2. Palliative care emergencies Dr Claire Curtis Consultant in Palliative Medicine September 2010

3. Content Spinal cord compression Hypercalcaemia Bowel obstruction Haemorrhage Seizures

4. Spinal cord compression NICE guidelines Early detection At risk patients: Cancer and back pain – review frequently for progressive symptoms Known bone mets High risk of bone mets Give them information about possible symptoms and what to do

5. Spinal cord compression: early detection Symptoms suggestive of spinal mets: pain in the thoracic or cervical spine progressive lumbar spinal pain severe unremitting lumbar spinal pain spinal pain aggravated by straining localised spinal tenderness nocturnal spinal pain preventing sleep. Any of the above – contact oncologist within 24 hours

6. Spinal cord compression: early detection Neurological symptoms or signs suggestive of cord compression radicular pain limb weakness difficulty walking sensory loss bladder or bowel dysfunction signs of spinal cord or cauda equina compression. Emergency – immediate discussion with oncologists

7. Imaging MRI Within 1 week if symptoms suggestive of spinal mets Within 24 hours if SCC

8. Treatment - SCC Nurse flat until spinal and neurological stability known Dexamethasone 16mg od immediately Continue until surgery or start of RT Then gradually reduce over 5-7 days If neurological function deteriorates – temporarily increase dose again If not for surgery or RT – gradually reduce dose,

9. Treatment Take into account: patient preferences neurological ability functional status general health and fitness previous treatments Do not deny surgery or radiotherapy on the basis of age alone.

10. Hypercalcaemia of malignancy Common (10%) Squamous cell (esp lung) Breast Prostate Myeloma Treatable Untreated – distressing and fatal Poor prognosis – 3-4 months

11. Hypercalcaemia of malignancy Mechanisms: Humoral hypercalcaemia of malignancy: release of factors acting on skeleton to increase bone resorption and renal conservation of calcium eg PTHrP parathyroid hormone related protein. Osteolysis due to bone mets

12. Hypercalcaemia General Pain Weakness Dehydration Polydypsia Pruritus

13. Hypercalcaemia General Pain Weakness Dehydration Polydypsia Pruritus CVS Arrhythmias

14. Hypercalcaemia General Pain Weakness Dehydration Polydypsia Pruritus CVS Arrhythmias Neurological Fatigue Lethargy Confusion Seizures Psychosis

15. Hypercalcaemia General Pain Weakness Dehydration Polydypsia Pruritus CVS Arrhythmias Neurological Fatigue Lethargy Confusion Seizures Psychosis GI Anorexia Nausea Vomiting Constipation Ileus

16. Hypercalcaemia: treatment Correct dehydration with N saline. Leads to a small reduction in calcium due to dilutional effect and an improvement in symptoms. Rate of admin depends on severity of hypercalcaemia, degree of dehydration, ability of CV system to tolerate volume expansion. Clinical improvement over 24-48hours, but Ca rarely normalises and other treatment is needed.

17. Hypercalcaemia: treatment Bisphosphonates Potent inhibitors of bone resorption. Not metabolised, renal clearance. SE’s: Nephrotoxicity – precipitation of complexes in the kidney Transient febrile reaction Osteonecrosis of the jaw - rare

18. Bisphosphonates Pamidronate 2-4 hour infusion Variable dose often recommended (30-90mg) in practice most patients will need 90mg Zoledronic acid More potent – more effective 4mg over 15 min infusion – more convenient Reduce dose if renal impairment Guidance in BNF

19. Bisphosphonates Delay of 24-48 hours before begin to act Max effect 6 days Likely to recur in the future – need monitoring

20. Bowel obstruction Establish diagnosis: History Predisposition – abdominal malignancy/adhesions Symptoms – acute or more chronic Depends on level of obstruction Consider: Constipation – bowel history, AXR, pr motility disorder – exclude peritonitis, sepsis, SCC, anti-peristaltic drugs

21. Symptoms High proximal obstruction Severe, large volume vomits, quickly dehydrate, sucussion splash?, often no pain and no distension Small bowel obstruction Vomiting and distension, usually hyperactive bowel sounds with borborygmi, upper to central abdominal colic Large bowel obstruction Distension++, borborygmi, central to lower abdominal colic, vomiting a late feature

22. Terms Complete obstruction May be acute, complete onset of symptoms Partial/subacute obstruction More chronic onset of symptoms – may gradually worsen, be intermittent and obstructive episodes may resolve spontaneously Ileus/dysmotility Absent/reduced bowel sounds Faeculent vomiting Not faeces (unless gastro-colic fistula) – small bowel contents colonised by colonic bacteria in obstructions lasting >1 week

23. Bowel obstruction Surgery Possible of patient agrees and reasonable medical and nutritional condition Poor prognosis from surgery if Poor medical condition Previous abdominal RT Multiple blockages Abdominal masses or diffuse peritoneal disease Small bowel obstruction Rapidly recurring ascites

24. Manage at home? Lady in 50s, recurrent ovarian cancer, intra- abdominal disease, ascites. Previous admission to WRH 2 months ago with small bowel obstruction, not operable, resolved with medical management. Symptoms recur. Discussion with her and family. Decided not for admission. 84 year old man, IHD. Cancer of descending colon, liver mets at diagnosis, Increasingly jaundiced and frail. Symptoms of bowel obstruction. Discussed with him and family, decided not for hospital admission, managed at home.

25. Medical management All drugs via non-oral route – ensure absorption

26. Encourage resolution Trial of prokinetic May resolve partial upper GI obstruction Metoclopramide 80-160mg/24 hours Dexamethasone May help resolve peri-tumour oedema and open bowel 8mg sc daily – trial for 5 days

27. Bowel obstruction: nausea If obstruction not resolving, or colic develops control symptoms Nausea Cyclizine 150mg/24hrs +/- haloperidol 2.5-5mg/24 hours If persisting nausea replace with levomepromazine 12.5-25mg/24hrs

28. Bowel obstruction: vomiting Vomiting May continue to vomit throughout, particularly if continue oral intake (although will absorb from proximal GI tract) If troublesome, frequent, large volume try hyoscine butylbromide 80-160mg/24 hrs (will also help if colic) If persistent, add (or replace with) octroetide 250-750mcg/24hrs

29. Bowel obstruction NG tube – may be helpful in patients with high obstruction who continue to vomit profusely despite medication

30. Outcome 90% pain free Small proportion will continue to vomit once a day Mean survival from first onset of obstructive symptoms = 3.7 months but may survive 12 months or more

31. Catastrophic haemorrhage Very rare Death is pain free and often no time for fear Distressing to watch – HC proff and relatives PATIENTS POTENTIALLY AT RISK INCLUDE: Head and neck cancer Haematological malignancies Any cancer around a major artery Bone marrow failure where platelets < 15 Disseminated intravascular coagulation

32. Catastrophic haemorrhage Think: Might this patient be at risk? Robust Multi Disciplinary Team (MDT) assessment is recommended liaising closely with the diagnostic team to assess risk. Stop any therapy predisposing to haemorrhage eg aspirin, heparin or warfarin. If patient is assessed as HIGH RISK of haemorrhage PLAN AHEAD.

33. Catastrophic haemorrhage Who needs to be informed Patient/family/primary care team/ OOH provider/hospice/hospital Agreed care plan across boundaries Telephone numbers available for emergency assistance Plan for who will clean up afterwards and how to get hold of them

34. Catastrophic haemorrhage Equipment Needed (as close as is practical to the patient) Dark sheets. Dark towels (green, blue or multi- coloured). Gloves, aprons, wipes Plastic sheet or inco pad. Clinical waste disposal system (including clinical waste bags).

35. Catastrophic haemorrhage Stay calm, encourage carer to stay calm Priority is to stay with the patient and stem or disguise the bleeding with dark towels Crisis medication – in practice difficult to achieve at home (rarely time to prepare an injection or calmly measure a sublingual dose) If felt appropriate needs to be: Rapid in onset (2-5 mins). Kept close to the patient.

36. Catastrophic haemorrhage Midazolam 10mg im (deltoid quicker than gluteal) Buccal midazolam 10-15mg (depending on source of bleeding) Opioid – no evidence to suggest pain, but often given with midazolam – use 10mg im if opioid naïve or 2 x usual breakthrough dose Afterwards: Debriefing – all staff involved Support carers/relatives

37. Seizure Uncommon even in advanced malignancy and known cerebral mets Risk higher if: Recent decrease/cessation of steroid Signs of increased ICP Myoclonus or other twitching present History of poor control or recent seizures Previously needing >1 anticonvulsant to control seizure Tonic-clonic usually resolve < 1min

38. Major Seizure (tonic-clonic type) Put the patient into the standard recovery position. If the seizure does not resolve spontaneously after 1min, give: diazepam 5-10mg PR, or midazolam 5-10mg im or 2.5-5mg buccally. If the seizure is persisting, may need to repeat above Unless in terminal phase, if persisting, will need iv treatment with benzodiazepine and appropriate monitoring. Review the anticonvulsant medication.

39. Seizure in terminal phase Unable to manage oral anti-convulsants Half life of oral anticonvulsants >24 hrs so parenteral treatment can be started any time within 24hrs after last dose Syringe driver – midazolam usual dose 30- 60mg/24 hrs If seizures despite increased dose of midazolam – consider second syringe driver with phenobarbital 200-400mg /24 hrs

40. Summary Spinal cord compression Hypercalcaemia Bowel obstruction Haemorrhage Seizures