1.1. Anaesthetics - Pain

Question 1

What is Pain?

Answer 1

An unpleasent Sensory and Emotional Experience associated with Actual / Potential Tissue Damage, or Described in terms of such Damage

Question 2

With Regards to Treating Pain, what are the

1. Physical benefits?
2. Psychological benfits?

Answer 2

1. a) Improved Sleep
2. b) Better Appetite
3. c) Fewer Medical Complications - M.I. / Pmeumonia
4. a) Reduced Siffering
5. b) Less Depression / Anxiety

Question 3

With Regards to Treating Pain, what are the benefits for:

1. The Family?
2. Society?

Answer 3

1. a) Improved functioning as a Family Member
2. b) Able to keep working
3. a) Lower Health Costs - Shorter Hospital Stays
4. b) Able to contribute to the community

Question 4

What are the Classifications of Pain under:

1. Duration?
2. Cause?
3. Mechanism?

Answer 4

1. Acute / Chronic / Acute on Chronic
2. Cancer / Non-Cancer
3. Nociceptive / Neuroathic

Question 5

What is the difference between:

1. Acute Pain?
2. Chronic Pain?

Answer 5

1. Pain of Recent Onset and probable Limited Duration
2. Pain > 3 months / Lasting after normal Healing
   Note - There is often no identifiable cause of Chronic Pain

Question 6

What is the difference between:

1. Cancer Pain?
2. Non-Cancer Pain?

Answer 6

1. Progressive - May be a mixture of Acute and Chronic

2. Many different causes - Acute or Chronic

Question 7

What are the Features of Nociceptive Pain?

Answer 7

1. Obvious Tissue Injury / Illness
2. Protective Function
3. Described as Well Localised and Sharp / Dull
   Note - Also called Physiological / Inflammatory Pain

Question 8

What are the Features of Neuropathic Pain?

Answer 8

1. Nervous System Damage / Abnormality
2. Tissue Injury may not be Obvious
3. Does not have a Protective Function
4. Described as:
5. a) Burning, Shooting +/- Numbness / Pins and Needles
6. b) Not Well Localised

Question 9

What us the Physiology of Pain?

Answer 9

1. Periphery = Tissue Injury - Chemical Release - Stimulation of Nociceptors - Signals in A-Delta / C Fibres
2. Spinal Cord = Dorsal Horn - Nerve Synapse with Second Nerve - Ascend up opposite side of Spinal Cord
3. Brain = Thalamus - Connection to Cortex / Limbic System / Brainstem - Pain Perception is in the Cortex
4. Modulation - Descending Pathway (Brain - Dorsal Horn) - Decreases Pain signal

Question 10

What is the Gate Theory of Pain?

Answer 10

Distraction Stimulus (Rubbing) Reduces pain by Inhibiton of Neurons

Question 11

What is Neuropathic Pain?

Answer 11

Abnormal Processing of Pain Signal due to Nervous System Damage / Dysfunction, e.g.:

1. Nerve Trauma
2. Diabetic Pain
3. Fibromyalgia
4. Chronic Tension Headache

Question 12

What are the Pathological Mechanisms for Neuropathic Pain?

Answer 12

1. Increased Receptor Numbers
2. Abnormal Sensitisation of Nerves - Peripheral / Central
3. Chemical Changes in the Dorsal Horn
4. Loss of Inhibitor Modulation

Question 13

What are the Drug Classifications?

Answer 13

1. Simple Analgesics - Paracetamol / NSAID’s
2. Mild Opioids - Codeine / Morphine / Oxycodone / Fentanyl / Tramadol
3. Antidepressants - Amitriptyline / Duloxetine
4. Anticonvulsants - Gabapentin
5. Ketamine - NMDA Receptor Antagonist
6. Local Anaesthetics
7. Topical Agents

Question 14

What are the Treatments for Pain from the Periphery?

Answer 14

1. Non-Drug Treatments - R.I.C.E.
2. NSAID’s
3. Local Anaestetics

Question 15

What are the Treatments for Pain from the Spinal Cord?

Answer 15

1. Non-Drug Treatments - Acupuncture / Massage / TENS
2. Local Anaesthetic
3. Opiods
4. Ketamine

Question 16

What are the Treatments for Pain from the Brain?

Answer 16

1. Non-Drug Treatments - Psychological

2. Drug Treatments - Paracetamol / Opiods / Amitriptyline / Clonidine

Question 17

What are the Advantages / Disadvantages of Paracetamol?

Answer 17

Advantages:

1. Cheap / Safe
2. Orally / Rectally / I.V.
3. Good for Mild - Moderate / Severe Pain

Disadvantages:
1. Liver Damage in Overdose

Question 18

What are the Advantages / Disadvantages of NSAID’s?

Answer 18

Advantages:

1. Cheap / Generally Safe
2. Good for Nociceptive Pain
3. Works Synergisticly with Paracetamol

Disadvantages:
1. G.I. / Renal Side effects and Sensitive Asthmatics

Question 19

What are the Advantages / Disadvantages of Codeine?

Answer 19

Advantages:

1. Cheap / Safe
2. Good for Mild-Moderate Acute Nociceptive Pain

Disadvantages:

1. Constipation
2. Not good for Chronic Pain

Question 20

What are the Advantages / Disadvantages of Tramadol?

Answer 20

Advantages:

1. Less Respiratory Depression
2. Can be used with Opioids / Simple Anagesics
3. Not a controlled Drug

Disadvantages:
1. Nausea and Vomiting

Question 21

What are the Advantages of Morphine?

Answer 21

1. Cheap / Generally Safe
2. Can be given Orally / I.V. / I.M. / S.C.
3. Effective if given regularly
4. Good for:
5. a) Moderate - Severe Acute Nociceptive Pain
6. b) Chronic Cancer Pain

Question 22

What are the Disadvantages of Morphine?

Answer 22

1. Constipation
2. Respiratory Depression in High Dose
3. Misunderstandings about Addiction
4. Controlled Drug

Question 23

What are the Advantages / Disadvantages of Amitriptyline?

Answer 23

Advantages:

1. Cheap / Safe in low dose
2. Good for Neuropathic Pain
3. Also treats Depression / Poor Sleep

Disadvantages:
1. Anti-Cholinergic Side Effects - Glaucoma / Urinary Retention

Question 24

What are the potential Delivery Routes for Medication?

Answer 24

1. Oral
2. Rectal
3. Sublingual
4. Subcutaneous
5. Transdermal
6. Intramuscular
7. Intravenous

Question 25

What are the Delivery Routes for Local Anaesthetics?

Answer 25

1. Epidural (+/- Opiates) 2. Intrathecal (+/- Opiates) 3. Wound Catheters 4. Nerve Plexus Catheters 5. Local Infiltration of Wounds

Question 26

What are the different methods of Pain Assessment?

Answer 26

1. Verbal Rating Score 2. Numeral Rating Score 3. Visula Analogue Score 4. Smiling Faces 5. Abbey Pain Scale - for Confused Patients

Question 27

What are the Non-Drug Treatment Options?

Answer 27

1. Physical - R.I.C.E. / Surgery / Acupuncture / Massage / Physiotherapy 2. Psychological - Explanation / reassurance / Counselling

Question 28

How are Drug Treatments decided?

Answer 28

1. Neuropathic Pain - use alternative Analgesics +/- Psychological and Non-Drug treatments 2. Acute Pain - WHO Pain Ladder: Step 1 - Non-Opioids (Aspirin / SNAID's / Paracetamol) Step 2 - Mild Opioids (Codeine) +/- Non-Opioids Step 3 - Strong Opioids (e.g. Morphine) +/- Non-Opioids

Question 29

What is involved in the RAT Approach to Pain?

Answer 29

1. Recognize 2. Assess - Severity / Type / Other Factors 3. Treat - Non-Drug / Drug Treatments

Question 30

How is Pain Recognized?

Answer 30

1. Ask 2. Look - Frowning / Moving Easily / Sweating 3. Other Know - Health Workers / Patient's Family

Question 31

How is Pain Assessed?

Answer 31

1. Pain Score - At Rest / With Movement 2. How it is Affecting the Patient - Move / Cough / Work 3. Type of Pain - Acute vs Chronic / Cancer vs Non-Cancer / Nociceptive vs Neuropathic 4. Physical Factors - other illnesses 5. Psycholigical / Social Factors

Question 32

How is Pain Treated with Non-Drug Methods?

Answer 32

1. R.I.C.E. 2. Nursing Care 3. Surgery / Acupuncture / Massage / TENS 4. Psychological

Question 33

How is Pain Treated with Drug Methods?

Answer 33

1. Mild - Paracetamol (+/- NSAID's) 2. Moderate - Paracetamol (+/- NSAID's) + Codeine 3. Severe - Paracetamol (+/- NSAID's) + Morphine