Palliative Care (PC) Emergencies

Dr. Weru K.J

16/07/2020
 Objectives
• Introduction
• Discussion
• What is an emergency?
• Name examples in PC
 General Principles- APAC
• Anticipate • Avoid
– Who is at risk? – Correct the
correctable
– Prophylaxis
• Plan
– Communication
– Share plan with • Consider
patient &family recurrence
– Preparation
– MDT approach
 Potential Goals in Treating PC
Emergencies
• Improved quality of life
• Improvement in function
• Decrease in symptoms
• Prolongation of life

• Less complicated bereavement

C. Woelk MD
Major emergencies in palliative care

• Hypercalcaemia

• Superior venal cava obstruction

• Spinal cord compression

• Hemorrhage
 Hypercalcemia

• Commonest PC emergency

• Corrected Ca < 2.6 mmol/L

• Symptomatic > 3.0 mmol/L

• Death in few days > 4.0 mmol/L

 Hypercalcemia

• 20% – 40% of all cancer patients.

• Breast, lung (Non Small Cell Ca),
Haematological, Squamous cell Ca
• Metastasis (20%) - 2° to osteolysis
releasing Ca++
• Hormones (80%) - PTH, PGL, peptides
- Renal tubules
 Hypercalcaemia

• Diagnosis
• Check renal function and corrected
calcium( need to know albumin
concentration)

• Corrected ca = measured Ca+(40-

albmumin)x0.02
 Clinical signs of
Hypercalcaemia
• Lethargy, Weakness
• Nausea, Polyuria, Polydypsia,
Constipation
• Dehydration, confusion, drowsiness
• Neurological deficits, Coma
• Cardiac arrhythmias
 Treatment of Hypercalcaemia

• Review with patient and family

• Hydration oral and IV
• Biphosphonates
• Calcitonin
• Loop Diuretics
• Steroids
• Recheck in 3-4 Days
 Hypercalcaemia

• Prognosis
– Hypercalcaemia is a sign of tumour
progression
– Survival is less than 3 months with treatment
– Calcium level >4 leads to renal failure, cardiac
arrhythmias and fits
 Prevention of Recurrence

• Consider disease modifying treatments

• Consider maintenance treatment
• Monitor at 3 weekly intervals or when
symptomatic
Spinal Cord Compression
 Spinal Cord Compression

• Compression of
Vasculature

• Direct
Compression
– Vertebral Mets
– Paraspinal
mass
 Spinal Cord Compression

• Is the 2nd most common neurological

complication of cancer
• 5-10% of all patients who die of
cancer
• Thoracic spine is most often affected
(70%)
• Can be multilevel
 Causes of Spinal Cord Compression-
cancers
• Prostate
• Breast
• Lung
• Myeloma
• Kidney
• Melanoma
Symptoms of Spinal Cord Compression
• BACK PAIN (90%)
(worse with movement, cough, straining, neck flexion
and lying down), band of pain encircling the body

• Paresthesias (50%)
• Urinary retention/ incontinence
• Loss of bowel function
• Weakness (75%)
• Stiffness, numbness– distal- proximal
• Peri-anal numbness
 Assessment of Spinal Cord
Compression
• Tender spine
• Sensory level
• Weakness of extremities
• Hyperreflexia
• Decreased sphincter tone on rectal exam
 Management of Spinal Cord
Compression
• TIME
– Risk of neurological damage is reduced by fast
diagnosis and management
– Delay reduces mobility – QOL
• 70% have substantial weakness by the time of
scanning
• 70% maintain mobility after treatment
• 35% with weakness regain mobility, but only 5%
of complete paraplegics
 Goal of Therapy for Spinal Cord
Compression

• To preserve neurological function

• To control local tumour growth
• To maintain spinal stability
• To control pain
 Management of SCC
• Steroids eg dexamethasone
• Radiotherapy
• Surgery and radiotherapy ( spinal
instability such as fracture)
• Chemotherapy
 Superior Vena Cava Syndrome

 The clinical manifestation: Venous

obstruction, with severe reduction
in venous return from the head,
neck and upper extremities

C. Woelk MD
Superior Venacaval Syndrome

.
Superior Venacaval Syndrome

• Extrinsic tumour or
Node
• Direct Invasion
• Intraluminal
Thrombus
– Complication of
Central Line
 Who is at risk

• Mostly tumours / nodes within the

mediastinum
• 75% primary bronchial carcinomas
• Lymphoma
• Seminoma
• Metastatic breast cancer
• Occurs in 3% of thoses with ca bronchus
 Clinical Effects of Superior
Venacaval Syndrome
Early:
• Periorbital oedema, facial swelling. All more obvious in the
morning and if patient bent over
• Cough, Dyspnoea, Dysphagia, Chest pain
Later:
• Engorged neck and chest veins, Plethora
• Upper extremity oedema
• Tachypnoea, Cyanosis
Severe:
• Headache, blurred vision, altered mental status, seizure.
 Superior Vena Cava Syndrome
Presentation
• Signs:
– Venous distension of neck 66%
– Venous distension of chest wall 54%
– Facial edema 46%
– Cyanosis 20%
– Edema of the arms 14%
– Plethora of the face 10%
– Vocal cord paralysis 3%

C. Woelk MD
 Superior Vena Cava Syndrome
Management
• Does not usually imply immediate threat to
life, except when trachea or pericardium is
compromised
• Important to establish a diagnosis
• Emergency treatment indicated if:
– Compromised airway
– Decreased cardiac output
– Cerebral dysfunction
C. Woelk MD
 Management

• Steroids
• Raise the head of the bed
• Diuretics
• Radiotherapy
• Chemotherapy
• Intravascular expandable stents
• Thrombolysis
• Symptomatic treatment of SOB
 Take home message
• Emergencies happen, even in dying individuals

• Emergencies ARE treated differently in the PC

settings, with emphasis on symptom management
than at reversing the disease process

• Communication with the patient and family is

extremely important

• MDT approach is key

C. Woelk MD