The document outlines various palliative care emergencies, defining them as urgent changes in a patient's condition requiring immediate intervention. It covers assessment, diagnosis, and management strategies for specific emergencies such as seizures, hypercalcemia, massive hemorrhage, superior vena cava obstruction, and malignant spinal cord compression. The document emphasizes the importance of effective communication with patients and families regarding treatment options and care plans.

1. PALLIATIVE CARE
EMERGENCIES

2.  Definition
 Assessment and diagnosis
 Management
OUTLINE

3.  NR a 58/F with cervical cancer and metastases
to the brain and lungs
 Could not benefit from surgical management
due to poor prognosis thus referred for
palliative care.
 Developed GTC convulsions on 8th
day of
admission.
case

4.  Definition of emergency (Miriam Webster
Dictionary)
1: an unforeseen combination of circumstances
or the resulting state that calls for immediate
action
2: an urgent need for assistance or relief.
So….In palliative care this means
 Any change in a patients condition that
requires urgent and immediate intervention.

5. Knowledge
 • Know what emergencies and their treatments
Assess and diagnosis
• Good history and examination
• Investigations- if possible and appropriate
Reflect on context
• Patient condition/prognosis
• Treatment success rate, availability, cost
• what the patient/ family wants us to do / not do
Act
• With this information make a plan with patient +/- family
Principles of care

6. Medical Knowledge
• Usually, Widespread boney metastasis in context of cancer
• Can also following trauma and because of osteoporosis
Assessment- History and Examination
• Sudden onset
• Often no history of significant trauma,
• Often weight bearing bones like vertebrae and femur
• Inability use limb
• Pain on movement •
Examination findings
• Deformity and/or swelling
• Bone grinding on moving the limb
Bone fracture

7. Immediate Treatments:
• Pain killer
• Immobilize with splint or cast
Further treatment
 Radiotherapy – for pain control and preventing
further growth of metastasis
•Surgery- surgical stabilization of the fracture
Considerations:
Bone fracture

8. Medical Knowledge.. There can be many causes
• Epilepsy Intracranial bleed
• Brain tumor/metastases Alcohol withdrawal
• Stroke Infection
• Biochemical Hypoglycemia
Assessment_- History and examination
• The patient loses consciousness
AND
• The patient’s whole body is jerking
OR
• Just a limb or part of the face may jerk
• Following a seizure the patient is often confused and sleepy for
sometime
Seizures

9. Immediate Treatment:
• Make sure the patient is safe
• Do not place anything in the patients mouth • Reassure the
family
• If the seizure is less than 5 minutes no treatment is required
• Once the patient has stopped seizing place in recovery position
Prolonged seizure
• If the seizure is prolonged give something to stop the seizure
• Diazepam 10mg rectally or IM
• Midazolam S/C or buccally
Further Treatment
• Investigation and treatment of the underlying cause
• A regular anti-epileptic such as sodium valproate
Seizures

11. Medical Knowledge
• This is a potentially life threatening condition
• Common in breast cancer, multiple myeloma, head and neck and renal
cancers
• Occurs mainly in context of lytic bone metastases due to increased
release of Calcium but can occur when no bone metastases
• Bad prognostic indicator, 80% die within year
Assess - History and Examination
• Constipation, confusion
• Increased fatigue/drowsiness increased bone pain
• nausea &vomiting Anorexia
• Dehydration increased thirst
• Polyuria cardiac arrhythmias
Hypercalcaemia

12. Assessment
• Bloods- serum calcium / albumin / renal function
•Remember to adjust calcium levels according to
albumin levels
Immediate Treatment
• Hydration – fluids IV or S/C
• Bisphosphonate- pamidronate/ zolondronic acid
• Bisphosphonate doses need adjustment relative to
renal function.
Further treatment
• Disease modifying chemo/immunotherapy
Hypercalcaemia

13. Medical Knowledge:
• A major bleed causing death from rupture of major
vessel eroded by a cancer.
• Affected blood vessels usually in stomach, neck or lungs
• Can be caused by disorders of blood clotting
• A rare event Very frightening for patient and family
Assessment- in advance of event!
• Is the tumour near big blood vessels
• Is there liver disease and varices
• Has the patient been coughing up blood or having
bloody vomits
Massive Haemorrhage

14. Immediate Action on recognizing the risk:
• Reduce risk- Do anti- coagulants and NSAIDs need to be
stopped? Would radiotherapy help?
• Discuss with the family and patient if appropriate to prepare
them
• Suggest they get dark bedding and towels (blood looks bright
and frightening on white, less so on dark colours)
• Explain if they are alone with the patient when a bleed occurs
to stay with the patient as the end will be very quick
• Consider providing diazepam 10mg suppository to sedate
patient during bleed
• If in hospital give midazolam 5-10mg s/c or diazepam 10mg
PR to sedate patient during bleed
Massive Haemorrhage

15. Medical Knowledge:
The superior vena cava (SVC) is a large vein that carries
blood from the head, neck and arms to the heart.
• Tumours or a blood clot can compress or block the
SVC
• SVCO occurs in 3-8% of cancer patients,
• Most commonly in lung cancer but can also occur in
lymphoma, breast, bowel and other cancers
Outlook very poor without treatment
Superior vena Cava Obstruction (SVCO)

17. Assess - History and Examination
• Upper body/face swelling, Symptoms worse on lying down,
Dilated veins on neck +/or arms and chest,
• shortness of breath, headache, visual changes, engorged
conjunctiva,
• Late signs : effusions in lung and heart and stridor
Treatment
• Start high dose steroids – 16mg dexamethasone +PPI
• Treat Shortness of breath – morphine +/- benzodiazepine
calming breathing exercise
• Consider radiotherapy
• Consider surgery - SVC stent
Super vena Cava Obstructions
(SVCO)

19. Medical Knowledge
• MSCC occurs when pressure is placed on the spinal
cord or cauda equina
• Can be caused by any cancer
• Most common in cancers that have a high risk of
bone metastasis - breast, bronchus & prostate cancer
• 20% of people have compression at more than one
level
Rapid treatment may prevent permanent life changing
nerve injury
Malignant Spinal Cord Compression (MSSC)

20. Assess - History and Examination
Pain- 9/10 people with MSCC have pain
• can be “banding”
• worse on coughing and lying
• often severe radiates
• often neuropathic in nature - sharp, shooting, burning
Reduced power
• May notice weakness in limbs
Altered sensation
• In limbs or trunk - saddle anaesthesia is a late sign!
Bowel and bladder - dysfunction are late symptoms!
Neurological Exam – will help confirm diagnosis

21. Immediate treatment:
• Dexamethasone 16mg stat
• Following days dexamethasone 16mg split into
morning and lunchtime dose +PPI.
Investigations:- if available and appropriate
• MRI is gold standard OR consider CT, Bone Scan or X-
ray
Further Treatment
• Urgent radiotherapy – if available
• Consider surgical options
• Physiotherapy to maintain residual function

23. Definition - a high-pitched breathing sound caused
by partial obstruction of the upper airways
• Usually caused by pressure from tumour or
lymph nodes on the airway
Assessment – History and Examination
• Sensation of shortness of breath (SOB)
• Fear and anxiety due to SOB
• Low O2 saturation
• Confusion secondary to anoxia
 Increased respirations
Stridor

24. If risk of stridor is recognised in advance
• make a plan with the patient and family regarding
possible pre-emptive radiotherapy or tracheostomy
Immediate treatment
• Treat shortness of breath with morphine
• Treat anxiety -diazepam 5-10mg S/C, IV or PR
• Give high dose dexamethasone 16mg daily divided
doses + PPI
Further treatment:
• Consider radiotherapy
• Consider a tracheostomy

26.  1.ABC of palliative care
 2. Scottish palliative guidelines
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliativeemergencies/
Hypercalcaemia.aspx
 3. D.Seccareccia, Cancer-related hypercalcemia. Canadian Family physician. 2010 Mar; 56(3):
244–246. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2837688/#:~:text=Unfortunately%2C
%20cancer %2Drelated%20hypercalcemia%20has,of%203%20to%204%20months.
 4. https://www.hopkinsmedicine.org/health/conditions-and-diseases/statusepilepticus#:~:text=A
%20seizure%20that%20lasts%20longer,permanent%20brain%20damage% 20or%20death.
 5. https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/
recognisingemergencies/recognising-emergencies
 6. Nice Clinical Guidelines Metastatic Spinal Cord Compression 2008
https://www.ncbi.nlm.nih.gov/books/NBK55007/
 7. A Handbook of Palliative Care in Africa African Palliatiive Care Association 2010
https://www.iccp-portal.org/system/files/resources/s19115en.pdf
 8. Pallitive Care Emergencies – Palliative HUB Training Power point
 Acknowledgement
 • These presentations have been developed by Make
References