Palliative Care Emergencies

Transcription

1 Palliative Care Emergencies LAURA BARNFIELD What might constitute an emergency in Palliative Care? 1

2 Palliative Care Emergencies Major haemorrhage Metastatic Spinal Cord Compression (MSCC) Superior Vena Cava Obstruction (SVCO) Hypercalcaemia Not Cardiac Arrest Anaphylaxis 2

3 Major Haemorrhage Major Haemorrhage Which patients might be at risk? Head and neck cancers GI tract cancers Lung cancer Any cancer encroaching on vessels Any patient with clotting problems 3

4 Major Haemorrhage (cont.) How might we manage this? Non-medical Planning ahead with patient and family Dark towels Stay with patient Keep them calm and warm Support patient and family Medical 5-10mg Midazolam SC, repeated as necessary Metastatic Spinal Cord Compression (MSCC) 4

5 MSCC Metastatic deposits push on the spinal cord, leading to neurological compromise at and below the area affected Can be a first presentation of cancer 5-10% of all cancer patients affected (4000 cases/year in England and Wales) Most common cancers to cause spinal metastases are: Prostate Lung Breast Myeloma MSCC symptoms Can be vague off legs Back pain often band-like, progressive and/or unremitting, worse on coughing/straining, nocturnal Weakness of limbs Tingling/numbness or feeling that legs don t belong to them Difficulty passing urine, faecal incontinence LATE SIGNS Consider in any patient with previous or current cancer and those with no known diagnosis 5

6 MSCC signs Localised tenderness to spine Weakness Altered sensation sensory level Reflexes can be absent or increased, extensor plantars, clonus Examine upper and lower limbs when assessing for MSCC MSCC management Consider immobilisation (lie flat, log rolling and spinal board for transfer) if concerns instability Discussion with Christie Hotline Urgent MRI whole spine Steroids high dose Dexamethasone 16mg daily start immediately if high index suspicion (check blood sugars) Surgery Radiotherapy 6

7 and documented throughout pathway 21/02/2017 All at risk patients Receive Patient Information leaflet: Spinal Cord Compression What You need to know MSCC Pathway Greater Manchester Cancer Services (part of Manchester Cancer) A&E, hospice and Community Nurse suspects MSCC Informs GP/OOH GP suspects MSCC Informs AHP / CNS suspect MSCC secondary care (possibly patient with no previous cancer diagnosis) Agrees Contact MSCC Co-ordinator (in hours) or Christie Hotline for advice Low level of suspicion: GP to review. If symptoms persist, discuss with Oncology team for possible imaging within 7 days (see Impending Pathway). Ensure adequate pain management Arrange urgent admission Low level of suspicion: Definite MSCC signs for assessment via A&E or MAU GP to review. If symptoms (local arrangements apply, persist, discuss with Uncertain MSCC signs transfer patient flat and log roll) Oncology team for possible imaging within 7 days (see Impending Pathway). Ensure adequate pain management MSCC likely Urgent MR scan within 24 hrs in Inform GP / responsible team. patient s local hospital. If symptoms persist or Commence 16 mg Dxm + PPI worsen review patient urgently (see pathway document on MSCC webpage) Christie patients Patient flat and log roll with high suspicion of MSCC (Inform Acute Oncology team) Refer to local Rehab team / AHP lead Referring clinician informs MSCC MR scan No Co-ordinator. AO team liaise with GP, local Medical or Oncology Patient Information given: Spinal Cord Compression: What it means and confirms MSCC Yes team. If symptoms worsen review patient urgently (see Impending Pathway) how it can be treated Urgent clinical triage takes place by the Network MSCC Co-ordinator (9-5), Christie Hotline (out of hours) in discussion with the on-call Clinical Oncology Specialty Trainee (SpR) Telephone number: (Bleep for internal Christie referrals) MSCC 7

8 MSCC aims of management Maximisation of recovery of neurological function if unable to walk at time of diagnosis 67% recover no function at 1 month, if able to walk at diagnosis 81% can still walk at 1 month Pain control Tumour control Improve stability of spine Good nursing care Pressure area care Psychological support Bladder/bowel management Superior Vena Cava Obstruction (SVCO) 8

9 SVCO Compression of superior vena cava due to tumour or nodes in mediastinum Common with lung cancer, possible with lymphoma SVCO Symptoms Swelling of face, neck, arms Headache Dizziness Breathlessness Prominent dilated veins to neck and arms Hoarse voice Stridor Management Sit up Oxygen High dose steroids (Dexamethasone 16mg daily) Discussion with oncology?radiotherapy, chemotherapy or stent 9

10 SVCO Hypercalcaemia 10

11 Hypercalcaemia Raised calcium in bloodstream Common in cancer (10-20% patients) traditionally if bony metastases, but can occur without bone disease Can develop over time or rapidly symptoms often dependent on rate of rise Used to be a terminal event Hypercalcaemia symptoms Bones, abdominal moans and psychic groans General Dehydration Polydipsia Polyuria Pruritus Malaise Arrythmias/conduction defects Gastrointestinal Anorexia Weight loss Nausea Vomiting Constipation Ileus Neurological Fatigue Confusion Myopathy Hyporeflexia Seizures Psychosis Coma 11

12 Hypercalcaemia management Check bloods Ca, U&Es Review medications for any that impact on renal function or calcium/vit D supplements Correct dehydration IV bisphosphonates- dose according to calcium level Recheck 5-10 days Likely to recur within 2-4 weeks make a plan for longer-term management Summary Major Haemorrhage MSCC SVCO Hypercalcaemia If concerns please flag them up! 12

13 Questions? References Palliativedrugs.com Pain and Symptom Control Guidelines, Greater Manchester & Cheshire Cancer Network November 2013 Christie.nhs.uk MSCC guidance Palliative Care MRCPuk.org NICE CKS Hypercalcaemia December 2014 Metastatic spinal cord compression in adults: diagnosis and management, NICE 2008 Macmillan.org.uk Cancerresearchuk.org 13