palliative emergencies

Management of malignant spinal cord compression, seizures/status epilepticus, SVC syndrome, catastrophic haemorrhage, and hypercalcaemia of malignancy in the palliative setting.

malignant spinal cord compression (MSCC)

suspect in any cancer patient with new progressive motor weakness, sensory level, or sphincter dysfunction
STAT: dexamethasone 8–10 mg IV/SC stat → 24–40 mg/day PO/SC divided TID–QID
urgent spine MRI + emergent spine oncology/radiation oncology consultation

MSCC is time-critical

Neurological function at treatment initiation determines final outcome. Delay = permanent paraplegia.

seizures and status epilepticus

acute rescue

midazolam 5–10 mg SC/IM/IV (repeat q5–10min) OR lorazepam 2–4 mg SC/IV

refractory status

phenobarbital 100 mg SC stat (at 50 mg/min) or 100 mg in 100 mL NaCl 0.9% IV over 30 min
maintenance: continuous SC infusion 300–600 mg/24h
alternative: IV phenytoin 15–20 mg/kg at ≤50 mg/min, or fosphenytoin

route loss strategy

When enteral route is lost in patients with high seizure risk:

Agent	Route	Half-life	Notes
phenobarbital	deep SC/IM	53–118h	preferred for long-term maintenance; long t½ allows q12–24h dosing
lorazepam	SC/SL	~12h	q4–6h dosing
midazolam	CSCI (CADD pump)	1.5–2.5h	short t½ necessitates continuous infusion

standing seizure orders

non-status PRN: midazolam 5 mg SC/IM PRN for seizure activity (prevents recurrent distress)
status order: midazolam 5 mg SC/IM q5min PRN for generalised tonic-clonic activity >3 min (max 3 doses; mandatory physician contact if administered)

SC route in palliative care

Midazolam IM provides faster absorption than SC in crisis. Phenobarbital is the preferred agent when IV access is unavailable and ongoing seizure control is needed.

SVC syndrome

elevate head of bed
dexamethasone 4–10 mg PO/IV BID–TID
avoid diuretics (intravascular depletion worsens obstruction)
urgent consultation: radiation oncology (EBRT) or interventional radiology (stenting)

catastrophic haemorrhage

pre-emption

identify high-risk patients (head and neck tumours, eroded major vessels, fungating wounds)
supply dark towels at bedside; brief family

crisis management

midazolam 5–10 mg IM/SC STAT (IM preferred for faster absorption)
goal is rapid sedation, not haemostasis — this is a dying event

non-catastrophic / chronic bleeding

tranexamic acid 1 g PO/IV TID (maintenance 500 mg PO TID)

hypercalcaemia of malignancy

pathophysiology

most commonly humoral: PTHrP → osteoclastic resorption + distal tubular Ca²⁺ reabsorption
corrected Ca²⁺ (mmol/L) = measured total Ca²⁺ + [(40 − albumin in g/L) × 0.02]

severity-based management

Severity	Threshold	Management
mild, asymptomatic	<2.8 mmol/L	monitor, increase PO/SC hydration
mild, symptomatic	2.65–2.8 mmol/L	NaCl 0.9% IV/SC at 80–100 mL/h; recheck 24–36h
moderate–severe	>2.8 mmol/L or symptomatic	IV hydration + IV bisphosphonate (below)

bisphosphonate dosing

zoledronic acid: 4 mg in 50 mL NaCl 0.9% IV over 15–30 min
pamidronate: 90 mg in 250 mL NaCl 0.9% IV over 2–4h

adjuncts

calcitonin 100–200 IU SC BID–TID — rapid onset, bridge while awaiting bisphosphonate effect; useful in renal failure
hydrocortisone 200–300 mg/day — specifically for lymphoma-mediated hypercalcaemia
loop diuretics no longer routinely recommended

goals-concordant care

In patients with refractory or recurrent hypercalcaemia and limited prognosis, repeated aggressive treatment may not align with goals of care. Discuss with patient/family before re-treating.