Palliative Care Emergencies

Convulsions

Convulsions can be distressing not only for the patient but also for the whānau-family and other carers. They should be managed effectively to reduce distress and anxiety wherever possible. It is important to have a clear history of the convulsion in order to diagnose the type (grand mal, focal, absence or status epilepticus). At times a convulsion can be mistakenly diagnosed when the true cause of loss of consciousness or absence is a syncopal attack, cardiac arrhythmia, or a transient ischaemic attack.

Causes

• previously diagnosed epilepsy, brain trauma/surgery, brain tumour/mets
• drugs
  • some lower seizure threshold e.g. phenothiazines, tricyclics
  • interactions – antiepileptics have many variable and unpredictable interactions – see individual drug pages
  • withdrawal e.g. of steroids, alcohol (Section 2)
• metabolic disturbance, e.g. hypoxia, hyponatraemia, hypoglycaemia

Management

Prophylaxis

• drugs
  • consider dexamethasone if related to raised intracranial pressure (primary brain tumour/metastases)
  • levetiracetam 500 mg bd initially
  • sodium valproate initially 500 mg bd to tds increasing every 3 days to 1 to 2 g per day
  • carbamazepine initially 100 to 200 mg once daily to bd increasing by 100 to 200 mg every 2 weeks to 800 to 1,200 mg per day – consider therapeutic drug monitoring of plasma concentrations
  • phenytoin 200 to 300 mg nocte – consider therapeutic drug monitoring of plasma concentrations
  • if oral route is not available consider
    • clonazepam 1 to 4 mg/24 hours by subcut infusion
    • midazolam 10 to 60 mg/24 hours by subcut infusion
    • levetiracetam 1 to 3 mg via CSCI/24 hours
    • consider the use of phenobarbitone if convulsions are not effectively managed by other agents

Grand mal convulsions or status epilepticus management

• make the patient safe, explain what is happening and reassure
• drugs
  • rectal diazepam 10 to 20 mg
  • buccal midazolam 5 to 10 mg – between the cheek and gum
  • subcut boluses of clonazepam or midazolam
  • if these measures are not effective consider the use of phenobarbitone

Haemorrhage

Haemorrhage is distressing for all concerned and should be treated with urgency.

• in many situations, the sight of blood is indicative of impending death and many patients and whānau-family experience a significant increase in anxiety – use red towels if possible
• staff are often alarmed by haemorrhage, as they often feel helpless to 'do' anything to prevent it
• anticipate this in high risk patients and prepare them and whānau-family with an explanation, DNR order available, proximity of dark-coloured towels and appropriate medication

Management

If the patient has been taking warfarin stop it, and consider reversal with fresh frozen plasma or vitamin K. If taking other anticoagulants e.g. enoxaparin or dabigatran stop them; consult a haematologist as not reversed by vitamin K.

If the bleeding is massive

• the normal ‘life saving’ interventions are inappropriate, reduce the patient’s awareness, fear and anxiety with subcutaneous midazolam (10 to 15 mg) with or without subcutaneous morphine. A midazolam plastic vial (15 mg) can be opened and squirt into the side of the mouth
• staff should stay with the patient and whānau-family until all concerned feel safe

Haemoptysis/ENT cancers

• mild
  • reassurance
• moderate
  • radiotherapy
  • bronchoscopy if appropriate
  • laser treatment if appropriate
• severe and rapid
  • subcut midazolam and/or morphine
  • have someone stay with the patient
• severe and slower
  • suction if appropriate
  • physical touch (reassures patient)
  • drugs as for severe and rapid
• other drug therapy
  • tranexamic acid 1 to 1.5 g po two to four times daily (inhibits plasminogen activation and fibrinolysis)
  • sucralfate for oral bleeding

Upper gastro-intestinal tract

• minimise causes e.g. discontinue NSAIDs
• treat gastritis and peptic ulceration
• drug therapy (perhaps parenterally)
  • proton pump inhibitor e.g. pantoprazole
  • H2 antagonist e.g. ranitidine
• radiotherapy and/or surgery may be appropriate

Lower gastro-intestinal tract

• radiotherapy and/or surgery may be appropriate
• drug therapy
• tranexamic acid rectally
• rectal steroids e.g. hydrocortisone rectal foam

Haematuria

• may occur with infection so check and treat if appropriate
• radiotherapy may help if tumour is present in the urinary tract
• endoscopic surgery may be appropriate
• drug therapy
• tranexamic acid orally (as before)

Vaginal

• often due to infection so treat with antifungals and/or antibiotics
• palliative radiotherapy may help

Hypercalcaemia of malignancy

The symptoms and signs of hypercalcaemia are often insidious in their onset. It can be classified as a paraneoplastic syndrome.

• should be considered in patients who have vague symptoms
• consider appropriateness of treatment BEFORE a calcium concentration
• if the patient has a serum calcium > 2.6 mmol/L consider treatment

Symptoms

• thirst and dehydration
• increased urinary output
• constipation
• loss of appetite
• nausea and or vomiting
• fatigue
• pain – usually back and abdominal
• confusion, depression

Causes

• bone metastases
• increased bone metabolism
• decreased renal clearance of calcium
• dehydration
• enhanced absorption from the gut

Management

• make the diagnosis
• decide about the most appropriate course of action together with the patient, whānau-family and team
• consider stopping diuretics, vitamin D and calcium
• the aim is to provide symptom relief and reduce serum calcium to an acceptable level using minimal intervention
  • mild to moderate (serum calcium 2.6 to 3 mmol/L)
    • initially oral then, if necessary, iv rehydration
    • consider steroids
  • moderate to severe (serum calcium 3 to 3.5 mmol/L)
    • initially iv or subcut rehydration
• 2 to 3 L normal saline/24 hours
  • then iv/subcut bisphosphonate (may take 72 hours to work)
• pamidronate 30 mg iv infusion (depending on renal function and degree of hypercalcaemia)
• zoledronic acid 3 to 4 mg iv infusion depending on renal function
• calcitonin may be useful when bisphosphonates begin to fail

Raised intracranial pressure

Raised intracranial pressure is a life-threatening event that needs to be carefully assessed and managed to optimise quality of life and minimise symptoms.

Symptoms

• severe headache which is worse when lying down or straining
• vomiting
• convulsions
• drowsiness, delirium
• diplopia
• restlessness
• personality changes

Causes / risk factors

• cerebral metastases (more common with some primaries, e.g. lung, breast, melanoma than with others, e.g. prostate)
• primary brain tumour
• abscess
• cerebro-vascular event
• sagittal sinus thrombosis
• secondary hydrocephalus following surgery

Management

If raised intracranial pressure is suspected look for papilloedema and signs of cerebral irritation. Computerised tomography or MRI may be appropriate

• raise the head of the bed
• consider cranial radiotherapy or neurosurgery for malignancy if prognosis/status warrants it
• drugs
  • dexamethasone up to 16 mg per day. Avoid doses after noon as may add to insomnia. Gradually reduce dose to minimum effective. Withdraw after 7 days if ineffective (note – some anticonvulsants can reduce effectiveness – see Dexamethasone Section 2)
  • opioids (sometimes eases head pain)
  • consider anticonvulsants particularly if seizures are present

Spinal cord compression

This is a relatively uncommon problem that requires urgent and effective management.

• it is one of the true medical emergencies in palliative care
• once paralysed 95% will not walk again

Symptoms

• pain (usually before neurological symptoms)
• weakness especially of lower limbs
• sensory disturbance
• loss of sphincter control

Management

• urgent assessment
  • history and clinical findings
  • MRI examination
• referral to radiation oncology is usually most appropriate
• as soon as the diagnosis is made or suspected
  • dexamethasone 16 mg daily, for a few days then tapered down according to symptom response
  • radiation therapy should be given concurrently

Decompressive laminectomy is rarely undertaken but should be considered as an option.