EMERGENCIES

1. Severe pain

2. Spinal cord compression

3. Superior Vena Cava (SVC) obstruction

4. Seizures

5. Hemorrhage

6. Acute urinary retention

7. Pathological fracture

8. Hypercalcemia

9. Panic attacks

10. Psychosis

1. Severe pain is a medical emergency, which requires an immediate response from the hospice or palliative care team. Hopefully the doctor has written orders allowing nurses to immediately increase the dose of morphine when necessary, and will promptly re-assess the patient and write new orders for analgesia at a higher range of doses. (see Introduction, Morphine, Pain)

2. Spinal cord compression requires immediate high dose steroids and same day radiotherapy (which have a chance of reversing symptoms if started within 24 hours of onset). (see Spinal Cord Compression)

3. SVC obstruction can occasionally occur suddenly, with dyspnea and extended neck veins. Urgent radiotherapy may be indicated, but sudden onset suggests that thrombosis has caused complete obstruction, and if the patient is very weak it should be managed as a terminal event. (see Superior Vena Cava Obstruction)

4. Seizures are best managed by diazepam enemas 10mg which can be repeated until the seizure is controlled. (The rectal route works as quickly as intravenous diazepam.) (see Seizures)

5. Hemorrhage heavy enough to be called an emergency is thankfully rare. Sometimes the patient dies before drugs can be given. Rapid sedation is difficult because the patient is shocked, veins are difficult to find and peripheral circulation is poor (so IM injections are less effective). Give diazepam enemas as for seizures and a combination of morphine, chlorpromazine and scopolamine IV or IM. Resuscitation and blood transfusion are considered only if the bleeding site can be controlled - otherwise it is dealt with as a terminal event. (see Bleeding)

6. Acute retention of urine is very distressing. There can be no justification for the upheaval of in-patient admission or a trip to the emergency ward merely for catheterization. A good hospice nurse or doctor carries a supply of catheters!

7. Pathological fracture of a vertebra, arm or leg is frightening and can be painful (especially the fracture of a vertebra). First aid involves stabilization and analgesia and then orthopedic fixation whenever possible. Internal fixation of a limb bone is important even if the patient is bed-bound and has a prognosis of only a few weeks, because such fractures are demoralizing and painful, and make comfortable nursing care very difficult.

For a fractured shaft of femur, if the patient is too ill for surgery, apply skin traction with a 5 lb to 8 lb weight (a catheter bag full of water) and consider an injection of 10ml 0.5% bupivacaine with 80mg (2ml) methylprednisolone into the fracture site using a long needle. (see Fractures)

8. Hypercalcemia can occasionally present suddenly with confusion, weakness and polyuria occurring over 24 to 48 hours. When this happens the blood calcium level is usually above 16.0mg/dL [4.0mmol/L], and the patient needs intravenous fluids and IV etidronate disodium to bring the calcium levels down. Maintenance therapy with oral phosphate will then be needed. (see Hypercalcemia)

9. Panic attacks are the commonest emergency situation. Whatever precipitates the panic, the underlying problem is fear. Company from a close relative or a trusted nurse usually helps more than anything else. Sedation may be necessary, and options include IV or rectal diazepam 10mg, or IM haloperidol 5mg to 10mg.

If severe panic and feelings of terror occur in a patient who is near death (for example, with broncho-pneumonia present) the patient needs sedation with a combination of morphine, chlorpromazine and scopolamine. (see Terminal Phase)

10. Psychotic symptoms are surprisingly rare. If a depression develops into agitation and obsessive rumination there can be, on rare occasions, a place for electro-convulsive therapy.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.