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Palliative care in the emergency department


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Palliative care in the emergency department

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Palliative care in the emergency department

  1. 1. SymptomManagementin TheEmergencyDepartment Ryan Cheng 2/8/18 PalliativeCare
  2. 2. Oneshoulddieproudly whenitisnolonger possibletoliveproudly. Friedrich Nietzsche
  3. 3. TheProblem Pain Delirium Dyspnoea Bladder and Bowel Nausea and Vomiting
  4. 4. PainManagement:OpiateNaïve IV Morphine 2.5-5mg q5min Fentanyl 25-50mcg q5min SC Morphine 2.5-5mg q10min Fentanyl 25-50mcg q10min
  5. 5. PainManagement:OpiateTolerant • Need to convert existing PO doses of opiate analgesics to IV/SC equivalent • Breakthrough should be charted as 1 12 to 1 6 of calculated equivalence Opioid Parenteral Oral morphine 10 mg IV/SC 30 mg oxycodone 10 mg IV/SC 20 mg hydromorphone 1.5 to 2 mg IV/SC 6 mg fentanyl 100 to 150 micrograms IV/SC – methadone Discuss with palliative care buprenorphine 400 micrograms IV/SC 800 micrograms sublingual codeine – 240 mg tapentadol – 100 mg tramadol 100 mg intravenous 150 mg
  6. 6. PainManagement:OpiateTolerant Patient is on Oxycodone 60mg BD • Daily dose = 120mg • Equivalent = Morphine 180mg PO • SC equivalent = 60mg in 24hrs • PRN range 1 12 to 1 6 = 5mg to 10mg morphine SC PRN Opioid Parenteral Oral morphine 10 mg IV/SC 30 mg oxycodone 10 mg IV/SC 20 mg
  7. 7. PainManagement • Re-review analgesic use in 24 hours (if still in ED…) to recalculate requirements • Don’t forget adjuncts! • Paracetamol • NSAIDs
  8. 8. Delirium • Haloperidol 1mg SC q1h PRN – max 5mg • Midazolam 1-2mg SC q1h PRN
  9. 9. DyspnoeaandSecretions • Opiate or benzos • Sit patient up, or in desired position for comfort • High flow oxygen (even in the absence of hypoxia) • Humidified air • Permit patient to hold mask to face rather than securing to minimize claustrophobia • Secretions: buscopan 20mg q1h SC PRN – max 80mg
  10. 10. BladderandBowelCare • Consider catheterization/urodome if patient is unable to mobilize to the toilet • Remember, the Lotus room does not have facilities or readily accessible nursing staff! • Patients without family/NOK present do not qualify for use of the lotus room • If not imminently dying, consider laxatives for management of constipation secondary to opiate use
  11. 11. Nauseaand Vomiting • Metoclopramide • Shouldn’t be used if pro-kinetic effect can worsen symptoms, i.e. bowel obstruction • Haloperidol • Ondansetron • If intracranial cause, consider dexamethasone 4-8mg PO/SC OD • Refractory nausea with multiple multimodal agents • Dexamethasone 4mg PO OD
  12. 12. OtherComplications • Seizures – midazolam • Acute airway obstruction/stridor • Dexamethasone 16mg PO/IV/SC stat • Adrenaline nebs • SVC obstruction or spinal cord compression • Dexamethasone 16mg PO/IV/SC stat
  13. 13. AcuteHaemorrhage • If active treatment is appropriate, treat as usual • If catastrophic bleeding secondary to a terminal event (i.e. arterial erosion), active treatment and medications unlikely to be administered in time • Remain with the patient to provide the comfort of physical presence • If not for active treatment, but not imminently dying • Morphine and midazolam
  14. 14. ExamplePRNRecap(OpiateNaïve) Morphine 2.5-5mg SC q10min Midazolam 1-2mg SC q1h Haloperidol 1mg SC q1h – max 5mg Buscopan 20mg SC q1h – max 80mg Metoclopramide 10mg SC q8h Consider Paracetamol/NSAIDs
  15. 15. BitsandPieces • Palliative care consultation available 24hrs • After hours = pall care consultant (they’re really nice!) • Flags patient for PC follow up • Need to liaise with PC, if lotus room is desired • Nobody should have to die alone • Comfort from physical presence should not be underestimated • Pre-empt dealing with the aftermath • Liaise with SW early • Have difficult discussions/breaking bad news with other team members present to reiterate and explain
  16. 16. Hopedoesnotlieina wayoutbutinaway through. Robert Frost