Key Facts

Palliative care emergencies require urgent medical management alongside consideration of the patient's overall condition, prognosis, and goals of care. Not all emergencies require active treatment — comfort may be the priority.

Epidemiology

• SCC: affects 3-5% of cancer patients; most common with breast, prostate, lung, myeloma
• SVC obstruction: 2-4% of cancer patients; most common with lung cancer and lymphoma
• Hypercalcaemia: 10-30% of advanced cancer patients (especially squamous cell, breast, myeloma)
• Catastrophic haemorrhage: rare but occurs in head and neck cancer, eroded major vessels

Aetiology

Causes are cancer-related:

• SCC: vertebral metastases compressing cord
• SVCO: mediastinal tumour/lymphadenopathy compressing SVC
• Hypercalcaemia: PTHrP (humoral), osteolytic metastases, vitamin D production
• Haemorrhage: tumour erosion into major vessel (carotid, aorta), coagulopathy
• Seizures: brain metastases, metabolic (hyponatraemia, uraemia), medications

Pathophysiology

• SCC: tumour compresses spinal cord → oedema → ischaemia → irreversible neurological damage if not treated within 24-48 hours
• SVCO: obstruction of venous return from head, neck, and upper limbs → facial/upper limb oedema, cerebral oedema
• Hypercalcaemia: PTHrP (80%) → increased bone resorption + renal calcium reabsorption; dehydration worsens it
• Massive haemorrhage: exsanguination within minutes if major vessel eroded

Spinal Cord Compression

• Back pain (90%) — often precedes neurological signs by weeks
• Leg weakness (motor)
• Sensory level
• Bladder/bowel dysfunction (late; usually irreversible)
• Band-like pain around thorax/abdomen

SVC Obstruction

• Facial oedema (especially worse on waking)
• Distended neck veins and chest wall veins (Pemberton's sign)
• Dyspnoea
• Headache (worse bending forward)
• Arm oedema (unilateral or bilateral)

Hypercalcaemia

• Confusion, drowsiness
• Nausea, vomiting, constipation
• Polyuria, polydipsia, dehydration
• Abdominal pain
• Cardiac: shortened QT, arrhythmias

Massive Haemorrhage

• Sudden onset massive bleeding (oral, rectal, vaginal, from wound/tumour)
• Rapid cardiovascular collapse
• Usually from eroded major vessel

Red Flags

• Any new back pain in a cancer patient → consider SCC until proven otherwise
• Facial swelling in cancer patient → SVC obstruction
• Confusion in cancer patient → check calcium urgently
• Patient at risk of catastrophic haemorrhage: must have anticipatory plan

Bedside

• Neurological examination (SCC)
• Oxygen saturations, blood pressure
• ECG (hypercalcaemia: shortened QT)

Bloods

• Corrected calcium (urgent if hypercalcaemia suspected)
• FBC, U&Es, LFTs
• Clotting (haemorrhage)
• Blood cultures (neutropenic sepsis)

Imaging

• MRI whole spine (SCC — within 24 hours; emergency if progressive neurology)
• CT thorax (SVCO — assess cause and suitability for stenting)
• CT head (seizures — brain metastases)

Special Tests

• As guided by emergency type

Spinal Cord Compression

• Dexamethasone 16mg IV immediately (then 16mg daily, taper over 2 weeks)
• MRI whole spine within 24 hours (or same day if progressive deficit)
• Refer to oncology + spinal surgery: radiotherapy or surgical decompression
• Maintain flat bed rest until spinal stability confirmed
• Bladder catheterisation if retention
• VTE prophylaxis

SVC Obstruction

• Dexamethasone 8-16mg IV (reduces peri-tumoral oedema)
• Elevate head of bed
• SVC stent (interventional radiology): rapid relief; preferred for most causes
• Radiotherapy: if lymphoma or radiosensitive tumour
• Chemotherapy: if chemo-sensitive (lymphoma, SCLC)

Hypercalcaemia

• IV normal saline 1L over 4-6 hours (rehydrate aggressively; 3-4L/24h)
• Zoledronic acid 4mg IV over 15 minutes (takes 2-4 days to work)
• Or denosumab 120mg SC (if renal impairment or bisphosphonate failure)
• Monitor calcium, U&Es daily
• Treat underlying cancer if possible
• May recur: repeat bisphosphonate as needed

Massive Haemorrhage

• Anticipatory plan must be in place for at-risk patients
• Dark towels (reduces visual distress of blood)
• Stay with patient; hold their hand
• Midazolam 10mg IM/SC (sedation to reduce distress)
• Do NOT attempt to stop catastrophic haemorrhage (futile in major vessel erosion)
• Call for help; support family
• Morphine if pain

Seizures

• Midazolam 10mg buccal/IM (first-line)
• If recurrent: CSCI midazolam 20-40mg/24h
• Levetiracetam 250-1,000mg BD if ongoing seizure risk
• Dexamethasone 8-16mg (if brain metastases causing seizures)
• Phenytoin/sodium valproate: alternatives for ongoing prophylaxis

Referral Criteria

• SCC: emergency oncology and spinal surgery
• SVCO: interventional radiology and oncology
• Refractory hypercalcaemia: oncology
• Complex emergencies: specialist palliative care

• SCC: neurological outcome depends on speed of treatment; 50% who are walking at diagnosis remain ambulant; paraplegia at presentation is usually irreversible
• SVCO: stenting provides rapid relief (90% response); median survival depends on underlying cancer
• Hypercalcaemia: responds to rehydration + bisphosphonate in 80%; recurrence common; poor prognostic sign (median survival 3-4 months)
• Massive haemorrhage: usually fatal within minutes; focus is on comfort and dignity
• Seizures: most controlled with anticonvulsants; brain metastases have poor prognosis

Palliative Care Emergency Summary

Catastrophic Haemorrhage Protocol