PALLIATIVE EMERGENCIES

MODERATOR – DR NISHKARSH
SPEAKER - DR PUNEET
 Emergencies
Most Medical Specialities Palliative Care

If left untreated, immediate If left untreated, seriously

threat to life threaten the QoL

Aim: Sustenance of life Aim: Relief of suffering

Arise: Arise: Usually expectedly

Expected/Unexpected
 Patient Centred Approach

Nature of Emergency Situation

Patient & Family
Factors Treatment Factors
Disease Factors
General Physical Condition Availability & Cost Issues
Stage
Co-morbidities & Effectiveness
Prognosis
Symptoms Expected Toxicity
Patient’s Decision
Questions to consider in patients with
advanced disease

What
Can
Should it is
it the
be reversed
always problem? ?
be reversed?
Emergency situations seldom arise unexpectedly. It is
therefore possible and
important to

have a high index of diagnostic suspicion

have a plan in place that either prevents them, or

institutes prompt intervention;
and

share this plan with patient and family.

 Palliative emergency??
Cardiovascular

neurological Hematalogical

Due to
metabolic cancer or infectious
its
treatment

requires immediate intervention to prevent

loss of life or quality of life
 Common conditions to be discussed :

o Superior Vena Cava Obstruction;

o Haemorrhage;
o Hypercalcaemia;
o Spinal Cord Compression;
o Seizures.
 Case 1
• A 64 year old women
presents with a 2 week
history of progressive
dyspnea on exertion,neck
swelling,decreased appetite
and fatigue.
• Smoker until 5 years ago.
• O/E-HR- 105/min and RR-
20/min.
• Superficial vascular
distention over neck, chest,
and upper limb.
• How to evaluate and
manage?
 SVC

SUPERIOR VENA CAVA

OBSTRUCTION.
 SVC Obstruction: Etiology
• May be due to:

External compression

Intraluminal tumor

Vessel Wall invasion

SVC Obstruction: Etiology
 Symptoms:

Markman M. Diagnosis and management of superior vena

cava syndrome. Cleve Clin J Med 1999; 66:59.
Signs
Pemberton’s sign
• Pt is asked to raise hands.
• facial congestion and cyanosis, as well as respiratory distress after
approximately one minute. POSITIVE,
• Demonstrate the presence of latent pressure in the thoracic inlet. 
 INVESTIGATIONS:

X ray
CECT chest venography

HISTOLOGICAL
Helical CT MRI
DIAGNOSIS
 XRAY

• Most have abnormal x ray

• superior mediastinal widening and right hilar prominence -mediastinal

mass.
Parish JM, Marschke RF Jr, Dines DE, Lee RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981;
56:407 .
 CT chest

• Preferred choice

• IV contrast
– defines the level of obstruction
– Maps out collateral pathways.
– Can identify underlying cause of obstruction
• Eren S, Karaman A, Okur A. The superior vena cava syndrome caused by malignant disease.
Imaging with multidetector row CT. Eur J Radiol 2006; 59:93.
 Management
• Prognosis is poor unless the primary tumor is
responsive to radiotherapy or chemotherapy.
 General principles
• Goal is to alleviate symptoms
• average life expectancy is approximately 6
months but for some patient with treatment
of uderlying cause can give lrelapse free
survival and cure
• 0
 Urgency of diagnosis and treatment

• patients who present with life-threatening

symptoms (central airway obstruction, severe
laryngeal edema, coma from cerebral edema
• -- secure ABS
• immediate endovascular recanalization with
SVC stent placement
In the past, it was thought that immediate RT was the quickest way
to relieve obstruction in potentially life-threatening malignant SVC
syndrome. However, immediate RT is no longer considered the best
option for most patients for the following reasons:

1.Endovascular recanalization with or without stenting is a

faster way to relieve symptoms compared with RT,
particularly for patients with life-threatening symptoms.

2.RT given prior to biopsy may obscure the histologic diagnosis

3.If RT is needed, it can be deferred until after severe

symptoms have been relieved through endovascular
techniques, and a biopsy is secured.
Supportive care and medical management
• When thrombus is present, systemic anticoagulation is
generally recommended to limit thrombus extension (in
the absence of contraindications) until definitive treatment
can be undertaken
• For patients who have obstruction of the SVC resulting
from intravascular thrombus associated with an indwelling
catheter, removal of the catheter may be indicated in
conjunction with systemic anticoagulation
• the head should remain elevated (the higher the better, as
tolerated) to decrease hydrostatic pressure and head and
neck edema.
 Glucocorticoids
• There are two settings in which systemic administration of glucocorticoids may be
helpful:

• ●For patients receiving RT on an emergency basis for severe airway obstruction

that is not amenable to stenting, we suggest a short course of high-dose
corticosteroids to minimize the risk of central airway obstruction secondary to
edema. Although glucocorticoids are commonly prescribed in this setting, their
efficacy has never been formally studied, and there are only case reports to
suggest benefit.

• ●Glucocorticoids can be effective in reversing symptomatic SVC syndrome caused

by steroid-responsive malignancies, such as lymphoma or thymoma. However, if a
suspected diagnosis of lymphoma has not yet been histologically confirmed, use
of glucocorticoids is not advisable, as they are lympholytic and may obscure the
diagnosis.
 Diuretics and hydration
• overhydration of the patient should be avoided if
possible. Diuretics can be used, as needed, but not
at the expense of intravascular volume depletion.
However, it is unclear whether venous pressures
distal to the obstruction are affected by small
changes in right atrial pressure [5]. In a
retrospective series of 107 patients with SVC
syndrome from a variety of causes, the rate of
clinical improvement was similar among patients
receiving glucocorticoids, diuretics, or both
Patients without life-threatening symptoms
• The placement of an endovenous stent restores venous return and provides rapid and
sustained symptom palliation in patients with malignant SVC syndrome even in the
absence of life-threatening symptoms. An endovenous stent is particularly appropriate
for rapid symptom palliation in patients with tumors for which response to
chemotherapy and/or RT is intermediate or poor (ie, NSCLC and pleural
mesothelioma), and for those with recurrent SVC syndrome who have previously
received systemic therapy or RT
• For patients with chemotherapy-sensitive malignancies such as small cell lung cancer
(SCLC) [54], non-Hodgkin lymphoma (NHL), or germ cell cancer (and possibly breast
cancer), initial chemotherapy is the treatment of choice for patients with symptomatic
SVC syndrome. The clinical response to chemotherapy alone is usually rapid, and these
patients can often achieve long-term remission and durable palliation with standard
treatment regimens
• RT is widely advocated for SVC syndrome caused by radiosensitive tumors in patients
with other less-chemotherapy-sensitive malignancies who have not been previously
irradiated.
 Management
• Prognosis is poor unless the primary tumor is responsive to radiotherapy or chemotherapy.

Tissue biopsy is must

• Up to 60% of patients with SVC syndrome related to neoplasm do not have a known diagnosis
of cancer
– Need a tissue biopsy for histologic studies
Radiotherapy Treatment
chemotherapy

modalities
surgery
Drugs
There is a need of simultaneous palliative
care:

Radiotherapy chemotherapy

modalitie
s

Drugs surgery

Lynn D. Wilson et al. Superior Vena Cava Syndrome with Malignant Causes. N Engl J
Med 2007;356:1862-9.
 management

Superior vena cava syndromea proposed classification system and algorithm for management. J Thorac
Oncol 2008; 3:811. Copyright © 2008 Lippincott Williams & Wilkins.
Review of evolving etiologies, implications and treatment strategies for the superior
vena cava syndrome. Straka et al. SpringerPlus (2016) 5:229
 General Principles.
• Upright sitting position
• Oxygen trial – family or patient anxious or requesting.

• Maintain calmness/ anxiety – low dose MORPHINE / midazolam

• Dexamethasone 16 mg IV stat followed by 8 mg IV BD (stop if no

improvement in 5 days or gradual tapering in those beneficial).
• FUROSEMIDE 40mg PO or IV ,then as needed

National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology.
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
 Exceptions: true medical emergencies
In most ,Malignancy SVC syndrome NOT A potentially life
threatening medical emergency requiring immediate
radiation therapy (RT).
use of
Emergency RT is Histologic
endovenous
no longer diagnosis prior
stents in
considered to starting
emergency.
necessary for therapy .
most patients. Better than
IMPORTANT
prebiopsy RT

National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in

oncologyhttp://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on
February 27, 2016).
Treatment recommendations

Stridor severe laryngeal edema

Require both endovenous

with depressed central stenting and emergent RT
nervous system status to decrease the risk of
from cerebral edema. sudden respiratory failure
and death

National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in

oncologyhttp://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27,
2016).
 • relieve symptoms and treat the underlying cause
AIM

• For patients receiving RT on an emergency basis for severe airway

obstruction, we suggest a short course of highdose corticosteroids
EMERGENCY to minimize the risk of central airway obstruction.
RT

• if the imaging studies are consistent with a malignancy, a histologic

EVEN IF diagnosis is required prior to initiating specific antitumor therapy.
MALIGNANT
 • malignancy (small cell lung
cancer[SCLC],
CHEMOTHERAPY • nonHodgkin lymphoma [NHL],
• germ cell tumor, and
• breast cancer.

ENDOVENOUS •
STENT + early New diagnosed NSCLC
RT
 Surgery
+ • Thymoma
• Residual germ cell
pre op chemo

PALLIATIVE RT
• Previously treated
+/- STENTING +
• Recurrent/ progressive
BEST
state
SUPPORTIVE
CARE
 Intra luminal stents
Systemic
anticoagulation. • SVC
+ 3months of
(Clopidogrel + thrombosis
aspirin)

Catheter directed
thrombolysis +
• Extensive SVC
mechanical
thrombectomy thrombosis
 2.Hypercalcemia
Most common life threatening metabolic disorder.

Often missed or mismanaged .

When undiagnosed or untreated cause affects QOL

Treat when DISTRESSING / chance of IMOROVEMENT

DON’T TREAT during TERMINAL STAGE

Pathogenesis
 INCIDENCE
•20-30% of malignancy

Under fluroscopy

Recurrent / previously
irratiated

Chemo refractory.
Too ill to tolerate RT/CT
 Serum calcium levels:
Always ask for corrected serum calcium level in a
patient with delirium.

An index of suspicion should be high.

Clinical judgment is required to decide whether

to treat or not.
• Corrected ca above 3.0 mmol/l is symptomatic
and thus treated.
• Normal 2.10 – 2.55 mmol/l
• Corrected ca(mmol/l)=measured ca+ 0.22 x (40-
Albumin).
• ECG- bradycardia, prolonged PR, short QT, wide t
waves and arrythmias.
• Treat when distressing.
• 80% patients survive less than a year.
Symptoms of hypercalcemia:
 Management
Clinical judgment based on :

Multiple myeloma & breast

cancer - 40-50%

Non small cell

ca of lung(sqa)
colo
rect
al
 Things to remember:
• Raised serum Ca is not an absolute indicator
to treat.
• In terminal stages where no active treatment
of primary disease, it may impose unnecessary
burden instead of benefits.

• Symptoms management better in such stages.

 General measures:
• Stop NSAIDS / thiazide Diuretics that reduce
Ca excretion.
• Re hydrate with I.V saline 0.9%. 3-4 L over 24
hrs for 2 days and then 2-3 L /24 hrs along
with k+ supplements.
• Saline reduces serum Ca by 0.2-0.4 mmmol/L.
 Recent recommendations
expected
symptoms
relief

expected
survival

Maier JD, Levine SN. Hypercalcemia in the Intensive Care Unit: A Review of Pathophysiology, Diagnosis, and
Modern Therapy. J Intensive Care Med 2015; 30:235.
 Recent recommendations
Patients with asymptomatic or mildly
symptomatic hypercalcemia (calcium <12 mg/dL
[3 mmol/L])
-thiazide diuretic
and lithium
carbonate therapy,
Do not require Avoid factors that -volume depletion,
immediate can aggravate -prolonged bed rest
treatment. hypercalcemia, or inactivity, and
-a high calcium diet
(>1000 mg/day).
 Recent recommendations
Asymptomatic or mildly symptomatic individuals with
chronic moderate hypercalcemia (calcium between 12
and 14 mg/dL [3 to 3.5 mmol/L])

Acute which requires

not require gastrointestinal treatment as
immediate side effects and described for
therapy. changes in severe
sensorium,. hypercalcemia

Maier JD, Levine SN. Hypercalcemia in the Intensive Care Unit: A Review of
Pathophysiology, Diagnosis, and Modern Therapy. J Intensive Care Med 2015; 30:235.
 immediate short term
Longer term control of hypercalcemi
management of hypercalcemia
in patients with more severe (calcium
>14 mg/dL) or symptomatic
hypercalcemia
• calcitonin (in addition to
saline hydration) only in • excessive bone resorption ..
patients with calcium >14 addition of a
mg/dL (3.5 mmol/L) who bisphosphonate rather than
are also symptomatic denosumab
 SPECIFIC MEASURES
BISPHOSPHONATES: only after
hydration. 4-8 mg over 15 minutes.
•Zoledronic acid (Zometta) 60 – 90 mg over 2 hours.
•Pamidronate (Lower dose in renal disease)/
osteonecrosis Of jaw.

Steroids Hydrocortiosne 100mg/ 6hrly.

In lymphomas Prednisolone 60mg orally
daily.
Furosemide 20-40mg / 12-24 hrly
Only after adequate hydration.
Calcitonin 4-8 IU/kg sc or iv every 12
Opp PTH hrly.
Tachyphylaxis +
.refractory to ZA
Denosumab .severe renal dysfunction
Haemorrhage
 Haemorrhage
• Clinically significant: 6-10%.

Patients with more severe (calcium >14 mg/dL

[3.5 mmol/L]) or symptomatic hypercalcemia

maintain the
administration of urine output at
dehydrated and
isotonic saline at 100 to 150
require saline
an initial rate of mL/hour
hydration as
200 to 300
initial therapy. Loop diuretics t
mL/hour
prevent overloa
 Etiology

Patient

• DISTRESSING
Family • SIGN OF
DEATH

Nursing
staff
 MANAGEMENT
Coagulopathy
Tumor Related Treatment Related
Related
• Head & Neck Ca, • Mucosal Damage: • Marrow Failure
Erosion of Major NSAIDs, Steroids • Thrombo-embolic
Artery • Chemotherapy - phenomenon: DIC
• Lung Ca: induced • Complications of
Hemoptysis thrombocytopenia Anticoagulation
• GI:
Haematemesis,
Melaena
• Uro: Haematuria,
Clot Retention
EARLY..........
• rate and the site of bleeding.
DEPEND

• catastrophic bleed is usually a

DECIDE event and resuscitation is futile

• reducing the stress, reassuran

GOAL explanation
 Identify the Patients at risk :

• Head & Neck, Hematological

• Lung Ca
• Co-existing: Bleeding Varices, Liver Failure
• Small Warning Bleeds
• Local Infection at Tumor Site
• Clotting Abnormalities
• Anticoagulants
 PLAN

ANTICIPATE

COMMUNICATE
Smaller, self limiting bleedings



 Pressure dressings
 Adrenaline 1:1000 soaked dressings
 radiotherapy • Head-neck,lungs, genitourinary

• 1gm TDS
Tranexamic acid • Careful in urinary bleedings----
clots,obstructions
• Liquid state as topical,oozing lesions

sucralfate + PPI • Oozing gastric mucosa

+/- octreotide

Interventional radiological
thrombo-embolic techniques

Haemostatic Dressings: Alginate Dressings calcium salt of an

alginic acid that calcium ions that are released into the wound
from the dressing activate platelets, which results in haemostasis
• If a patient is close to death from underlying
cancer, it is usually appropriate to regard
major haemorrhage as a terminal event and
not to intervene with resuscitation measures.
Family and patient: quite warnings
 Quite warnings

Effective communication
When @risk,
If @ home Explain need
Balance anxiety and purpose of
Discuss clear
and prepare CRISIS ORDER
plans with
patient and
family (not to end life)
relatives
 CRISIS ORDERS FOR SEDATION
Severe bleeding/
inevitable death

Sedation given

Calm and lessen

patient distress to
rapid onset shock

Schur S, Weixler D, Gabl C, et al. Sedation at the end of life a nationwide study in palliative care
units in Austria. BMC Palliat Care 2016; 15:50
 4.Malignant spinal cord compression

Definition

Compression of spinal cord or cauda equina by direct pressure

and/or induction of vertebral collapse or instability by metastatic spread

or direct extension of malignancy that threatens or causes neurological

disability

[NHS guideline 2015]

 Epidemiology of SCC
• Incidence :5-10% patients with cancer( most
commonly breast, prostate and lung cancer)
• Median age at diagnosis is 40-65 yrs
• Sex differences- depending on primary neoplasm-
breast or prostate
• Skeletal system metastases are the 3rd most common
metastases after pulmonary and hepatic systems
• Vertebral metastases>>>MSCC
 c
o
C i
s
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a
Location
: r
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v s
r
i p
a
c i
l
1 a n
7 l s e
- p
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%
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Pathophysiology of cord compression

85%From vertebral body or

pedicle (hematogenous
spread)

10% Through intervertebral

foramina (from
paravertebral nodes or
mass)

4% Intramedullary spread

1% Direct spread to epidural

space David schiff, Clinical features and diagnosis of
neoplastic epidural spinal cord compression, including
cauda equina syndrome,2014
What are the signs &
symptoms of MSCC?
 First symptoms
Pain-thoracic or cervical

Pain increased by straining

Nocturnal spinal pain

Limb weakness
RED FLAGS signs…..
Difficulty walking
(NICE -2008)
Bladder or bowel dysfunction

Neurological signs

Sensory loss
 First Red Flag: Back pain

Usually first symptom

• Usually precedes other neurologic
symptoms by 6-8 weeks
• Aggravated by lying down or increased
intra-abdominal pressure:coughing or
sneezing
 Etiology of back pain
• Stretching of pain sensitive cortical bone
and periosteum

• Nerve compression

• Distension of epidural venous plexus

• Pathologic compression fracture

 Second Red Flag: Motor
• Weakness: 60-85%
– Tends to be symmetrical and B/L lower limb
weakness
– Severity greatest with thoracic metastases

• If cervical or upper thoracic spine involved-

– Upper limb weakness
• Weakness-gait disturbances-paralysis

• In lateral lesion, nerve root is affected-radiculopathy

• 50% ambulatory, 35% paraparetic, 15 % paraplegic

 Third Red Flag: Sensory
• Less common than motor findings-78%

• Ascending numbness and paresthesia

• Numbness or 'pins and needles' in toes & fingers or over
the buttocks
– Sensory level
– Saddle anaesthesia-cauda equina lesions
– Usually 1-5 levels below actual compression

• Feeling unsteady on feet, having difficulty with walking, or

legs giving way

• Altered sensation to touch,pain,temperature

 Fourth Red Flag: Bladder & Bowel
Dysfunction
• Late finding
• 40-64%

• Problems passing urine

– may include difficulty controlling bladder
function
– passing very little urine
– Urinary retention

• Constipation or problems controlling bowels

• Autonomic neuropathy presents usually as urinary retention

– Bad prognostic sign-B/L cord or root damage
Duration of symptoms before diagnosis
• 2-5 months median

Delay in diagnosis and referrals

• Back pain of 2 months before diagnosis of SCC
• 10 days delay between the onset of neurologic
symptoms and start of therapy
• Deterioration of motor or bladder function during
delay
 Investigations & information needed
prior to treatment
1. MRI scan of the whole spine
 Can get compression at
multiple levels

2. Knowledge of cancer type &

stage

3. Knowledge of patient fitness

4. Current neurological function

 Have they lost power in
their legs?
 Can they walk?
 Do they need a
catheter?
 Treatment

Until spinal stability is confirmed

patients should be managed on
bed rest
BUT Wherever possible keep the
patient moving
Goals of treatment-5P’s
• Stay calm, support patient and family.
• Ensure someone is always there

• Dark towels
• Treat if pain

• Comfort
• Keep warm

• Nurse in recovery postion

• Maintain airway
Choice of treatment depends on:
Tho
raci
c
spin
e
70%
Lumbosacral spine
: 20%

Cervical spine : 10%

Multiple sites : 17-30%

(more common in breast cancer)
 Treatment options include:

1. Analgesia
2. Steroids & gastric protection
3. Radiotherapy
4. Surgery – decompression & stabilisation of
the spine
5. Interventional radiology
6. Chemotherapy
7. Hormonal therapy
8. Bisphosphonates
9. Rehabilitation and counselling
 In IRCH-pain management
• Analgesic titration with morphine
• Adjuvants-Gabapentin, pregablin,
tryptomer
• Flexon or Etocox for bony pain
• Epidural steroid
• Steroid
• Radiotherapy
• Zometa
Glucocorticoids
Metastatic spinal cord compression guidelines ,christie, november 2013, NHS
 NHS reducing regimen for MSCC

Metastatic spinal cord compression guidelines ,christie, november 2013, NHS

 In IRCH-steroid
• Dexamethasone 16 mg IV bolus
• Followed by 8 mg BD
• 8 am and 2 pm after food
• Under PPI prophylaxis
• Continued for 48 hrs
• No improvement in neurological function in
48 hrs-stop
• Taper-Dose is halved every weekly
 Steroids
Advantages Disadvantages

Decreases spinal cord Gastric ulcer, epigastric

oedema pain,dyspepsia
Prevent further neurological Hyperglycemia
deterioration and improves
neurological function

Oncolytic effect on Psychosis, mania

lymphoma and breast cancer

Relieves pain Life threatening infections

and death
 Role of radiotherapy
• Reduce pressure on spinal cord through
tumour shrinkage

• Local tumour control

• Pain palliation

• Prevent further neurological deterioration

Indication Relative contraindication

Cancer diagnosis established No histological diagnosis of cancer

MSCC confirmed by imaging Radio resistant tumour

Life expectancy of 3 months or less Vertebral displacement/ spinal instability

More than one level of simultaneous Poor general condition due to co-
SCC morbidities

Patients with paraplegia greater than 12- Previous RT to same spinal site
24 hours duration

Known radiosensitive tumour

 Pre-requisites for surgery
• Good general condition for surgical intervention

• Be ambulant, or parapletic or have been

paraplegic for <24 hrs

• Have no pre-existing neurological problems

• Have an expected survival of minimum 6

months
 Indications for surgery
• Unknown primary tumour/ no tissue diagnosiss
• Relapse post RT/ radio-resistant tumour
• Neurological progression while on RT
• Intractable pain
• Instability of spine
• Patients with a single level of cord compression
who have not been totally paraplegic for longer
than 48 hours
• Prognosis >4 months
• Bony compression of spinal cord by bone
Advantages Disadvantages

Decompress neural elements Wound Infection

Provides stability to vertebral column Severe bleeding

Removes tumour Non fusion

Better ambulation, decrease dose of Neurological deterioration

opioids and steroids
Thankyou