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Palliative Care Emergencies

This section covers common emergency situations in palliative care, and some measures to manage them.

Acute Pain Crisis

  • Introduction

    • A pain crisis is defined as severe, uncontrolled pain that is causing the patient severe distress.
    • It may be acute in onset or worsening gradually to an intolerable level and requires immediate intervention.
  • Assessment

    During a pain crisis, history-taking needs to be focused. The assessment and pain management usually occurs simultaneously. Important aspects in the assessment include:

Stridor

  • Introduction

    • Airway obstruction can occur in the upper or lower airways.
    • Stridor is an abnormal, high-pitched breath sound (usually inspiratory) that is produced by turbulent airflow through a narrowed airway.
    • Once stridor is heard, the airway passage is often less than 5mm.
    • Onset may be gradual or sudden. It can be very distressing to the patient or anyone who witnesses it.
  • Causes

    Airway obstruction can be anatomical or functional:

Bleeding in Cancer

  • Introduction

    • Causes of bleeding can include vascular tumours, tumour invasion into vascular structures, or systemic processes like disseminated intravascular coagulopathy or thrombocytopenia.
    • When it is visible and massive, it can cause significant distress to anyone who witnesses it.
    • The approach includes general and pharmacological measures relating to the site of bleed.
  • Approach

Seizures

  • Introduction

    • Seizures are a result of abnormal electrical conductions in the brain causing the sudden onset of transient neurological symptoms.
    • Continuous seizure activity that lasts longer than 30 minutes is termed as ‘status epilepticus’.
    • There are convulsive and non-convulsive seizures.
    • Convulsive seizures can be very distressing to family members.
  • Approach

    • In the palliative care setting, the common causes of seizures include:

Malignant Spinal Cord Compression

  • Introduction

    • Spinal cord compression requires early identification and immediate treatment to prevent permanent neurological impairment.
    • There should be a high index of suspicion in cancer patients who present with back pain or sudden worsening of previously well controlled back pain, especially with known spinal metastases. If in doubt, consider an early MRI of the spine.
    • Patients can present acutely (within hours) or subacutely (weeks to months).

Superior Vena Cava Obstruction (SVCO)

  • Introduction

    • SVCO is the obstruction of blood flow in the superior vena cava.
    • Most SVCOs are caused by primary or secondary lung tumours.
    • Many patients present with an insidious onset of symptoms rather than acutely.
    • In the event of rapid onset of SVCO, it may be life-threatening
    • Generally, prognosis of the patient is that of the underlying cancer if appropriate treatment is instituted for SVCO
  • Approach

Hypercalcaemia

  • Introduction

    • Hypercalcaemia is a common metabolic disorder affecting up to one third of cancer patients.
    • It is a poor prognostic indicator in malignant disease.
    • Malignant causes include osteolysis, humoral mediators, dehydration and tumour specific mechanisms
    • Non-malignant causes includes primary hyperparathyroidism, dehydration, tuberculosis, sarcoidosis, certain medications (e.g. Lithium), and excessive Calcium/Vit D supplements

Contact: lcpc@duke-nus.edu.sg

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