Palliative Care Emergencies
Subtopic:
Hemorrhage
Hemorrhage refers to significant bleeding that can originate from major blood vessels. This can be a distressing experience for both patients and those caring for them.
Often, the possibility of hemorrhage can be anticipated, making proactive strategies important. This includes ensuring essential medications are readily available in a home care environment in case of emergencies.
Causes of Hemorrhage
Bleeding due to tumor invasion: When cancerous growths erode into nearby blood vessels, significant bleeding can occur. This is particularly relevant in areas like the head and neck region, as well as in tumors affecting the stomach, pelvis, bladder, or lungs. The physical invasion of blood vessel walls by tumor cells weakens them and can lead to rupture.
Bleeding from esophageal varices in liver disease: Individuals with advanced liver conditions, notably cirrhosis, may develop enlarged veins in the esophagus known as varices. These varices are fragile and prone to rupture, which can result in substantial blood loss. The increased pressure in the portal vein due to liver damage contributes to the formation of these fragile vessels.
Blood-clotting problems: Patients receiving palliative care might have pre-existing conditions that affect their blood’s ability to clot. This could involve issues with the number or function of platelets, or a deficiency in clotting factors, making them more susceptible to bleeding.
Low platelet counts in cancer and HIV: Certain cancers, especially those that infiltrate the bone marrow, can disrupt the production of platelets, leading to a reduced platelet count (thrombocytopenia). Similarly, HIV infection can also cause a decrease in platelet levels, thereby elevating the risk of bleeding.
Assessment and management of hemorrhage in palliative care patients
It is paramount that a patient experiencing bleeding is never left unattended until the bleeding is controlled. Constant monitoring and support are essential during such an event.
If there’s an identified risk of bleeding, medications that thin the blood, such as warfarin, should be either discontinued or carefully managed at the lowest effective dose to minimize the likelihood of excessive bleeding.
A careful review of all the patient’s medications is necessary to identify any that might contribute to bleeding. If these medications are not critical for managing the patient’s symptoms, their use should be stopped to lower the risk of hemorrhage.
In certain situations, referring the patient for radiotherapy should be considered. This includes:
Coughing up blood (hemoptysis) caused by lung tumors. Radiotherapy can help shrink the tumor and reduce bleeding.
Bleeding from Kaposi’s sarcoma (KS) lesions and tumors that have broken through the skin (fungating tumors). Radiotherapy can help control the growth and bleeding.
Bleeding from tumors located in the head and neck area.
Blood in the urine (hematuria) due to cancer of the bladder.
Tumors that are growing rapidly and causing erosion and bleeding.
If the patient has a history of minor bleeding episodes, tranexamic acid can be considered. A typical dose is 0.5g to 1g, administered two or three times per day, if available. This medication helps to stabilize blood clots and reduce bleeding.
For bleeding occurring on the surface of tumor areas, applying gauze soaked in adrenaline (epinephrine) solution (1ml concentration) or topically applying crushed tranexamic acid can be attempted to stop the bleeding. Adrenaline constricts blood vessels, and tranexamic acid promotes clotting locally.
If the bleeding is coming from a specific blood vessel, surgical ligation might be an option. This involves surgically tying off or sealing the bleeding blood vessel.
In situations where the hemorrhage is severe and may lead to a terminal event, the following supportive measures can be taken:
Having dark-colored towels readily available for the family can be helpful, as blood appears less voluminous on dark surfaces, which can be emotionally easier to manage.
Administering sedatives such as benzodiazepines, like diazepam (10 mg given orally or rectally), can help to reduce anxiety and fear during episodes of significant bleeding. However, it’s important to recognize that in rapidly progressing bleeding, the effect of sedation may be limited.
For Children
When managing hemorrhage in children, particularly those with blood cancers, the following approaches should be considered:
The goal is to achieve rapid and complete sedation using benzodiazepines and/or opioid medications, if available. These should be given via injection (parenterally) to ensure quick action. This helps keep the child calm and comfortable during the bleeding.
If the child is able to swallow, administering double the usual dose of morphine, with or without diazepam, as prescribed, can be effective. This helps manage pain and anxiety, especially associated with severe nosebleeds (epistaxis).
If the child is unable to swallow, administer larger doses of morphine and diazepam rectally. The recommended dose for rectal diazepam (rectal valium) is:
For children whose weight is unknown: 5mg for those under 3 years old, and up to 10mg for children older than 3 years.
For children whose weight is known: Administer a dose of 0.5–1mg per kilogram of body weight, up to a maximum of 10mg.
Superior Vena Cava Obstruction (SVCO)
SVCO signifies a situation where the flow of blood through the superior vena cava is either partially or fully blocked. This blockage hinders the normal return of blood to the heart’s right atrium.
Superior vena cava syndrome (SVCS) occurs when the superior vena cava, the major vein responsible for carrying blood from the head, neck, and upper chest back to the heart, becomes obstructed.
This obstruction can arise from several causes: external pressure on the vein from a nearby tumor or enlarged lymph node, direct invasion of the vein wall by a tumor, or the formation of a blood clot (thrombosis) within the vein. When the vein’s passage is narrowed or blocked, the flow of blood to the heart is restricted, and the drainage of blood from the areas above the chest is impaired.
SVCS is most frequently observed in individuals with lung cancers, particularly small cell carcinoma, which accounts for approximately 75% of cases. Lymphoma is another common cause, representing about 15% of cases. Other cancers, including breast, colon, esophageal, and testicular cancers, can also lead to SVCS. Without timely intervention, SVCS can worsen rapidly, potentially leading to complications like further blood clots, swelling of the brain (cerebral edema), and even death within a short period. The respiratory, cardiovascular, and central nervous systems are typically affected by this condition.
Signs and symptoms of SVCS
Respiratory system: Difficulty breathing or feeling short of breath (dyspnea), bluish discoloration of the skin due to lack of oxygen (cyanosis), coughing, a raspy or weak voice (hoarseness), a high-pitched noisy breathing sound (stridor), and difficulty swallowing (dysphagia).
Central nervous system: Changes in mental awareness, headache, feeling lightheaded or unsteady (dizziness), blurred vision, fainting (syncope), and seizures.
Cardiac system: Rapid heartbeat (tachycardia), chest pain, and low blood pressure (hypotension).
Swelling or puffiness of the face, upper body, and arms due to the backup of blood.
Difficulty swallowing (dysphagia). Some individuals may describe a sensation of feeling like they are drowning due to the pressure and fluid buildup. SVCO is often seen in patients with tumors located in the mediastinum (the space in the chest between the lungs), such as those associated with bronchial carcinoma, breast cancer, and lymphoma.
A physical examination might reveal signs like swelling (edema) of the face, arms, and upper chest, visibly enlarged veins in the upper chest, shoulders, and arms, distended jugular veins in the neck, and swollen or bloodshot conjunctiva (the clear membrane over the white part of the eye).
Later signs that may develop include fluid accumulation in the space around the lungs (pleural effusion), fluid buildup around the heart (pericardial effusion), and a harsh, vibratory sound during breathing (stridor).
Assessment and Management.
Assessment
A physical examination can reveal specific indicators, such as engorged conjunctivae (bloodshot eyes), swelling around the eyes (periorbital edema), visibly dilated neck veins, and the presence of collateral veins (new pathways for blood flow) on the arms and chest wall.
Later signs that may be observed include pleural effusions (fluid around the lungs), pericardial effusion (fluid around the heart), and stridor (noisy breathing).
Management of Superior Vena Cava Obstruction (SVCO):
Aim
In advanced cases, the main objective is to provide relief from immediate and severe symptoms.
Relief of Acute Symptoms:
High-dose Corticosteroids: Medications like dexamethasone are administered at high doses (for example, 16mg by mouth or intravenously). These medications help to reduce inflammation and thereby ease the symptoms of SVCO.
Radiotherapy: If it’s an available option, urgent radiotherapy should be considered to target the underlying cause of the obstruction, such as tumors or enlarged lymph nodes pressing on the superior vena cava. This can help to shrink the mass and improve blood flow.
Symptomatic Management:
Dyspnea: To alleviate shortness of breath (dyspnea), medications such as morphine (e.g., 5mg every 4 hours) and/or benzodiazepines can be used. These help to reduce anxiety and make breathing more comfortable.
Cough: Address coughing using appropriate medications, such as cough suppressants to reduce the urge to cough or expectorants to help clear mucus, as advised by a healthcare professional.
Dysphagia: If the patient experiences difficulty swallowing (dysphagia), consulting with a speech therapist is beneficial. They can provide strategies and exercises to help improve swallowing ability and safety.
Supportive Care:
Patient Positioning: Maintaining the patient in an upright or seated position can help improve the return of blood to the heart and reduce the severity of symptoms.
Oxygen Therapy: If needed, supplemental oxygen should be administered to help alleviate breathing difficulties and improve the level of oxygen in the blood.
Calm Environment: Creating a peaceful and quiet environment can help to reduce anxiety and promote overall comfort for the patient.
Multidisciplinary Approach:
It’s crucial to collaborate with a team of healthcare professionals, including oncologists (cancer specialists), palliative care specialists (focused on comfort and quality of life), and other supportive care staff. This ensures comprehensive management of the patient’s physical, emotional, and social well-being.
Psychological Support: Providing emotional support to both the patient and their family is essential. Addressing their concerns, offering reassurance, and providing guidance throughout the treatment process is important.
Close Monitoring and Follow-up:
The patient’s condition should be monitored regularly, including vital signs, symptom progression, and their response to the treatment.
Scheduled follow-up appointments are necessary to evaluate the effectiveness of the treatment, manage any ongoing symptoms, and make any necessary adjustments to the overall management plan.