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