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Basic Principles > 3 - Acute Pain > Flashcards

3 - Acute Pain Flashcards

1
Q

Allodynia

A

painful response to a normally non-painful stimuli

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2
Q

Hyperalgesia

A

exaggerated pain response to a normally painful stimuli

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3
Q

Neuronal Plasticity

A

Acute pain induced changes in the brain

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4
Q

What are nociceptors?

A

Free nerve endings located in the skin, muscle, bone

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5
Q

The nociceptice pathway is an ________ ascending system, made up of which two Nerve fiber types?

A

Afferent

A delta

Polymodal C

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6
Q

A delta fibers transmit _______

A

First pain

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7
Q

Polymodal C fibers transmit

A

Second Pain

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8
Q

What is the difference between first and second pain?

A

First pain is sharp and stinging

Second pain is dull/diffuse pain

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9
Q

What are the three primary afferent nerve fibers types?

A

A beta

A delta

C

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10
Q

What is the smallest afferent nerve fiber?

Largest?

Slowest?

Fastest?

A

C

A beta

C

A beta

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11
Q

A delta fibers carry signals from _______ receptors

C fibers carry signals from _______ receptors

A

specialized sensory

Free nerve ending

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12
Q

What are first order and second order neurons?

A

1st order neurons are located in the specialized sensors and carry impulses to the dorsal horn where they synapse with second order neurons on the same level

OR

ascend via lissauer’s tract to the second order neurons above

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13
Q

Where are third order neurons located?

A

in the reticular formation

periaqueductal gray

thalamus

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14
Q

What is the function of the efferent modulating pathway?

A

It sends impulses from the brain down to the level of the dorsal horn and modulates the response transmitted by afferent nerve fibers

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15
Q

What are the four elements of pain processing?

A
  1. Transduction
  2. Transmission
  3. Modulation
  4. Perception
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16
Q

Define:

Transduction

Transmission

A

Transduction is when a stimuli sparks an action potential in receptors

Transmission is when they action potential is passed to the first, second and third order neurons

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17
Q

Identify the location of cell bodies for the following:

First order neurons

Second order neurons

Third order neurons

A

Dorsal root

Dorsal Horn

Thalamus

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18
Q

Modulation involves altering ________

A

afferent neural transmission along the pain pathway

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19
Q

What is the most common site of modulation?

A

Dorsal Horn

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20
Q

List two types of spianl inhibitory modulation:

A
  1. Release inhibitory neurotransmitters (GABA)
  2. activation of efferent pathway (norepinephrine, serotonin 5HT, Enkephalin endorphin)
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21
Q

Traditional analgesic therapies targeted only _________

A

pain perception

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22
Q

IV fentanyl will affect which element of the pain pathway?

A

Perception

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23
Q

Ketamine will affect which element of the pain pathway?

A

Modulation

NMDA receptor antagonist

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24
Q

Duramorph will affect which element of the pain pathway?

A

Modulation

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25
Q

A peripheral nerve block will affect which element of the pain pathway?

A

Transmission

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26
Q

A bupivicaine epidural will affect which element of the pain pathway?

A

Transmission

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27
Q

How is preventive analgesia accomplished?

A

preventing NMDA receptor activation in the dorsal horn

(associated with windup, facilitation, central sensitization expansion of receptive fields, and long-term potentiation, all of which can lead to a chronic pain state)

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28
Q

What are the three necessities for preventive analgesia to be effective?

A
  1. Must block ALL nocicpetive stimulation during surgery
  2. Must include the entire surgical field
  3. Duration must span both operative and postoperative periods
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29
Q

What causes neuropathic pain?

A

Damage to the nerves themselves

may be delayed and may not be dermatomal

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30
Q

What are the top five surgeries that are known to cause neuropathic pain?

A
  1. Limb amuptation
  2. breast surgery
  3. gallbladder surgery
  4. thoracic
  5. inguinal repair
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31
Q

Codeine and tramadol are examples of ________

A

prodrugs

Require metabolism by CYP2d6 to be activated

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32
Q

Three primary mechanisms of opiods at the level of the spinal cord:

A

(1) inhibition of calcium influx presynaptically, resulting in inhibition of depolarization of the cell membrane and decreased release of neurotransmitters and neuropeptides into the synaptic cleft
(2) enhanced potassium efflux from the cell postsynaptically, resulting in hyperpolarization of the cell and a decrease in pain transmission
(3) activation of a descending inhibitory pain circuit via inhibition of GABAergic transmission in the brainstem

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33
Q

What are the signs of inadequate dosing of opiods during surgery?

A

dilated pupils

increased HR and BP

increased RR

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34
Q

multimodal perineural analgesia is a cocktail of:

A

buprenorphine

bupivicaine

clonidine

dexmedetomidine

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35
Q

NSAIDs inhibit:

A

Cyclooxygenase (COX) enzymes

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36
Q

Why do NSAIDs shred your stomach?

A

Cox 1 is responsible for gastric protection and hemostasis

Cox 2 produces prostaglandins which lead to pain and inflammation

If you inhibit cox to inhibit COX2, you also end up inhibiting COX1

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37
Q

Why do NSAIDS and COX2 inhibitors cause fluid retention and hypertension?

A

Prostaglandins play a crucial role in renal function because they are potent local and humoral vasodilators

If you block them, you get constriction in the afferent arterioles of the glomerulus, leading to fluid retention and high blood pressure

38
Q

How do inhaled volatiles effect neuromuscular function? (2)

A
  1. directly relax skeletal muscle (dose dependent)
  2. Potentiate the action of NMBA agents
39
Q

How is uterine muscle tone effected by inhaled anesthetics?

A

Decreased uterine tone

40
Q

When administering volatile anesthetics for an emergent c-section under general, what can be done to prevent uterine atony?

A

Use 05-0.75 MAC of gas in combination with N2O

41
Q

Experienced nurses tend to ________ pain

Inexperienced nurses tend to ________ pain

A

underestimate

overestimate

42
Q

What is glutamate?

A

Major excitatory neurotransmitter released from A delta and C nerve fibers

Fast, sharp pain

43
Q

What is nociceptive pain?

A

caused by the stimulation of specific nociceptors

44
Q

What are the two types of nociceptive pain?

A

Somatic (identifiable locus, sharp, stinging) - i.e. first pain

Visceral (dull, cramping, diffuse - i.e. second pain)

45
Q

Visceral pain is often associated with ________

A

distention of an organ capsule

obstruction of a hollow viscus

46
Q

Visceral pain is often accompanied by which autonomic reflexes?

A

Nausea

vomiting

diarrhea

47
Q

Non-nociceptive pain is categorized as _______

A

neuropathic

48
Q

What causes inflammatory pain?

A

multiple mediators released from the site of inflammation cause sensitization of the nociceptive pathway

49
Q

Pain transmitted by Polymodal C fibers is often described as _________

A

burning, throbbing, dull, aching

50
Q

What is Substance P?

A

released from C fibers

Involved in slow, chronic pain

51
Q

What is histamine?

A

Released from mast cells, basophils, and plateletes via substance P

Produces edema and vasodilation

Potentiates bradykinin pain

52
Q

What is serotonin?

A

Amine stored and released from platelets after tissue injury

Algesic effect on peripheral nociceptors

potentiates bradykinin pain

53
Q

What are prostaglandins?

A

metabolite synthesized from COX-1 and COX-2

Associated with chronic pain

Sensitizes peripheral nociceptors, causing hyperalgesia

54
Q

What are cytokines?

A

Mediators released by tissue damage and inflammation

lead to increased production of prostaglandin, causing excited and sensitized nociceptive fibers

55
Q

What is CGRP?

A

Calcitonin gene-related peptide

released from C fibers

causes sensitization of sensory nerves

56
Q

What happens when chemical mediators and neurotransmitters stimulate peripheral nociceptors?

A

sodium channels open

nerve is depolarized

action potential develops into a pain impuse

57
Q

What are the two types of second order neurons?

A

Nociceptive (received from A delta and C fibers)

Wide-dynamic Range (WDR) that receive from A delta, C, and A beta

58
Q

What is the other name for serotonin?

A

5HT

59
Q

Where do second order neurons synapse with third order neurons?

What happens once they do?

A

In the thalamus

Thalamus sends projection of pain to the cerebral cortex, the hypothalamus, and anterior cingulate

60
Q

The descending efferent modulatory pathways are considered the body’s __________

A

pain control system

61
Q

What are the excitatory neurotransmitters?

A

Substance P

Gultamate

62
Q

What receptor does Glutamate bind to in order to cause excitation?

A

NMDA receptor

This is how ketamine works

63
Q

What are the inhibitory neurotransmitters?

A

Glycine

GABA

Enkephalin

Serotonin

Norepinephrine

64
Q

Norepinephrine is an inhibitory neurotransmitter. How does this relate to regional anesthesia?

A

This is why A2 agonists cause analgesia. They bind to the Alpha 2 receptors, just like norepinephrine would, and inhibit pain transmission

65
Q

What are four predictors of post op pain?

A

Presence of preop pain

patient fear regarding the outcome of their surgery

patients who catastrophize pain

if post op pain is expected

66
Q

All NSAIDs possess what properties?

A

anti-inflammatory

anti-pyretic

analgesic

67
Q

Why does inhibiting COX decrease pain and inflammation?

A

By inhibiting COX, they prevent conversion of arachindonic acid to prostaglandins

Prostaglandins are responsible for sensitizing and ampliying peripheral nociceptors to the inflammatory mediators

68
Q

How do prostaglandins influence pain?

A

They do not directly cause pain

they contribute to hyperalgesia by increasing the sensitivity of nociceptors to inflammatory mediators

69
Q

30mg IM ketorolac is equivalent to how much morphine?

A

12mg IM

70
Q

When should ketorolac not be given?

A

Beyond five days

coagulopathy, renal failure, active ulcers, GI bleed, asthma

71
Q

Tylenol is not a true NSAID. So why does it decrease pain?

A

Reduces prostaglandin synthesis somehow

minimal anti-inflammatory effects

72
Q

How do opioids inhibit pain?

A

bind to and activate G-protein coupled receptors (GPCR) both peripherally and in the CNS

This inhibits calcium channels and decreases release of excitatory neurotransmitters (like substance P) presynaptically

It also hyperpolarizes the post-synaptic junction and inhibits response to excitatory neurotransmission

73
Q

What does NMDA stand for?

A

N-Methyl-D-Aspartate

74
Q

What is the resting state of the NMDA receptor?

A

Closed

plugged by magnesium

75
Q

What causes the NMDA receptor to open?

What happens once it does?

A

Glutamate

binding causes an influx of calcium, resulting in second messengers

Second messengers causes hyperexcitability of the NMDA receptors, which amps up algesia

Hence ketamine’s role in preventing “wind-up”

76
Q

Clonidine and Precedex are _______agonists

A

A2 adrenergic

77
Q

What do clonidine and precedex bind with?

A

GCPA A2 receptors in dorsal horn and peripherally

activation results in inhibition of cAMP 2nd messenger

78
Q

What happens when A2 agonists bind with GPCA?

A

decreased cAMP

presynaptic: inhibits voltage gated Ca channels
postsynaptic: activates potassium channels to hyperpolarize

79
Q

Which is more selectively an A2 adrenergic agonist, precedex or clonidine?

A

Precedex

80
Q

What would be the effect of A1 adrenergic agonist action?

A

sedation, hypotension, bradycardia

81
Q

How do local anesthetics block transmission?

A

block sodium channels in afferent and efferent neuronal membranes

82
Q

Which anticonvulsants are often used to treat pain?

A

gabapentin and lyrica

83
Q

Which antidepressants help with pain?

A

SNRIs

duloxetine, venlafaxine

84
Q

What is a unique side effect of methadone that isn’t seen with other opiods?

A

QT prolongation

85
Q

Define opioid tolerance

A

a change in the dose-response relationship

86
Q

What is opioid induced hyperalgesia?

A

escalating doses of opioids result in increasing hyperalgesia and allodynia

87
Q

What is the difference between opioid addiction and pseudoaddiction?

A

addiction is pathologically pursuing reward/relief by substance use (cravings, obsessive thoughts, compulsive use)

Pseudoaddiction in drug seeking behavior that is actually due to inadequate analgesia. when they receive higher doses, they no longer demonstrate drug seeking behavior

88
Q

Should you leave or remove an implanted intrathecal or epidural opioid infusion system preop?

A

It should stay and continue perioperatively

89
Q

In neonates, how well developed is the nociceptive pathway?

Descending pathway?

A

Well

Poorly

Leads to increased pain perception and stress response

90
Q

85% of ascending C fibers terminate in the:

A

Reticular Formation

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