about the fact that this is what they've had, and I've looked after two people in the last six months. One was discharged with no idea that they were this ill and then died a couple of days later at home, which was very traumatic. And another was still for recess and had had an arrest on Ward, having had a massively sort of increasing oxygen requirement over two or three days, and I don't think it was really recognized. And so if you ever see that on the scan report where you suspect it, just it's something to act on quite quickly because their patients who deteriorate very fast and it's not always sort of picked up. Um, so on the chest X ray, you often get quite fine crackles when you listen to the chest bilaterally, you can get this sort of particular particular modular infiltrates on the chest. X ray can look a bit like pulmonary edema. When you look at the CT, you can get this thickening of the inter lobular septum, and the fish is because that's where your lymphatics are so it can look a bit like pollen edema, Um, and just be so just if you don't know anything about it, maybe have a read about it and have it. Is something in your mind and just the last thing about fractures. So obviously this is a sort of, uh, emergency. Um, just think about politics, patients many. You have met you at risk of fractures, making sure you think about whether they would benefit from it thing which, waiting until somebody does have a fracture. Um, thinking about radiotherapy and thinking about bisphosphonates and making sure that they're discussed in an M d. T. Because it's obviously quite catastrophic when it's very difficult to know what to do when people do have fractures, who are very near the end of their life and not being in the hospital and is preventable. I think that's everything I wanted to say. But if you have any questions, um, I'm very happy to answer them. Thank you so much for that EKG. That was absolutely fantastic. Um, also, if anyone, I find it really, really useful as enough to working in e. D. I think that's so many things to to go away and think about and then apply 22 clinical settings. Um, if anyone thinks of questions in the coming days or weeks that they don't think of right now. That's absolutely fine. I can, um, pass them across to Katie if you just put them in the Facebook group. Um, but Nicola does have a question. Um so Pamidronate think is on quite a lot of older guidelines, and it's not really available anywhere that I've. I've worked in probably four hospitals and in hospice in the last five years. It hasn't really been available or sort of on the formulary anywhere. So everywhere I've worked, it's sort of chronic acid. And then it's just a slightly reduced dose of people have poor renal function, and that's what I was used to and what's available. I think it may be on the formulary in some places, but I don't think there's a massive evidence of sort of superiority of either of them. I think there is. I can find it for you if you want. There is some evidence that some chronic acid is slightly better, and I yeah, I've never I don't know if anyone else got any thoughts on it, but I haven't seen permission. It it was sort of in the guidelines when I was in medical school, but I haven't actually seen it used, but I think it's probably quite just regional and to do with what your kind of formula is. Um, yeah. Anyway, thanks very much for listening everybody. And do you just if you got any questions or you want to discuss, just send an email. Thank you so much for speaking Katie and thank you. Who joined? I'm just gonna just post a link in the Oh, sorry. That's okay. I hope there's not a fire a link in the chat, which is for our next event, which will be next Thursday evening. Um, and we'll be having an event about advanced care planning. So it'd be great to have anyone there who wants to join. But for now, thank you all so much for being here and have a lovely rest of the evening. Thank you very much, Katie. Everyone