Acute & Chronic Pain (Singh) Flashcards
large diameter primary afferent neurons that resond to touch, vibration, limb position and fine discrimination
A beta fibers
small diameter slower conducting primary afferent neurons that are responsible for sharp, pricking or stabbing “first pain”
A delta fibers
these are small diameter, unmyelinated, slowly conducting primary afferent neurons that are responsible for the diffuse, spreading or burning type of “second pain”
C fibers
Which of the following is the not an appropriate use of local anesthetics?
A. IV regional anesthesia for a patient with a tourniquet on his arm
B. Infiltation anesthesia for suturing a laceration on a child’s face
C. Peripheral nerve block for a patient undergoing intra-arterial thrombolysis
D. Central neuraxial block for a woman in labor
C. Peripheral and central neuraxial blocks are contraindicated in patients who are anticoagulated.
Which of the following statements about opioids is TRUE?
A. Are not commonly used post-operatively because of the risk of addiction
B. They are most efficacious for neuropathic pain
C. They should not be given to treat nociceptive pain because of build up tolerance
D. Appropriate use of opioids for managing acute pain does not necessarily increase the risk of addiction or abuse
D.
A - opioids are commonly used post-operatively for management of pain
B and C - opioids are efficacious for acute nociceptive pain but not for neuropathic pain
this class of meds is efficacious for acute pain management but is not widely used in the post-op setting and is not a good choice for patients with renal damage
anti-inflammatory meds
45 yo man is having a thoracotomy for a lung tumor. He has a 30 pack year smoking history and moderate COPD, with no other comorbidities, and uses inhalers for symptom control. Which of the following would be least beneficial to the patient in combination therapy?
A. NSAIDs
B. Tylenol
C. PCA opioids
D. Nerve blocks
E. Epidural analgesia
D. Nerve blocks are a good option but are short lasting, only about 6-12 hours of pain relief. Ideal management of this patient would be preoperative epidural catheter placement, scheduled tylenol with judicious use of NSAIDs, and PCA with opioid.
A 50 yo male with recent MI and stent placement 3 weeks ago has reminaed on plavix since the stent placement. He isnow presenting with subacute bowel obstruction and is scheduled for a laparotomy. Which of the following is the best choice for managing this patient’s post operative pain?
A. NSAIDs
B. Epidural analgesia
C. PCA opioids
D. PRN opioids
C. NSAIDs are not a good idea as this patient is on a blood thinner and his risk of bleeding would be increased. Epidural is contraindicated for patients on anticoagulant therapy. PRN opioids are ok but not better than PCA - PCA is always preferable to avoid troughs and peaks in pain relief and to prevent overdose.
Which of the following statements regarding the use of opioids for non-cancer pain is TRUE?
A. Weak opioids are first on the WHO pain management ladder and is the primary treatment of choice in chronic pain.
B. Treatment of chronic pain with opioids is a widely accepted therapeutic practice
C. Opioids for chronic pain offers no better decrease in pain than any other drugs.
D. Long term use of opioids is considered safe but should be evaluated carefully - long term side effects are unknown.
C. Statistics show a 20-30% decrease, which is the same for other medications.
A - weak opioids are the second step after NSAIDs and tylenol, and given the lack of long term benefit these are not first line agents if pain is expected to last longer than 1 month
B - treatment of chronic pain with opioids is highly controversial.
D - long term side effects are known and include osteoprosis, immune suppression, sexual dysfunction and opioid hyperalgesia
for chronic low back pain, imaging is recommended in patients with pain > ____ months
3
*imaging recommended prior to 3 months if there is significant incapacitation due to pain or if there are red flags: cancer risk, trauma, signs of infection, neurological problems
A 43 yo obese woman with moderatley sedentary lifestyles presents with low back pain and numbness/tingling in the S1 territory (post thigh, calf, outer foot) for 3 months. No inciting event is noted. PE confirms reduced sensation and pain with straight leg raise on the left side. How should this be treated?
A. S1 epidurla steroid injection
B. Physical therapy and simple analgesics
C. Weak opioids since it has been 3 months of pain
D. Muscle relaxants only are needed at this point
B
this type of pain is associated with taut bands of muscle that may induce limitation of movement, perhaps caused by overuse, trauma, or prolnged muscle tension from poor posture
myofascial pain
*no specific diagnostic test; diagnosis made by history and PE
38 yo male construction worker has a h/o 4 months of progressively worse, constant daly dull aching pain in the base of his neck, upper back and shoulders. On PE there is tenderness to palpation of his cervico-thoracic-paraspinous muscles with focal areas of increased musle tone and exquisite pain with radiation. Limited ROM of neck and shoulders. No other relevant findings. Which of the following would be the least appropriate component of initial therapy?
A. Physical therapy
B. NSAIDs and muscle relaxants
C. Ice/heat
D. Trigger point injections
E. Massage
D.
Which of the following would be least effective in the treatment of neuropathic pain?
A. Gabapentin
B. Amitriptyline
C. Duloxetine
D. Tramadol
E. Carbamazepine
D. Tramadol is an opioid, and these have not been shown to be effective against neuropathic pain.
Non-conventional medications that seem to work against neuropathic pain are:
- antidepressants - amitriptyline, nortriptyline, duloxetine
- anticonvulsants - gabapentin, pregabalin (gabapentanoids); oxcarbazepine, carbamazepine (Na channel blockers)
Which of the follwing regarding neuropathic pain treatment is FALSE?
A. Fundamental pillars of treatment are anticonvulsants and antidepressants
B. Non pharmacologic strategies have been shown to have very little impact
C. Adjuvant drugs can and should be used
D. 30% improvement in pain indicates appropriate therapy
E. Spinal cord stimulation and intrathecal drug delivery systems can be successful
B
