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ACE Review - pain Flashcards

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1
Q

What is allodynia

A

It is pain to a non painfuli stimuli

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2
Q

What is complex regional pain syndrome

A

It is a pain syndrome that has type 1 And type 2

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3
Q

What is crps type 1

A

Pain with the following. 1. Inciting event 2. not limited to one peripheral nerve 3. Pain out of proportion to inciting event.

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4
Q

What symptoms are associated with crps type 1.

A

Edema. Changes of skin blood flow. Pseudomotor abnormality. Allodyna or hyperalgesia

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5
Q

What is type 2 crps

A
  1. After a nerve lesion. Constant burning pain, allodynia, hyperpathia. Vasomotor changes and trophic changes.
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6
Q

What is neuralgia

A

Pain in the distribution of a nerve.

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7
Q

What is hyperalgesia

A

Increased pain to an already painful stimuli

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8
Q

What is the salient feature that distinguishes crps from neuralgia

A

The presence of sympathetic disturbances

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9
Q

What are sympathetic disturbances of crps

A

Sudomotor: sweating, pilomotor: goosebumps, vasomotor: edema or skin color changes

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10
Q

What kind of surgery may be associated with ulnar cutaneous nerve crps2 injury

A

Styloid process surgery of ulnar at the wrist

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11
Q

What kind of nerve injury would have numbness at the webspace at the bottom of the thumb and at the dorsal surface of the wrist?

A

Radial nerve injury

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12
Q

What are two types of organic pain

A

Nociceptive and neuropathic

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13
Q

What is nociceptive pain

A

Pain of somatic and visceral organs

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14
Q

What is neuropathic pain

A

Pain secondary to damages in the neuro pathway

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15
Q

What is the medication treatment for nociceptive pain

A

Opioids

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16
Q

What are the treatments for neuropathic pain

A

Tca, anticonvulsant, nmda

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17
Q

What is an example of nociceptive pain.

A

Pancreatitis

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18
Q

What is an example of neuropathic pain

A

Diabetic neuropathy, trigeminal neuralgia, multiple sclerosis

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19
Q

Neuropathic pain is secondary to efferent or afferent nerve involvement?

A

Afferent

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20
Q

What is physiological dependance.

A

When a patient shows signs of withdrawl when a substance is taken away, but has no behavioral problems. ( aka no addiction problems)

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21
Q

What is tolerance

A

When a patient requires increasing doses to maintain the same effect, but does not have behavioral problems ( aka no signs of addiction )

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22
Q

What is opioid induced hyperalgesia

A

Long term use of opioids causes patients to have increase pain to noxious stimuli

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23
Q

What is common in pt with opioid hyperalgesia

A

They usually complain of pain outside the initial site of injury

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24
Q

What are 5 terms to describe neuropathic pain

A

Allodynia, dysethesia, paresthesia, hyperesthesia, hyperpathia

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25
Q

What is hyperesthesia

A

Increases sensitivity to stimulation

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26
Q

What is allodynia

A

Pain due to a non noxious stimuli

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27
Q

What is hyperpathia

A

No sense of pain to a repetitive stimuli until a threshold is met and an explosive response is met

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28
Q

What is paresthesia

A

An ABNORMAL sensation (spontaneous or evoked) (like tingling)

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29
Q

What is dyesthesia

A

An UNPLEASANT sensation (spontaneous or evoked) (like burning)

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30
Q

Patients on chronic opiod used are more prone to what

A

That have an increase experience with pain and increase risk of respiratory depression

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31
Q

Are chronic opiod users more or less prone to nausea and itching

A

They are less prone to nausea and itching

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32
Q

What history or physical exam finding is a finding to rule out facet arthropaty

A

Pain radiating pass the knee

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33
Q

What is the history or physical exam pathonomonic for facet arthropathy

A

There is none

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34
Q

What test is pathonomonic for facet arthropathy

A

Medial branch blocks and intraarticular joint injections are not pathonomonic, but relief is strongly indicative of facet arthropathy

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35
Q

At what level is the celiac plexus

A

Below diaphragm, behind stomach, anterior to aorta, L1L2

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36
Q

What is the celiac plexus

A

It is a collection of cell bodies of the post synaptic neurons making the sympathetic chain

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37
Q

Where are the preganglion nerves of the celiac plexus coming from

A

T5 to t12

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38
Q

What are 2 transient effects that are seen with celiac plexus block

A

Hypotension (which may require IVf and pressors) and DIARRHEA

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39
Q

Does celiac plexus block cause complete pain relief

A

No. It only does visceral block, no somatic block

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40
Q

What is Allodynia

A

It is pain to a non noxious stimulus

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41
Q

herpes zoster…how long does it last

A

2-4 weeks

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42
Q

herpes zoster…what are the 3 goal of antiviral therapy

A

decrease chronic pain, decrease time of shedding, decrease of acute pain

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43
Q

herpes zoster…what are the 3 drugs u can use

A

famocyclovir, valcyclovir, acyclovir

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44
Q

herpes zoster…what are the better drugs to use

A

famocyclovir and valcyclovir bc more bioavailable

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45
Q

herpes zoster…when should u start antiviral drugs

A

within 72 hours of onset of symptoms

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46
Q

trigeminal neuralgia…how long do episodes last

A

a few minutes

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47
Q

trigeminal neuralgia…do patients have pain in between episodes

A

no

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48
Q

trigeminal neuralgia…where is the distribution of the pain

A

following the facial nerve…57% of the time on the right side of the face

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49
Q

trigeminal neuralgia…what age group gets this

A

usually after the age of 30

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50
Q

trigeminal neuralgia…people who have it before the age of 30 has what associated disease

A

multiple sclerosis

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51
Q

atypical face pain…how is it different from trigeminal neuralgia

A

there are not periods of pain free…there are no specific triggers

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52
Q

reflex sympathatic dystrophy of the face…how is it dfferent from trigeminal neuralgia

A

there are no pain free moments…usually has allodynia…has vasomotor changers

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53
Q

geniculate neuralgia….how is this pain described

A

pain near the ear

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54
Q

geniculate neuralgia…what nerve is this associated with

A

seventh cranial nerve

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55
Q

geniculate neuralgia…is the pain constant or paroxysmal

A

paroxysmal

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56
Q

trigeminal neuralgia…what is the medication treatment

A

carbamazepine…tegretol

57
Q

trigeminal neuralgia…what is a second line adjunct that has been shown to improve pain

A

gabapentin

58
Q

trigeminal neuralgia…what intervention can be done if medicaiton cannot help

A

retrogasserian rhizotomy

59
Q

trigeminal neuralgia…what drug is used in retrogasserian rhizotomy

A

glycerol

60
Q

trigeminal neuralgia…what is the side effect of retrogasserian rhizotomy

A

facial sensory loss

61
Q

trigeminal neuralgia…what other intervention besides retrogasserian rihzotomy can be done

A

stellate ganglion block

62
Q

trigeminal neuralgia…what are the side effects of a stellate ganglion block

A

there will be sympathectomy associated with this block as well as faical sensory loss

63
Q

what is the stellate ganglion block useful for

A

reflex sympathetic dystrophy of the face

64
Q

Mastectomy…what nerve is the pain if there is axillary pain as well as upper inner arm pain

A

Intercostal Brachialis

65
Q

Mastectomy…what nerve makes up the intercostal brachailis

A

T2 and sometimes t3

66
Q

Mastectomy…what kind causes more intercostal nerve damage

A

Implants are associated with 50% chance…30% in no implants and 30% in mastectomy with no reconstruction.

67
Q

Mastectomy…what treatment can increase likelihood of post surgical breast pain.

A

Chemotherapy.

68
Q

Mastectomy…what is the treatment for post surgical Breast pain.

A

Snri and tca

69
Q

Mastectomy…what is a Tca that is useful in treating post surgical breast pain

A

Amytriptyline

70
Q

Mastectomy…what is an snri that is useful for post surgical breast pain

A

Venlafaxine

71
Q

Trochanteric bursitis…where is the pain

A

Directly over the greater trochanter

72
Q

Trochanteric bursitis…what can be done to make sure that it is not a ridiculous thy

A

Check for motor or sensory loss…if there is any…it is more likely L2 radiculopathy

73
Q

Trochanteric bursitis…what physical exam test can be done to make sure it is not a radiculopathy of L2

A

Do flexion and extension of the spine…if pain is not worsened…it is not likely radiculopathy

74
Q

Meralgia peresthetica…what nerve injury is it

A

It is lateral femoral cutaneous nn injury

75
Q

Meralgia peresthetica…where is the pain distribution.

A

Lateral side of the thigh

76
Q

Meralgia paresthetica…where is the pressure point that can illicit the pain.

A

Anterior iliac spine.

77
Q

Meralgia paresthetica…what surgeries are associated with this pain.

A

Inguinal canal surgery, or surgery of the anterior superior iliac spine

78
Q

Avascular necrosis …where is the pain…

A

Groin region

79
Q

Avascular necrosis.. How can you exacerbate the pain.

A

Internal rotation of the hip

80
Q

Avascular necrosis…you have normal radiographs…what other test can u do to check for it

A

MRI

81
Q

Trochanter bursitis…what treatment can you do to diagnose it

A

Local anesthetic injection

82
Q

Trochanteric bursitis…what is a long term treatment for it

A

Steroid injection into the bursa

83
Q

Trochanteric bursitis…what is a treatment for those refractory to steroid injection

A

Iliotibial band release

84
Q

Tolerance. Are chronic opioid users more or less post op nausea and vomit.

A

Less nausea and vomit

85
Q

Tolerance. Are chronic opiod users more or less postoperative respiratory depression.

A

They are more prone to postoperative respiratory depression.

86
Q

Trigeminal neuralgia. What is the nerve is the problem

A

Cranial nerve 5. The trigeminal nerve.

87
Q

Trigeminal neuralgia. Is the facial nerve the problem.

A

No. Facial nerve is cn7.

88
Q

Trigeminal neuralgia. What is the best intervention treatment

A

Percutaneous radiofrequency Rhizotomy of the gasserian ganglion.

89
Q

Facial nerve. Injury to this will cause what

A

Geniculate neuralgia or hemifacial spasm.

90
Q

Facial nerve. What is be geniculate neuralgia presentation

A

Pain in the ear area.

91
Q

Trigeminal neuralgia. What are the landmarks of the gasserian ganglion Rhizotomy procedure

A

Needle is first at the corner of the out and aims toward the foremen ovale near the sphenoid bone.

92
Q

Trigeminal neuralgia. What is a complication of trigeminal neuralgia gasserian ganglion radiofrequency Rhizotomy

A

It can lead to more facial pain even if the ganglion is ablated …called anesthesia dolorosa

93
Q

Pca. What is a basal rate most likely associated with.

A

Respiratory depression.

94
Q

Pca. Is there a decrease in demand does when a basal rate is given.

A

No.

95
Q

Pca. Is there improved pain or sleep with a basal rate

A

No.

96
Q

Codeine. What is special About this drug

A

It is dependent on the liver cyp2d6 for metabolism.

97
Q

Codeine. How potent is it compared to morphine.

A

It is 300 times less affinity for the mu receptor.

98
Q

Codeine. How much of the oral drug is converted to morphine with normal cyp2d6

A

Only 2-3 percent.

99
Q

Codeine. What can happen to some people who have low levels ofcyp2d6

A

They will not get pain relieve

100
Q

Codeine. What patients can have low cyp2d6

A

Pt who are on fluoxetine because this antidepressant can reduce thecyp2d6 function

101
Q

Codeine. Can it ever cause fatality if it is this non potent.

A

It can cause mortality in some patients who are hypermetabolizers. Some have a genetic mutation of the cyp2d6

102
Q

Codeine. How can u test for a high metabolizer condition.

A

In your dead patient, you can check for high amounts of morphine

103
Q

Codeine. What drug also has similar pharmacodynamics to Codine

A

Hydrocodone

104
Q

methadone. where is the site of action

A

agonist of mu, snri, and nmda antagonist

105
Q

methadone. what is special about nmda antagonism

A

it prevents hyperalgesia…commonly associated with chronic opiod use that does not have nmda antagonism

106
Q

ziconotide. what is this drug

A

n type voltage calcium channel blocker of conus magnus venomous snail used for pain

107
Q

ziconotide. what is the route of administration

A

intrathecal

108
Q

ziconotide. what is the side effect if given iv

A

profound hypotension

109
Q

ziconotide. what is the side effect if given intrathecal

A

nystagmus, confusion, dizzyness

110
Q

ziconotide. what should be attempted first before ziconotide use

A

optomization of nsaid, systemic opiods, adjuncts, and intrathecal morphine

111
Q

intrathecal baclofen. what is it used for

A

spasticity and dystonia

112
Q

crps. what is the long term outcome of most patients

A

resolution of their pain

113
Q

crps. what can happen to their pain on the extremities

A

it may ascend and extend up the extremity

114
Q

crps. what is it called when another limb experiences similar pain to the affected limb

A

mirror pain

115
Q

pain receptors. how do c fibers differ from a-delta fibers

A

c-fibers can exhibit temoporal summation

116
Q

pain receptors. why are c fibers suspects of chronic pain

A

because they can exhibit temporal summation

117
Q

pain receptors. c fibers. what is temporal summation

A

repetiton of a stimuli to the c fiber does not allow the c-fiber to return to base line…and each subsequent stimulation causes an increase response to a given stimuli

118
Q

pain receptors. what kinds of pain are related to temporal summation

A

allodynia or hyperalgesia

119
Q

pain receptors. what drugs are used to prevent temporal summation

A

nmda antagonist

120
Q

Methadone. What are the receptors of interest

A

Mu agonist. Delta agonist. Nmda antagonism.

121
Q

Methadone. Compared to morphine. Which has more affinity for the receptor.

A

Morphine.

122
Q

Methadone. When is the onset of effect.

A

30 mins.

123
Q

Methadone. How long does it last.

A

It can accumulate in the system up to 1 week after discontinuation

124
Q

Methadone. Why is it good for use in chronic pain.

A

Because it activates the delta receptor. This receptor has a role in tolerance. Thus it can help from decreasing effects of tolerance.

125
Q

Methadone. What cardiac risk does it have.

A

It can cause prolong qt and then lead to torsades.

126
Q

pancreatic cyst. what kind of block will work in treating it

A

celiac ganglion block

127
Q

pancreatic cyst. what is an adverse effect of celiac block

A

lysis an sympathetics…increase parasymp tone…diarrhea

128
Q

celiac plexus block. why do u have to block a sympathetic chain for visceral pain

A

because both visceral and sympathetic nerves share the same nerve bundle

129
Q

duloxetine. what kind of pain is it used for

A

diabetic periphereal neuropathy

130
Q

duloxetine. moa

A

snri

131
Q

duloxetine. how would an snri help with diabetic neuropathy

A

the increase in serotonin and norepi help enhance inhibitory neurons that inhibit transmission from nociceptive ascending nerve fibers

132
Q

duloxetine. besides snri. does it do nmda blockade

A

no

133
Q

suboxone. what is it

A

buprenorphine/naloxone

134
Q

suboxone. compared to morphine. which has more mu affinity

A

it has higher mu affinity, but once bound has less activation compared to morphine…thus morphine is the better analgesic

135
Q

suboxone. what does it do to the kappa recepetor

A

antagonist

136
Q

suboxone. if taken before surgery. will the naloxone affect the intraop opiods?

A

no…suboxone is given sublingual…so its systemic absorption is so low, that it does not effect intraop opiods

137
Q

suboxone. so why is naloxone given if it does not prevent abuse of other IV narcotics

A

it is placed in the sublingual pill to prevent abuse of the suboxone itself

138
Q

suboxone. so if the naloxone does not have effect on intraop opiods…are pt on chronic suboxone have any effect with pain meds intraop and post op

A

these pts may be more resistant and have higher tolerance to pain meds bc the buprenorphine may antagonize other IV mu drugs

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