ACE Review - pain Flashcards
1
Q
What is allodynia
A
It is pain to a non painfuli stimuli
2
Q
What is complex regional pain syndrome
A
It is a pain syndrome that has type 1 And type 2
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.
4
Q
What symptoms are associated with crps type 1.
A
Edema. Changes of skin blood flow. Pseudomotor abnormality. Allodyna or hyperalgesia
5
Q
What is type 2 crps
A
- After a nerve lesion. Constant burning pain, allodynia, hyperpathia. Vasomotor changes and trophic changes.
6
Q
What is neuralgia
A
Pain in the distribution of a nerve.
7
Q
What is hyperalgesia
A
Increased pain to an already painful stimuli
8
Q
What is the salient feature that distinguishes crps from neuralgia
A
The presence of sympathetic disturbances
9
Q
What are sympathetic disturbances of crps
A
Sudomotor: sweating, pilomotor: goosebumps, vasomotor: edema or skin color changes
10
Q
What kind of surgery may be associated with ulnar cutaneous nerve crps2 injury
A
Styloid process surgery of ulnar at the wrist
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
12
Q
What are two types of organic pain
A
Nociceptive and neuropathic
13
Q
What is nociceptive pain
A
Pain of somatic and visceral organs
14
Q
What is neuropathic pain
A
Pain secondary to damages in the neuro pathway
15
Q
What is the medication treatment for nociceptive pain
A
Opioids
16
Q
What are the treatments for neuropathic pain
A
Tca, anticonvulsant, nmda
17
Q
What is an example of nociceptive pain.
A
Pancreatitis
18
Q
What is an example of neuropathic pain
A
Diabetic neuropathy, trigeminal neuralgia, multiple sclerosis
19
Q
Neuropathic pain is secondary to efferent or afferent nerve involvement?
A
Afferent
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)
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 )
22
Q
What is opioid induced hyperalgesia
A
Long term use of opioids causes patients to have increase pain to noxious stimuli
23
Q
What is common in pt with opioid hyperalgesia
A
They usually complain of pain outside the initial site of injury
24
Q
What are 5 terms to describe neuropathic pain
A
Allodynia, dysethesia, paresthesia, hyperesthesia, hyperpathia
25
What is hyperesthesia
Increases sensitivity to stimulation
26
What is allodynia
Pain due to a non noxious stimuli
27
What is hyperpathia
No sense of pain to a repetitive stimuli until a threshold is met and an explosive response is met
28
What is paresthesia
An ABNORMAL sensation (spontaneous or evoked) (like tingling)
29
What is dyesthesia
An UNPLEASANT sensation (spontaneous or evoked) (like burning)
30
Patients on chronic opiod used are more prone to what
That have an increase experience with pain and increase risk of respiratory depression
31
Are chronic opiod users more or less prone to nausea and itching
They are less prone to nausea and itching
32
What history or physical exam finding is a finding to rule out facet arthropaty
Pain radiating pass the knee
33
What is the history or physical exam pathonomonic for facet arthropathy
There is none
34
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
35
At what level is the celiac plexus
Below diaphragm, behind stomach, anterior to aorta, L1L2
36
What is the celiac plexus
It is a collection of cell bodies of the post synaptic neurons making the sympathetic chain
37
Where are the preganglion nerves of the celiac plexus coming from
T5 to t12
38
What are 2 transient effects that are seen with celiac plexus block
Hypotension (which may require IVf and pressors) and DIARRHEA
39
Does celiac plexus block cause complete pain relief
No. It only does visceral block, no somatic block
40
What is Allodynia
It is pain to a non noxious stimulus
41
herpes zoster...how long does it last
2-4 weeks
42
herpes zoster...what are the 3 goal of antiviral therapy
decrease chronic pain, decrease time of shedding, decrease of acute pain
43
herpes zoster...what are the 3 drugs u can use
famocyclovir, valcyclovir, acyclovir
44
herpes zoster...what are the better drugs to use
famocyclovir and valcyclovir bc more bioavailable
45
herpes zoster...when should u start antiviral drugs
within 72 hours of onset of symptoms
46
trigeminal neuralgia...how long do episodes last
a few minutes
47
trigeminal neuralgia...do patients have pain in between episodes
no
48
trigeminal neuralgia...where is the distribution of the pain
following the facial nerve...57% of the time on the right side of the face
49
trigeminal neuralgia...what age group gets this
usually after the age of 30
50
trigeminal neuralgia...people who have it before the age of 30 has what associated disease
multiple sclerosis
51
atypical face pain...how is it different from trigeminal neuralgia
there are not periods of pain free...there are no specific triggers
52
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
53
geniculate neuralgia....how is this pain described
pain near the ear
54
geniculate neuralgia...what nerve is this associated with
seventh cranial nerve
55
geniculate neuralgia...is the pain constant or paroxysmal
paroxysmal
56
trigeminal neuralgia...what is the medication treatment
carbamazepine...tegretol
57
trigeminal neuralgia...what is a second line adjunct that has been shown to improve pain
gabapentin
58
trigeminal neuralgia...what intervention can be done if medicaiton cannot help
retrogasserian rhizotomy
59
trigeminal neuralgia...what drug is used in retrogasserian rhizotomy
glycerol
60
trigeminal neuralgia...what is the side effect of retrogasserian rhizotomy
facial sensory loss
61
trigeminal neuralgia...what other intervention besides retrogasserian rihzotomy can be done
stellate ganglion block
62
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
63
what is the stellate ganglion block useful for
reflex sympathetic dystrophy of the face
64
Mastectomy...what nerve is the pain if there is axillary pain as well as upper inner arm pain
Intercostal Brachialis
65
Mastectomy...what nerve makes up the intercostal brachailis
T2 and sometimes t3
66
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.
67
Mastectomy...what treatment can increase likelihood of post surgical breast pain.
Chemotherapy.
68
Mastectomy...what is the treatment for post surgical Breast pain.
Snri and tca
69
Mastectomy...what is a Tca that is useful in treating post surgical breast pain
Amytriptyline
70
Mastectomy...what is an snri that is useful for post surgical breast pain
Venlafaxine
71
Trochanteric bursitis...where is the pain
Directly over the greater trochanter
72
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
73
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
74
Meralgia peresthetica...what nerve injury is it
It is lateral femoral cutaneous nn injury
75
Meralgia peresthetica...where is the pain distribution.
Lateral side of the thigh
76
Meralgia paresthetica...where is the pressure point that can illicit the pain.
Anterior iliac spine.
77
Meralgia paresthetica...what surgeries are associated with this pain.
Inguinal canal surgery, or surgery of the anterior superior iliac spine
78
Avascular necrosis ...where is the pain...
Groin region
79
Avascular necrosis.. How can you exacerbate the pain.
Internal rotation of the hip
80
Avascular necrosis...you have normal radiographs...what other test can u do to check for it
MRI
81
Trochanter bursitis...what treatment can you do to diagnose it
Local anesthetic injection
82
Trochanteric bursitis...what is a long term treatment for it
Steroid injection into the bursa
83
Trochanteric bursitis...what is a treatment for those refractory to steroid injection
Iliotibial band release
84
Tolerance. Are chronic opioid users more or less post op nausea and vomit.
Less nausea and vomit
85
Tolerance. Are chronic opiod users more or less postoperative respiratory depression.
They are more prone to postoperative respiratory depression.
86
Trigeminal neuralgia. What is the nerve is the problem
Cranial nerve 5. The trigeminal nerve.
87
Trigeminal neuralgia. Is the facial nerve the problem.
No. Facial nerve is cn7.
88
Trigeminal neuralgia. What is the best intervention treatment
Percutaneous radiofrequency Rhizotomy of the gasserian ganglion.
89
Facial nerve. Injury to this will cause what
Geniculate neuralgia or hemifacial spasm.
90
Facial nerve. What is be geniculate neuralgia presentation
Pain in the ear area.
91
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.
92
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
93
Pca. What is a basal rate most likely associated with.
Respiratory depression.
94
Pca. Is there a decrease in demand does when a basal rate is given.
No.
95
Pca. Is there improved pain or sleep with a basal rate
No.
96
Codeine. What is special About this drug
It is dependent on the liver cyp2d6 for metabolism.
97
Codeine. How potent is it compared to morphine.
It is 300 times less affinity for the mu receptor.
98
Codeine. How much of the oral drug is converted to morphine with normal cyp2d6
Only 2-3 percent.
99
Codeine. What can happen to some people who have low levels ofcyp2d6
They will not get pain relieve
100
Codeine. What patients can have low cyp2d6
Pt who are on fluoxetine because this antidepressant can reduce thecyp2d6 function
101
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
102
Codeine. How can u test for a high metabolizer condition.
In your dead patient, you can check for high amounts of morphine
103
Codeine. What drug also has similar pharmacodynamics to Codine
Hydrocodone
104
methadone. where is the site of action
agonist of mu, snri, and nmda antagonist
105
methadone. what is special about nmda antagonism
it prevents hyperalgesia...commonly associated with chronic opiod use that does not have nmda antagonism
106
ziconotide. what is this drug
n type voltage calcium channel blocker of conus magnus venomous snail used for pain
107
ziconotide. what is the route of administration
intrathecal
108
ziconotide. what is the side effect if given iv
profound hypotension
109
ziconotide. what is the side effect if given intrathecal
nystagmus, confusion, dizzyness
110
ziconotide. what should be attempted first before ziconotide use
optomization of nsaid, systemic opiods, adjuncts, and intrathecal morphine
111
intrathecal baclofen. what is it used for
spasticity and dystonia
112
crps. what is the long term outcome of most patients
resolution of their pain
113
crps. what can happen to their pain on the extremities
it may ascend and extend up the extremity
114
crps. what is it called when another limb experiences similar pain to the affected limb
mirror pain
115
pain receptors. how do c fibers differ from a-delta fibers
c-fibers can exhibit temoporal summation
116
pain receptors. why are c fibers suspects of chronic pain
because they can exhibit temporal summation
117
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
118
pain receptors. what kinds of pain are related to temporal summation
allodynia or hyperalgesia
119
pain receptors. what drugs are used to prevent temporal summation
nmda antagonist
120
Methadone. What are the receptors of interest
Mu agonist. Delta agonist. Nmda antagonism.
121
Methadone. Compared to morphine. Which has more affinity for the receptor.
Morphine.
122
Methadone. When is the onset of effect.
30 mins.
123
Methadone. How long does it last.
It can accumulate in the system up to 1 week after discontinuation
124
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.
125
Methadone. What cardiac risk does it have.
It can cause prolong qt and then lead to torsades.
126
pancreatic cyst. what kind of block will work in treating it
celiac ganglion block
127
pancreatic cyst. what is an adverse effect of celiac block
lysis an sympathetics...increase parasymp tone...diarrhea
128
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
129
duloxetine. what kind of pain is it used for
diabetic periphereal neuropathy
130
duloxetine. moa
snri
131
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
132
duloxetine. besides snri. does it do nmda blockade
no
133
suboxone. what is it
buprenorphine/naloxone
134
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
135
suboxone. what does it do to the kappa recepetor
antagonist
136
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
137
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
138
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
