The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:

Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea

Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors

Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort

Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam

Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.

Suggested articles:

1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207

Other resources: website gives nice medication conversions

My thoughts on the final day at the review course will come shortly….

Tanya Stewart MD FAAHPM