Page 66 Guide to Pain Management in Low-Resource Settings

54 Lukas Radbruch and Julia Downing

Neuroleptic medication may be required, with halo- hours, and care has to be delivered by auxiliary staff or
peridol as a fi rst-line approach. High dosages may be family caregivers.
required, with doses as high as 20–30 mg per day. Oth-
What is rescue or breakthrough medication?
er neuroleptics such as levomepromazine have more
sedative properties and may be benefi cial in severely Rescue or breakthrough medication should be pre-
agitated patients. For patients with HIV disease, HIV- scribed for patients with advanced disease, where ex-
related brain impairment can cause agitation and confu- acerbations of pain or other symptoms are possible,
sion earlier on in the disease trajectory, and thus similar and rapid treatment of these exacerbations is required.
symptoms may have to be controlled prior to the fi nal Rescue medications can include diff erent drugs, but
phase of life. for most patients they should include at least an opi-
oid with fast onset for treatment of pain, dyspnea, and
Emergency interventions anxiety as well as a benzodiazepine such as lorazepam
for the treatment of dyspnea, anxiety, and agitation
What constitutes an emergency (Table 2).
in palliative care? Respiratory secretions may lead to labored

Exacerbation of pain and other symptoms as well as se- breathing in dying patients, and may cause distress in
vere psychological distress with anxiety or even panic patients as well as in caregivers. Anticholinergic drugs
may lead to emergency situations that require immedi- such as hyoscine butylbromide may alleviate this “death
ate action. In these emergencies, the onset of symptom rattle” quickly.
relief should not be delayed unduly by prolonged assess- For all drug interventions, the route of admin-
ment or diff erential diagnosis. However, the usual medi- istration should be considered. Oral application may
cal emergency procedures may also be detrimental, for be much easier if no professional help is available, but
example when pain exacerbation leads to a hospital ad- in some patients oral intake is not possible. Opioids as
mission with transport time as well as radiographic and well as many other drugs used in palliative care can be
laboratory investigations, but without analgesic inter- injected subcutaneously, with little risk of complications
vention or comforting care. and with a faster onset of action than with oral applica-
Emergencies that have to be treated rapidly and tion. Intravenous application off ers the option for rapid
adequately are exacerbations of preexisting symptoms, titration with small bolus administrations if trained staff
new symptoms with sudden and intense onset, or rare are available.
complications such as massive hemorrhage. Individual
treatment plans in palliative care should try to foresee What should be done in the case
of massive hemorrhage?
such emergencies and provide adequate interventions.
Prescription (or even better, provision) of rescue medi- Cancer growth in the skin or mucous membranes may
cation for emergencies is especially important when lead to excessive bleeding if major blood vessels are
health care professionals are not available out of offi ce ruptured. Th is can manifest with sudden onset or with

Table 2
Th e essence of symptom control: emergency intervention
Medication Dosage Drug Class Comments
Rescue Medication (Given as Required)
Morphine 10 mg 10–20 mg orally Opioid (μ-agonist) Indication: pain, dyspnea
10 mg s.c. (or i.v. in small steps)
Hydromorphone 1.3–2.6 mg orally Opioid (μ-agonist) Indication: pain, dyspnea
2–4 mg s.c.
Hyoscine butylbromide 40 mg 20 mg s.c. Antimuscarinergic drug Indication: respiratory tract secretions
Lorazepam 1 mg 1 mg sublingually Benzodiazepine Indication: agitation, anxiety
Palliative Sedation
Midazolam 3–5 mg/h s.c., i.v. Benzodiazepine Paradoxical eff ect/
or 3–5 mg bolus as required inadequate eff ect