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Palliative Care Emergencies. Wesam S. Aziz, MD 11/5/13. Overview. Pain Crisis Respiratory Crisis Massive Hemorrhage Uncontrolled Hiccups Hypercalcemia Drug Toxicity. Seizures Tumor Lysis Syndrome SVC Obstruction SC Compression Fecal Obstruction Others. Goals. Definition - PowerPoint PPT Presentation
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Palliative Care Emergencies
Wesam S. Aziz, MD11/5/13
OverviewPain CrisisRespiratory CrisisMassive HemorrhageUncontrolled HiccupsHypercalcemiaDrug Toxicity
SeizuresTumor Lysis
SyndromeSVC ObstructionSC CompressionFecal ObstructionOthers
GoalsDefinitionRecognitionPreventionApproach
Non-Pharm TxPharm Tx
Acute Pain CrisisDefinition: Episodes of acute pain either new
or flare of underlying chronic pain.Recognition: Pain not controlled; patient’s
vocalization, vital signs (VS), grimacing, body posturing, pain scales
Prevention: Educating caregivers, nursing, and staff to recognize pain. Treat sooner than later. Anticipate pain and types of pain as disease progresses and patient nears end-of-life (EOL).
Acute Pain CrisisApproach
First and Foremost: rapidly titrate opioids to effect; increase dose by 50-100% Q2H, best achieved by short acting IV such as morphine,
PCA if possibleConsider: Corticosteroids (i.e.
Dexamethasone) Other:
NSAIDs or acetaminophen, Severe Neuropathic Pain: IV lidocaine 0.5mg/kg over
30 min, dose can be doubled every few hours. Interventional Pain: intrathecal or epidural catheters
Palliative Sedation (Meds)Consider proportional palliative sedation
(PPS)Midazolam (SC, IV): 5 mg bolus, 1 mg/hrLorazepam (SC, IV): 2-5 mg bolus, 0.5-1.0 mg/hr Thiopental (IV): 5-7 mg/kg/hr bolus, then 20-80
mg/hr Pentobarbital (IV): 1-3 mg/kg bolus, 1 mg/kg/hr Phenobarbital (IV, SC): 200 mg bolus (can repeat
q10-15 min), then 25 mg/hr Propofol (IV): 20-50 mg bolus (may repeat), 5-10
mg/hr Ketamine (IV) 1-4 mg/kg bolus, 0.1-0.5 mg/min
Respiratory CrisisDefinition:
Dyspnea: A complex, uncomfortable sensation that includes air hunger, increased work/effort of breathing, and chest tightness
Like pain; a subjective sensation, can be very disturbing for patient and caregivers
PreventionRecognizing underlying co-morbidities, and
anticipating potential outcomes
Respiratory CrisisRecognition: BREATH AIR mnemonic
B: BronchospasmR: RalesE: EffusionsA: Airway Obstruction/AspirationT: Thick SecretionsH: Hemoglobin (low)
A: AnxietyI: Interpersonal IssuesR: Religious Concerns
Respiratory CrisisApproach
Non-Pharm Tx:Oxygen (especially if hypoxic), Fan
Pharm Tx:Opioids, opioids, opioidsAnxiolyticsPPS
Massive HemorrhageDefinition:
Catastrophic exsanguination. Can occurs when tumors erode into adjacent vessels. Underlying medical conditions or medications
thrombocytopenia, coagulopathy, ASA or warfarin tx.
Recognition: Gross Bleeding, acute changes in VS ie.) tachycardia, tachypnea
Prevention: reversal of underlying condition or stopping potential medications that can cause bleeding. Educate family and caregivers.
Massive Hemorrhage Approach
EOL patient’s: utilize dark sheets and towels, reposition patient, recovery position Palliative Patient’s: give back lost bloodReverse cause of bleeding: FFP, vit K, plts
First line compression, can use cold (such as ice water)
Hemoptysis: Aerosolized Vasopressin, embolization, bronchoscopy
Uremic Bleeding: DDAVP (desmopression) SC/IV/Nasal
Thrombocytopenia: Aminocaproic acid (plasmin inhibitor) IV/PO
GI bleed: Endoscopy, sclerotherapy, embolization
HemorrhageBleeding gums:
Transenic Acid (anti-fibrinogen) SprayThrombin SprayAminocaproic acid
Uncontrolled HiccupsDefinition: (singultus) Involuntary reflex involving the
respiratory muscles of the chest and diaphragm, mediated by the phrenic (C3-C5) and vagus (CN X) nerves basically diaphragm contracts and pushes air up
through closed larynx. Recognition: “I know it when I see it” – Supreme
Court Justice Potter Stewart. Once hiccups have lasted to annoyance, intervention may be appropriate
Prevention: treatment of underlying cause ie.) medications, infection
Uncontrolled HiccupsApproach
Non-Pharm Txgargling with water, biting a lemon,
swallowing sugar, vagal stimulation such as carotid massage or
valsalva maneuver Rubbing over the 5th cervical vertebrae
(interrupting phrenic n.)interrupting the respiratory cycle through
sneezing, coughing, breath holding, hyperventilation, or breathing into a paper bag
Uncontrolled HiccupsPharm TxAnti-Psychotics
Chlorpromazine – the only FDA approved drug for hiccups.
Haloperidol – useful alternative to chlorpromazine; Anti-Convulsants
OtherGabapentin, Phenytoin, Carbamazapine, Valproic Acid
MiscellaneousBaclofen – the only drug studied in a double blind
randomized controlled study for treatment of hiccupsMetoclopramide Nifedipine - a relatively safe alternative if other
interventions have failed.
HypercalcemiaDefinition: Elevated calcium,
11-12 mg/dL Mild 12-14 mg/dl moderate >14 mg/dl severe
10-20% of cancer patients most common in NSCLC, Beast Ca, H&N Ca, RCC, MM, T-Cell Lymphoma;
80% caused by PTH-Like Peptide released by cancer or Bone destruction caused by metastatic disease
Prevention: Treating underlying causes
HypercalcemiaRecognition:
Mnemonic: Groans (constipation), Moans (fatigue, lethargy, nausea), Bones (bone pain), stones (kidney), and Psychiatric overtones (confusion, depression)
Caution: Can be falsely lowhypoalbuminemia can mask hypercalcemia,
measured calcium is the calcium bound to albumin,
HypercalcemiaApproach
Non-Pharm Tx: Volume expansion to increase calcium excretionEliminate extra sources of calcium
Pharm TxLoop diuretic: inhibits resorption of calcium at
loop of henleBiphosphonates: Mainstay therapy, takes 2-4
days to work, risk of BONJ – high incidence with IV formulation vs. low incidence with PO
Calcitonin: given acutely because, short lasting
Drug ToxicityMorphine Myoclonus - uncontrollable muscle
spasms, dose-related effect of opioids, associated with somnolence and AMSTX - change to another analgesic, can use
intermediate/short-acting BZD such as clonazapam or lorazapam
Opioid-Induced Hyperanalgesia – patient’s receiving opioids may actually become more sensitive to certain painful stimuli and may experience pain from ordinarily non-painful stimuli (allodynia)
SeizuresDefinition:
Most often occur in patients with cerebral or leptomeningeal malignancies, cerebrovascular diseases, and electrolyte abnormalities (ie. hyponatremia, hypercalcemia)
Recognition: Acute mental status changes, partial or generalized tonic/clonic movements, maybe incontinence (urinary/fecal). Most challenging to recognize is NCSE (Non-Convulsive
Status Epilepticus)Prevention
In patients with advanced brain tumors AAN (American Association of Neurology) does not recommend prophylactic use of anti-epileptic drugs
SeizuresApproach
Non-PharmPlace in recovery positionRemove objects that may cause injury
Pharm TxStatus Epilepticus
1st Line: BZD & Phenytoin2nd Line: replace phenytoin with valproic acid or
barbiturate 3rd Line: Levetiracetem (levels more consistent, don’t
need to monitor levels, and less drug/drug interactions)
Tumor Lysis Syndrome (TLS)Definition - an oncologic emergency caused by massive
tumor cell lysis with the release of large amounts of potassium, phosphate, and nucleic acids into blood steam
Recognition – Patient’s recently started on chemotherapy: nausea, vomiting, diarrhea, anorexia, lethargy, heart failure, cardiac dysrhythmias, seizures, muscle cramps, tetany, and possible sudden death
Prevention – Anticipate in patients with Rapidly growing tumors Chemosensitivity of the malignancy Large tumor burden
Tumor Lysis Syndrome (TLS)Approach is prevention
Aggressive IV fluids – 2 to 3 L daily to achieve a urine output of at least 80 to 100 mL/m2 per hour.
Allopurinol – decreases the formation of new uric acid
Rasburicase – alternative to allopurinol, useful in patients who are currently hyperuricemic.
SVC (Superior Vena Cava) ObstructionDefinition: Obstruction of SVC (upper right
mediastinum) caused by primary or metastatic dz
Recognition: Facial plethora, facial and/or upper extremity edema, dilated vessels of the chest/neck/arms, patient can experience cough, hoarseness, headachePrevention: Treat underlying causes
SVC ObstructionApproach
Non-Pharm TxConsider XRT, Sx, or endovascular
techniques when tumor not chemosensitive
Pharm TxSteroidsChemotherapy: especially with lymphomas
SC CompressionDefinition: Compression of Spinal Cord (SC) putting patients
at risk for pain, paresis or paralysis, incontinenceRecognition: PB KTL (lead kettle) – cancers that metastasize
to bone P: Prostate B: Breast K: Kidney T: Thyroid L: LungSIGNS: Red-Flags New, progressively severe back pain (particularly thoracic) presenting as (burning, shooting, numbness), saddle paresthesia
Bowel or bladder disturbance - loss of sphincter control is a late sign with a poor prognosis.
SC CompressionApproach
Non-Pharm TxXRTSurgical decompression
Pharm TxSteroids: DexamethasoneOpioids – pain control
Severe Constipation/Fecal ObstructionDefinition: A fecal impaction is a solid, immobile
bulk of feces that can develop in rectum or colon as a result of chronic constipation.
Opioid induced constipation: side-effect that one does not grow tolerance to, opioids decrease gastic and intestinal motility, via mu-receptors.
Recognition: “need to ask” “when was your last BM?”No BM after conventional methods of stimulants and softenersRectal exam reveal solid mass in rectumImaging studies may reveal constipation more proximal
Severe Constipation/Fecal ObstructionPrevention:
Water, water, waterFiber & foods high in fiberStool SoftenersStimulantsLaxatives
Severe Constipation/Fecal ObstructionApproach:
Non-Pharm Water Fiber
Pharm Titrate up softeners and stimulants Add Laxative Retention enemas Methlynaltrexone, selectively antagonized peripheral
mu-opioid receptors, inhibiting opioid-induced hypomotility. Weight based, given SQ, pt must not be obstructed, risk of perforation.
Other ProblemsObstructive nephropathy
FoleyCardiac tamponade Febrile neutropenia Hyper viscosity Syndrome
Plasma exchange Increased intracranial pressure
Diuretics, acetazolamide, surgical decompression/shuntHypoglycemia
IV Fluids, Insulin
Referenceshttp://www.eperc.mcw.edu/EPERC/FastFactsandCo
nceptsUp To DateUNIPAC 4th edition