Emergencies in the management of critical terminal illness is an important aspect in the managment of such patients

1. Palliative Care Hub Training

2.  For each emergency we must ask ourselves
these questions:
 What effect will reversal of the symptom have
on patient’s overall condition?
 What is your medical judgment?
 What does the patient want?
 What do the carers want?
 Could active treatment maintain or
improve this patient’s quality of life?
HAU IHPCA Pocket Book for Health Professionals

3. Severe uncontrolled pain
(on initial presentation or a sudden escalation
of pain) is an emergency; the patient
needs constant attention until the pain
is controlled.
 The immediate goal: reduction of the
Pain, allow the patient to rest.
HAU IHPCA Pocket Book for Health Professionals

4.  Treatment of pain emergencies:
 Give a dose of oral morphine 5-10mg,
or, if already on morphine, give a break
through/rescue dose (equivalent of the
4 hourly dose) immediately.
 Response to oral morphine normally
begins in 30 minutes.

5.  Response is most rapid with i.v.injection but
needs to be given slowly. (s.c., im. or i.v. slow
injection).
 If already on oral and changing to parenteral,
give the correct dose by dividing the patient’s
regular oral dose by 2. E.g. if patient was on
15
mg morphine orally every 4 hours, an
appropriate SC/IM stat dose would be 7.5 mg.

6.  Reassess response to dose; if s.c. injection is
given, after 20 minutes if i.v. injection is
given after 5 minutes, if oral dose is
administered, after 40 minutes.
 Repeat dose if pain is still unrelieved after
this time!

7.  When the patient is comfortable, complete
thorough pain assessment.
 Consider specific causes of severe sudden
and exacerbation of pain:
◦ Vertebral collapse
◦ Pathological fracture
◦ Biliary /Ureteric Spasm
◦ Bladder Spasm

8.  Treatment of fractures:
 Immobilization through orthopaedic surgery
is the ideal way
 Splinting and comfortable positioning are
very important in achieving pain control,
when surgery isn’t possible.
 Ensure that adequate analgesia is provided in
the same way as for pain emergencies!

9.  Biliary /Ureteric Spasm:
• The best treatment for biliary or ureteric
spasm is an oral, im or IV NSAID like
Diclofenac 75mg.
• If this fails to relieve pain in 20 minutes,
should be supplemented with an opiate:
morphine 5-10mg oral or sc/im/iv.
• For the patient who is already receiving
opiates, give double dose of morphine
orally or the equivalent sc/im/iv

10. Bladder Spasm:
• local cancer,
• treatment (radiotherapy)
• infective cystitis or
• mechanical factors like a catheter.
The cause should be treated (if possible)
• analgesics to relieve background pain

11. Drugs that reduce Detrusor sensitivity like
 Anticholinergics (Amitriptyline 25 – 50mg at
night, Propantheline bromide 15 mg bd);
Buscopan (hyoscine butylbromide 10mg);
 NSAIDS (naproxen 250 –500mg bd) can also
be helpful.
 Secondary muscle spasm: oral diazepam 5mg
stat and 5 –10mg at night.
 Nerve compression: dexamethasone 4 – 8 mg

12.  Acute Dyspnoea/Breathlessness
 Spinal Cord Compression (SCC)
 Haemorrhage
 Superior Vena Cava Obstruction (SVCO)
 Tumour lysis syndrome
 Seizures
 Neutropenia and fever
 Raised intracranial pressure
 Haemoptysis
 Morphine overdose

13.  Surgical Emergencies:
 Acute Urinary Retention
 Intestinal Obstruction

14. Acute Dyspnoea/Breathlessness – a very frightening sensation
• Simple measures are often helpful;
- a patient should not be left alone,
- a calming environment gives much relief-
- increase air movement over the patients face (fan/window)-
- explain what is happening
- sit the patient up if possible
- Treat reversible causes where possible and if appropriate, e.g.
administering antibiotics for infection,pleural tap for large
effusion, steroidsfor bronchial or tracheal obstruction or PCP.
- • Consider disease-modifying treatments such as radiotherapy
and corticosteroids.

15. Acute Dyspnoea/Breathlessness
 Low dose morphine 2.5 – 5mg 4 hourly
If already on morphine for pain relief, increase
the 4 hourly dose by increments of 2.5mg until
dyspnoea is controlled
 Diazepam 2.5- 10 mg BD (or alternative
benzodiazepine) is effective both as an
anxiolytic and in reducing the sensation
of breathlessness.

16.  Spinal Cord Compression
 Treatment:
Steroids
• Corticosteroids reduce peri-tumour
oedema and inflammation and often
lead to early improvement and pain
relief. Dexamethasone is usually given
in high dosage: 16mg - 24 mg daily in
divided doses with the first dose given
IV if possible.
Radiotherapy (RT)on (SCC):

17.  Haemorrhage
 stop or keep at the lowest possible doses
anticoagulants such as wafarin
 If GI bleeding, stop NSAID and consider PPI or H2
antagonist (support with fluids and transfusion as
appropriate)
 Consider radiotherapy referral for haemoptysis from
lung tumours, KS, bleeding due to bladder carcinoma
and rapidly growing erosive tumour
 If history of smaller bleeds, consider transexamic acid
1g QDS if available. (Antifibrinolytoic agent).
 For surface bleeding from tumour areas, consider
gauze soaked in adrenaline (1ml) or transexamic acid
applied topically.

18.  Superior Vena Cava Obstruction (SVCO)

19.  Superior Vena Cava Obstruction (SVCO)
• Poor prognosis, may not be reversible.
• Sit patient up in comfortable position
• Give high dose corticosteroids e.g. dexamethasone 16mg oral/iv,
reducing slowly over 10 days or until symptoms reoccur
• If available, radiotherapy should be considered together with high
dose steroids to prevent initial swelling and worsening of
symptoms during treatment.
• Improvement usually occurs within 72 hours.
• Treat dyspnoea symptomatically with morphine and/or
benzodiazepine

20.  Tumour lysis syndrome
Standard preventive approach:
allopurinol, urinary alkalinization, and
aggressive hydration.
Cautiously administer bicarbonate for acidosis
Rasburicase is given when other measures can
not lower urate levels adequately.
Dialysis may be necessary

21.  Seizures
 benzodiazepine (eg diazepam 10-20mg)
 anticonvulsive treatment with phenytoin
(hepatic enzyme Inducer) 18mg/kg/day.
(Prophylactic anticonvulsant therapy is not recommended
unless the patient is at a high risk for seizures - eg melanoma
primary or hemorrhagic metastases)

22.  Neutropenia and fever
 Management includes empirical broad
 spectrum antibiotics. Cultures should be
 performed. Treat for 14days or longer
 guided by clinical response and culture
 results. Regimens are often multi-drug eg
 aminoglycoside ( avoid gentamicin) with a
 cephalosporin ( eg ceftriaxone or
ceftazidime).

23.  Raised intracranial pressure
 Treatment: Hyperventilation and
 infusions of mannitol (1–1.5 g/kg) every
 6 h. Dexamethasone is the best initial
 treatment for all symptomatic patients
 with brain metastases. Radiotherapy if
 available.

24.  Haemoptysis
 often a terminal event - so
 conservative treatment of symptoms while
 keeping calm and assisting the family to be
calm, is essential.
 (Cyklokapron – Tranexamacid)

25.  Morphine overdose:
 can be reversed by Naloxone
If administering Naloxone
it is important to titrate it against
respiratory rate i.e. give a sufficient
dose to ensure that the respiratory rate
returns to normal. If the morphine is
completely reversed, excruciating pain
may ensue for the patient

26.  Acute Urinary Retention:
 A selective alpha blocker (e.g.
indoramin) can be used to relax urethral
smooth muscle in prostatism and can
improve urine flow. Care is needed as it
can cause postural hypotension.
 Urinary retention due to clot retention
following bleeding from the urogenital
tract requires catheterization and
bladder washouts.

27.  Intestinal Obstruction
Usually there is more
than one block or insipient block due to
peritoneal metastases so surgical intervention
is contraindicated. The main approach is to
keep the patient comfortable by controlling
symptoms.

28.  Remember
 Treat the symptom
 Treat the patient and family
 Treat the underlying problem
 If and when the crises is resolved it is a good
opportunity to review with the patient and family
what to expect in future and to consider options
in various scenarios