Palliative emergencies in the pre-hospital setting
Parkinson, Martin
Parkinson, Martin
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Abstract
Abstract published with permission.
Objective: To provide a narrative on the most common palliative emergency
situations that requires the attendance of a paramedic. This narrative looks
specifically at pain, seizures and breathlessness, and critiques the underpinning
evidence supporting their treatment and protocols.
Discussion:
Pain—the presence of pain in palliative care is highly prevalent with up to 70%
of patients living in a permanent painful state. Clinician-led pain assessment has
been shown to underestimate the patient’s pain by as much as 60–68% and
none of the assessment tools used are fully inclusive. Further research is needed
to formulate an assessment tool that recognises palliative pain as a progressive
disorder requiring constant assessment.
Seizures—Seizures occur as either a result of disease progression or as a
side effect of medications. Studies have shown that intramuscular midazolam
is more effective than intravenous lorazepam, which is itself more effective
than intravenous diazepam. The ease of administration of intramuscular and
buccal midazolam for out-of-hospital use should make midazolam the first-line
treatment for palliative care patients that suffer from seizures. The implication
for future paramedic practice highlighted from these studies is the need for more
research in the treatment of palliative patients with seizures.
Breathlessness—Cold facial stimulation has been shown to be very effective
as a non-pharmacological treatment for breathlessness. Opioids help to relax
the patient which aid in regulating breathing patterns although a consensus
on the route of administration which provides the best possible effect is yet
to be reached. The evidence base for the use of anxiolytics is weak and some
studies have shown no beneficial effect to their use. Although anxiolytics are
effective in reducing anxiety their effectiveness in helping breathlessness in
palliative patients is questionable. Home oxygen should be adopted as a first
line treatment according to experts working in end-of-life care, and treatment
of oxygen should not be delayed by waiting for results of other trials for other
treatments.