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Spinal Cord Compression

This document provides guidance on palliative care management for several common issues including spinal cord compression, superior vena cava obstruction, hypercalcemia, last days of life care, dyspnea, opioid conversion, delirium, opioid overdose, convulsions, and nausea and vomiting. It lists symptoms, investigations, and treatment recommendations including medications, dosages, and administration routes for each condition.

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ian3yeung-2
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0% found this document useful (0 votes)
122 views

Spinal Cord Compression

This document provides guidance on palliative care management for several common issues including spinal cord compression, superior vena cava obstruction, hypercalcemia, last days of life care, dyspnea, opioid conversion, delirium, opioid overdose, convulsions, and nausea and vomiting. It lists symptoms, investigations, and treatment recommendations including medications, dosages, and administration routes for each condition.

Uploaded by

ian3yeung-2
Copyright
© © All Rights Reserved
Available Formats
Download as ODT, PDF, TXT or read online on Scribd
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Last edit date: 17/06/20

Spinal cord compression


• Breast, lung, prostate, myeloma, kidney
• Thoracic-spine (70%), LS-spine, cervical
Investigations
• XR spine
• MRI spine
Management
• Bed rest
• Foley to BSB
• Dexamethasone 16mg per day PO or IV
(with PPI)
• Consult O&T
Supportive care:
• splinting
• prevent DVT

SVC obstruction
• Lung CA, Lymphoma, breast, colon Management
Presentation • CXR
• SOB • Dexamethasone 8-16mg PO/IV (with PPI)
• Periorbital edema, non-pulsatile dilated neck • Lasix 40mg PO / IV
• Headache (cerebral oedema) • IR for stenting
• Oncological treatment

Hypercalcaemia
Presentation (cont. Mx)
• delirium, malaise, thirst, nausea, constipation • Rehydration (NS 500ml Q4H x1, then Q6H)
Common primary: • Keep urine output 2L/day
• myeloma, breast, lung, head & neck, kidney • Pamidronate
Management ◦ Ca 3.0-3.25 - 60mg in 500ml NS over 2-4hrs
• Bld x CBC, LRFT, Ca PO4 ◦ Ca>3.25 - 90mg in 500ml NS over 2-4hrs
• Chart IO • Zoledronic acid 4mg iv infusion over 15 min
• Withhold meds (thiazide, ranitidine, vit D) • (Adjust infusion rate in renal impairment)
• Do NOT repeat bisphosphonate until Day 7
(Effect lasts x 2-4 weeks)

Last Days of Life


• Pain = Morphine 2.5-5mg SC • Agitation = Haloperidol 2.5mg sc prn hrly
Do NOT use morphine for sedation. • Myoclonus: Midazolam 2.5mg SC prn hourly
• Nausea = Haloperidol 0.5-1 mg SC prn hourly • Anorexia = Megestrol 160mg tab / 40mg/ml

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Dyspnoea
• Watch out for SVCO Opioid for dyspnoea:
• Dexamethasone 4-8 mg daily for lymphangitis • Start with morphine 2.5 mg stat + Q4H SC
carcinomatosis, post-irradiation or post- • Increment of 25% of baseline dosage for patient
chemotherapy pneumonitis; on morphine
Ix • Monitor mental state, RR, SaO2. Withhold opioids
• CXR if there is sign of respiratory depression.
• SaO2 • Full dose in terminal cases
NOT correlate with SOB ◦ Morphine 5mg SC q24h + 2mg SC q2h prn
• Look out for trapped lung in chest tapping ◦ (Renal failure patients:
• USG guided tapping fentanyl 50-100 microgram SC q24h
+ fentanyl 12.5 microgram SC q2h prn)
◦ Buscopan 20-60 mg q24h SC

Opioid conversion
Drug Route Onset Effect (hr) Equivalent dose Comments
Oral 30-60min 30mg PO
Reduce in renal impairment
Morphine 3-6 10mg IV
IV / SC 5-10min Active metabolites: M6G
15mg SC
Oxycodone Oral 10-15min 4-6 15mg PO
IV / SC 0-10min 1-3 0.1mg IV / SC Infrequent dosing needed
Fentanyl
Trans-dermal 12-24 hr 72hr / Lack of active metabolites

Oral 30-60min 20mg PO Duration of effect increases


Methadone 3-4
IV / SC 10mg IV / SC after repeated use.

MST Oral 12 1:1 PRN = 1/6 MST daily dose

Neuropathic pain

• Other useful meds for neuropathic pain = amitriptyline or carbamazepine CR

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Delirium
Common causes: MX
1. Drugs: opioid, anticholinergic, steroid, sedatives • CBC/dc, LRFT, Ca, (c/st)
2. Uncontrolled symptoms: pain, constipation, AROU • Review drugs, esp. Morphine
3. Infections (reduce morphine to 1/3 to half dose)
4. Metabolic: hyperCa, electrolytes disturbance, • CT brain
hyper/hypoglycaemia, liver failure, uraemia, dehydration, Drugs (lower dose in frail elderly)
hypoxia, CO2 retention • Haloperidol PO/SC 0.5-1 stat, then 1-2mg q6h
5. Organic brain disorder: brain tumour Or 5 – 20mg SC q24h via a syringe driver
(up to 5mg SC stat)
PE • Alternative = Chlorpromazine po 25 – 50 mg q8h
• hydration status, SaO2 and H’stix • If not in control = Midazolam 2.5–5mg SC stat for
• neurological exam, PR exam, acute control, then 5–30mg q24h SC infusion
• palpating for urinary bladder, (Up to 10mg SC stat)

Opioid overdose
Causes: Cont. Mx
• excessive dose • Haloperidol for delirium
• dehydration / renal impairment • midazolam for myoclonus
• infection Indications for use of naloxone
• hepatic dysfunction • Respiratory rate <8 breaths/min, or
• Amitriptyline increases bioavailability • <10–12 breaths/min, difficult to rouse and
Symptoms clinically cyanosed, SpO2<90%
• Drowsiness / confusion / hallucination Use of Naloxone
• Vomiting • Dilute 0.4mg naloxone in 10mL NS
• Pinpoint pupils Give 0.5mL (=20mcg naloxone) every 2min IV
• Myoclonus until satisfactory respiratory status
• Respiratory depression • Naloxone half-life 5-20min  repeat if needed
Management:
• Withhold Morphine
• Do NOT titrate up morphine if pulse/RR ratio
>6:1. look for pinpoint pupils

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Convulsion
Categories AED Antiepileptic
• Partial seizure – Simple vs. Complex
• Generalized – tonic-clonic vs. absence
Treatment
• Prophylaxis is NOT recommended
• AED
• For end of life:
◦ Midazolam 2.5mg stat + 10mg q24h driver
◦ Clonazepam 1mg stat + 1mg via q24h driver

Nausea and Vomiting


Associate with morphine (first few days)
• Haloperidol 1-5mg Q24H

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