ACE Review - pain Flashcards
What is allodynia
It is pain to a non painfuli stimuli
What is complex regional pain syndrome
It is a pain syndrome that has type 1 And type 2
What is crps type 1
Pain with the following. 1. Inciting event 2. not limited to one peripheral nerve 3. Pain out of proportion to inciting event.
What symptoms are associated with crps type 1.
Edema. Changes of skin blood flow. Pseudomotor abnormality. Allodyna or hyperalgesia
What is type 2 crps
- After a nerve lesion. Constant burning pain, allodynia, hyperpathia. Vasomotor changes and trophic changes.
What is neuralgia
Pain in the distribution of a nerve.
What is hyperalgesia
Increased pain to an already painful stimuli
What is the salient feature that distinguishes crps from neuralgia
The presence of sympathetic disturbances
What are sympathetic disturbances of crps
Sudomotor: sweating, pilomotor: goosebumps, vasomotor: edema or skin color changes
What kind of surgery may be associated with ulnar cutaneous nerve crps2 injury
Styloid process surgery of ulnar at the wrist
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?
Radial nerve injury
What are two types of organic pain
Nociceptive and neuropathic
What is nociceptive pain
Pain of somatic and visceral organs
What is neuropathic pain
Pain secondary to damages in the neuro pathway
What is the medication treatment for nociceptive pain
Opioids
What are the treatments for neuropathic pain
Tca, anticonvulsant, nmda
What is an example of nociceptive pain.
Pancreatitis
What is an example of neuropathic pain
Diabetic neuropathy, trigeminal neuralgia, multiple sclerosis
Neuropathic pain is secondary to efferent or afferent nerve involvement?
Afferent
What is physiological dependance.
When a patient shows signs of withdrawl when a substance is taken away, but has no behavioral problems. ( aka no addiction problems)
What is tolerance
When a patient requires increasing doses to maintain the same effect, but does not have behavioral problems ( aka no signs of addiction )
What is opioid induced hyperalgesia
Long term use of opioids causes patients to have increase pain to noxious stimuli
What is common in pt with opioid hyperalgesia
They usually complain of pain outside the initial site of injury
What are 5 terms to describe neuropathic pain
Allodynia, dysethesia, paresthesia, hyperesthesia, hyperpathia
What is hyperesthesia
Increases sensitivity to stimulation
What is allodynia
Pain due to a non noxious stimuli
What is hyperpathia
No sense of pain to a repetitive stimuli until a threshold is met and an explosive response is met
What is paresthesia
An ABNORMAL sensation (spontaneous or evoked) (like tingling)
What is dyesthesia
An UNPLEASANT sensation (spontaneous or evoked) (like burning)
Patients on chronic opiod used are more prone to what
That have an increase experience with pain and increase risk of respiratory depression
Are chronic opiod users more or less prone to nausea and itching
They are less prone to nausea and itching
What history or physical exam finding is a finding to rule out facet arthropaty
Pain radiating pass the knee
What is the history or physical exam pathonomonic for facet arthropathy
There is none
What test is pathonomonic for facet arthropathy
Medial branch blocks and intraarticular joint injections are not pathonomonic, but relief is strongly indicative of facet arthropathy
At what level is the celiac plexus
Below diaphragm, behind stomach, anterior to aorta, L1L2
What is the celiac plexus
It is a collection of cell bodies of the post synaptic neurons making the sympathetic chain
Where are the preganglion nerves of the celiac plexus coming from
T5 to t12
What are 2 transient effects that are seen with celiac plexus block
Hypotension (which may require IVf and pressors) and DIARRHEA
Does celiac plexus block cause complete pain relief
No. It only does visceral block, no somatic block
What is Allodynia
It is pain to a non noxious stimulus
herpes zoster…how long does it last
2-4 weeks
herpes zoster…what are the 3 goal of antiviral therapy
decrease chronic pain, decrease time of shedding, decrease of acute pain
herpes zoster…what are the 3 drugs u can use
famocyclovir, valcyclovir, acyclovir
herpes zoster…what are the better drugs to use
famocyclovir and valcyclovir bc more bioavailable
herpes zoster…when should u start antiviral drugs
within 72 hours of onset of symptoms
trigeminal neuralgia…how long do episodes last
a few minutes
trigeminal neuralgia…do patients have pain in between episodes
no
trigeminal neuralgia…where is the distribution of the pain
following the facial nerve…57% of the time on the right side of the face
trigeminal neuralgia…what age group gets this
usually after the age of 30
trigeminal neuralgia…people who have it before the age of 30 has what associated disease
multiple sclerosis
atypical face pain…how is it different from trigeminal neuralgia
there are not periods of pain free…there are no specific triggers
reflex sympathatic dystrophy of the face…how is it dfferent from trigeminal neuralgia
there are no pain free moments…usually has allodynia…has vasomotor changers
geniculate neuralgia….how is this pain described
pain near the ear
geniculate neuralgia…what nerve is this associated with
seventh cranial nerve
geniculate neuralgia…is the pain constant or paroxysmal
paroxysmal
trigeminal neuralgia…what is the medication treatment
carbamazepine…tegretol
trigeminal neuralgia…what is a second line adjunct that has been shown to improve pain
gabapentin
trigeminal neuralgia…what intervention can be done if medicaiton cannot help
retrogasserian rhizotomy
trigeminal neuralgia…what drug is used in retrogasserian rhizotomy
glycerol
trigeminal neuralgia…what is the side effect of retrogasserian rhizotomy
facial sensory loss
trigeminal neuralgia…what other intervention besides retrogasserian rihzotomy can be done
stellate ganglion block
trigeminal neuralgia…what are the side effects of a stellate ganglion block
there will be sympathectomy associated with this block as well as faical sensory loss
what is the stellate ganglion block useful for
reflex sympathetic dystrophy of the face
Mastectomy…what nerve is the pain if there is axillary pain as well as upper inner arm pain
Intercostal Brachialis
Mastectomy…what nerve makes up the intercostal brachailis
T2 and sometimes t3
Mastectomy…what kind causes more intercostal nerve damage
Implants are associated with 50% chance…30% in no implants and 30% in mastectomy with no reconstruction.
Mastectomy…what treatment can increase likelihood of post surgical breast pain.
Chemotherapy.
Mastectomy…what is the treatment for post surgical Breast pain.
Snri and tca
Mastectomy…what is a Tca that is useful in treating post surgical breast pain
Amytriptyline
Mastectomy…what is an snri that is useful for post surgical breast pain
Venlafaxine
Trochanteric bursitis…where is the pain
Directly over the greater trochanter
Trochanteric bursitis…what can be done to make sure that it is not a ridiculous thy
Check for motor or sensory loss…if there is any…it is more likely L2 radiculopathy
Trochanteric bursitis…what physical exam test can be done to make sure it is not a radiculopathy of L2
Do flexion and extension of the spine…if pain is not worsened…it is not likely radiculopathy
Meralgia peresthetica…what nerve injury is it
It is lateral femoral cutaneous nn injury
Meralgia peresthetica…where is the pain distribution.
Lateral side of the thigh
Meralgia paresthetica…where is the pressure point that can illicit the pain.
Anterior iliac spine.
Meralgia paresthetica…what surgeries are associated with this pain.
Inguinal canal surgery, or surgery of the anterior superior iliac spine
Avascular necrosis …where is the pain…
Groin region
Avascular necrosis.. How can you exacerbate the pain.
Internal rotation of the hip
Avascular necrosis…you have normal radiographs…what other test can u do to check for it
MRI
Trochanter bursitis…what treatment can you do to diagnose it
Local anesthetic injection
Trochanteric bursitis…what is a long term treatment for it
Steroid injection into the bursa
Trochanteric bursitis…what is a treatment for those refractory to steroid injection
Iliotibial band release
Tolerance. Are chronic opioid users more or less post op nausea and vomit.
Less nausea and vomit
Tolerance. Are chronic opiod users more or less postoperative respiratory depression.
They are more prone to postoperative respiratory depression.
Trigeminal neuralgia. What is the nerve is the problem
Cranial nerve 5. The trigeminal nerve.
Trigeminal neuralgia. Is the facial nerve the problem.
No. Facial nerve is cn7.
Trigeminal neuralgia. What is the best intervention treatment
Percutaneous radiofrequency Rhizotomy of the gasserian ganglion.
Facial nerve. Injury to this will cause what
Geniculate neuralgia or hemifacial spasm.
Facial nerve. What is be geniculate neuralgia presentation
Pain in the ear area.
Trigeminal neuralgia. What are the landmarks of the gasserian ganglion Rhizotomy procedure
Needle is first at the corner of the out and aims toward the foremen ovale near the sphenoid bone.
Trigeminal neuralgia. What is a complication of trigeminal neuralgia gasserian ganglion radiofrequency Rhizotomy
It can lead to more facial pain even if the ganglion is ablated …called anesthesia dolorosa
Pca. What is a basal rate most likely associated with.
Respiratory depression.
Pca. Is there a decrease in demand does when a basal rate is given.
No.
Pca. Is there improved pain or sleep with a basal rate
No.
Codeine. What is special About this drug
It is dependent on the liver cyp2d6 for metabolism.
Codeine. How potent is it compared to morphine.
It is 300 times less affinity for the mu receptor.
Codeine. How much of the oral drug is converted to morphine with normal cyp2d6
Only 2-3 percent.
Codeine. What can happen to some people who have low levels ofcyp2d6
They will not get pain relieve
Codeine. What patients can have low cyp2d6
Pt who are on fluoxetine because this antidepressant can reduce thecyp2d6 function
Codeine. Can it ever cause fatality if it is this non potent.
It can cause mortality in some patients who are hypermetabolizers. Some have a genetic mutation of the cyp2d6
Codeine. How can u test for a high metabolizer condition.
In your dead patient, you can check for high amounts of morphine
Codeine. What drug also has similar pharmacodynamics to Codine
Hydrocodone
methadone. where is the site of action
agonist of mu, snri, and nmda antagonist
methadone. what is special about nmda antagonism
it prevents hyperalgesia…commonly associated with chronic opiod use that does not have nmda antagonism
ziconotide. what is this drug
n type voltage calcium channel blocker of conus magnus venomous snail used for pain
ziconotide. what is the route of administration
intrathecal
ziconotide. what is the side effect if given iv
profound hypotension
ziconotide. what is the side effect if given intrathecal
nystagmus, confusion, dizzyness
ziconotide. what should be attempted first before ziconotide use
optomization of nsaid, systemic opiods, adjuncts, and intrathecal morphine
intrathecal baclofen. what is it used for
spasticity and dystonia
crps. what is the long term outcome of most patients
resolution of their pain
crps. what can happen to their pain on the extremities
it may ascend and extend up the extremity
crps. what is it called when another limb experiences similar pain to the affected limb
mirror pain
pain receptors. how do c fibers differ from a-delta fibers
c-fibers can exhibit temoporal summation
pain receptors. why are c fibers suspects of chronic pain
because they can exhibit temporal summation
pain receptors. c fibers. what is temporal summation
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
pain receptors. what kinds of pain are related to temporal summation
allodynia or hyperalgesia
pain receptors. what drugs are used to prevent temporal summation
nmda antagonist
Methadone. What are the receptors of interest
Mu agonist. Delta agonist. Nmda antagonism.
Methadone. Compared to morphine. Which has more affinity for the receptor.
Morphine.
Methadone. When is the onset of effect.
30 mins.
Methadone. How long does it last.
It can accumulate in the system up to 1 week after discontinuation
Methadone. Why is it good for use in chronic pain.
Because it activates the delta receptor. This receptor has a role in tolerance. Thus it can help from decreasing effects of tolerance.
Methadone. What cardiac risk does it have.
It can cause prolong qt and then lead to torsades.
pancreatic cyst. what kind of block will work in treating it
celiac ganglion block
pancreatic cyst. what is an adverse effect of celiac block
lysis an sympathetics…increase parasymp tone…diarrhea
celiac plexus block. why do u have to block a sympathetic chain for visceral pain
because both visceral and sympathetic nerves share the same nerve bundle
duloxetine. what kind of pain is it used for
diabetic periphereal neuropathy
duloxetine. moa
snri
duloxetine. how would an snri help with diabetic neuropathy
the increase in serotonin and norepi help enhance inhibitory neurons that inhibit transmission from nociceptive ascending nerve fibers
duloxetine. besides snri. does it do nmda blockade
no
suboxone. what is it
buprenorphine/naloxone
suboxone. compared to morphine. which has more mu affinity
it has higher mu affinity, but once bound has less activation compared to morphine…thus morphine is the better analgesic
suboxone. what does it do to the kappa recepetor
antagonist
suboxone. if taken before surgery. will the naloxone affect the intraop opiods?
no…suboxone is given sublingual…so its systemic absorption is so low, that it does not effect intraop opiods
suboxone. so why is naloxone given if it does not prevent abuse of other IV narcotics
it is placed in the sublingual pill to prevent abuse of the suboxone itself
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
these pts may be more resistant and have higher tolerance to pain meds bc the buprenorphine may antagonize other IV mu drugs
