Acute Pain Flashcards by Eresi Obewu

What is meant by pain?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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True/False: pain report is the most reliable indicator of pain

True

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Tie/False: pain remains the most inadequately or mapproprantely treated issue

True

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True/False: it requires a multidisciplinary team to address pain management needs

True

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What are the two types of pain

Nociceptive

Pathophysiologic

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Which pain type occurs due to protection and is physiologic in nature

Nociceptive

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Which pain is harmful

Pathophysiologic

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Chronic pain for example neuropathic pain is what type of pain?

Pathophysiologic

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What are the two types of nociceptive pain?

Somatic

Visceral

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Pain arising from skin, bone, joint, muscle or any type of connective tissue is called

Somatic nociceptive pain

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How is somatic nociveptive pain described

Throbbing, well localized

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What type of pain arise from internal organ such as large intestine, pancreas etc or pain coming from other structures

Visceral nociceptive pain

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Nociceptive pain is usually what category of pain

Acute pain

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List examples of conditions that can give rise to acute pain

Surgery

Acute illness

Trauma

Labor

Medical procedures

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What can unrelieved pain cause

Tachycardia

Chronic pain

Hyper-coagulable

Increased myocardial oxygen consumption

Immuno-suppression

Catabolism

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For each characteristic describe if is for acute and chronic pain

Relief of pain

Highly desirable for both

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For each characteristic describe if it is for acute and chronic pain

Dependence/Tolerance

Acute: unusual

Chronic: common

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For each characteristic describe if it is for acute and chronic pain

Physiologic component

Acute: rare

Chronic: often

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For each characteristic describe if it is for acute and chronic pain

Organic cause

Acute: common

Chronic: may not be present

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For each characteristic describe if it is for acute and chronic pain

Environmental or Social issues

Acute: small

Chronic: significant

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For each characteristic describe if it is for acute and chronic pain

Insomnia

Acute: unusual

Chronic: common

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For each characteristic describe if it is for acute and chronic pain

Treatment goal

Acute: pain reduction

Chronic: functionality and qualify of life

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For each characteristic describe if it is for acute and chronic pain

Depression

Acute: uncommon

Chronic: common

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What is the A in ABC’s of pain management

Assess pain systematically

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What is the B in ABC's of pain management

Baseline medication utilization

What is the C in ABC's of pain management

Choose most appropriate medication

What is the D in ABC's of pain management

Determine adjuncts /supportive care as well as follow ups and monitoring plans

What is the E in ABC's of pain management

Educate the patient

When a patient present to the clinic how do you best assess them for therapy recommendation

Comprehensive patient history and physical exam Patient report is the best tool Look for other indicators of pain but not used as a diagnostic of pain

What can be indicator of a patient is in pain

Changes in eating habit Agitation Hypertension Tachycardia Diaphoresis (Sweatingexcessively) Mydriasis (pupil dilation) Pallor (pale appearance)

What Assessment tools can guide you to identify how much pain a patient is experiences

PQRST-U VAS- visual analog scales ( no pain - worst possible pain) Graphic scale (emoji faces) Verbal pain (on a scale of one - ten) Functional pain scale (on a scale of one-five how does the pain limit your activity) Word descriptor scale Critical care pain observation tool

No pain

1-2

Mild pain

3-5

Moderate pain

6-7

Severe pain

8-9

Very severe pain

Worst possible pain

What 's the primary goal of acute pain relief

Rapid pain relief or reduction in pain intensity

What are the non-pharmacologic therapy that may provide some benefit

Physical manipulation Topical application of heat or cold Massage Exercise Acupuncture Biofeedback Cognitive behavioral therapy Relaxation

What is the cornerstone of acute pain management

Pharmacologic treatment

What is the best thing to look for when prescribing pharmacological pain therapy

Most effective pain analgesic with the fewest side effect

Therapy for mild-moderate pain

Acetaminophen or NSAIDs

Therapy for moderate-severe pain

Opioids

Choice of particular agent depends on what factor

Availability Cost PK Pharmacologic characteristics ADR

What is the preferred route of analgesic administration

Oral

When is onset via oral administration seen

45 minutes

What is the preferred rout for immediate relief

Parenteral route

When it comes to dosing frequency what should be considered

Initial around the clock or as needed

Easier to prevent pain than to treat once it occurs • As needed regimens rely on patient to ask for pain medications each dose (negative connotations) and produce wide swings in drug concentrations • May require escalating doses to relieve pain with PRN dosing which may precipitate side effects

Just know this

What is the use of acetaminophen

Antipyretic Antianalgesic No anti-inflammatory properties

Acetaminophen MOA

Prostaglandin synthesis inhibition in CNS to block pain impulse generation

Acetaminophen usual dose

325-1000 mg q 4-6hours

Acetaminophen max dose

4g daily

Which patient should maximum acetaminophen dose be 2g daily

Hepatic dysfunction Alcohol use Poor nutritional intake

What is the major toxicity of acetaminophen

Hepatotoxicity

What is a good monitoring parameter for acetaminophen dosing

Monitor total close of APAP utilized in all OTC or prescribed medication

When is IV acetaminophen (ofirmev) used

In postoperative pain

What is the use of NSAIDs

Antipyretic Analgesic Anti-inflammatory

NSAIDs MOA

Reversible inhibition a COX 1 and2 enzymes which decrease formation of prostaglandin precursors

What does the higher dose of NSAIDs have more effect on

Inflammation. Ceiling effect exist for the analgesic effect of NSAIDs.

True or false: NSAIDs have dependence or tolerance

False

What are the most Common NSAIDs for acute pain

Ibuprofen Naproxen Ketorolac

What's the initial dose of ibuprofen

200-800 mg every 4-6 hours

What is the Max dose for ibuprofen

3200 mg daily

What is the initial dose of naproxen

275-550mg every 6-12 hours; variable by product

What is the max dose of naproxen

1100 mg daily

What is the route of administration for ketorolac

IM/IV

What is the initial dose of ketorolac

15-30mg IV or 60-120mg daily 1M-60 mg Every 6 hours

Holy is the maximum daily use of ketolorolac 5 days

To reduce risk of GI bleeding

Which patient should lower dose be given

Elderly ≥ 65 years Mild to moderate renal impairment

For which patient is ketorolac contraindicated

Several renal impairment Low body weight < 50 kg due to increased risk of bleeding

What is the GI ADR of NSAID

Acute GI: irritation, abdominal pain Chronic GI: bleeding

What are the risk factors for GI problem with NSAID use

Prior history of GI bleeding Corticosteroid use Anticoagulants Alcoholism Older age Chronic NSAID use Smoking H-Pylori

Which is the order for which GI problem is higher in NSAID use

Ibuprofen - least Aspirin Naproxen Ketorolac - most

What should you counsel patient an hour to reduce GI bleeding

Take with food or milk

For patient with high risk of GI bleeding or history of gastric ulcer what medication can be given to decrease their risk of developing GI ADR

PPI

What is the Hematologic ADR for NSAIDs use

Decreased platelet aggregation It is reversible depending on the drug half life

Who are at risk of developing Hematologic ADR with NSAIDs use

Anticoagulant Thrombocytopenia Prior GI bleed Elective surgery

What is the renal ADR for NSAID use

Decreased glomerular filtration ratel

Who are at risk for renal ADR from NSAID use.

Chronic or dual NSAID use Dehydration CHF Hepatic disease Concomitant use with ACEi

Which medication is reserved for moderate to severe pain

Opioid

Opioid MOA

Analgesic effect through central and peripheral opioid receptors ( mu receptors)

Is pain a ways eliminated in opioid use

No, however unpleasantness decreases meaning that they feel pain but it no longer bothers them

What is the GI ADR of opioid use

Decreased GI motility leading to constipation Nausea and vomiting

How is this constipation relieved in patients taking opioid

prescibe stool softener with or without a stimulant

How is nausea and vomiting in patients taking opioids managed

Antiemetic

What CNS effect might opioid have

Sedation

Why can opioid use cause rash

Some activate the release of histamine from mast cells

How is opioid induced rash managed

Antihistamine but may contribute to sedation

What effect does opioid have On un'ne output and why this not worrisome

Urinary retention but patient will develop tolerance over time

How does opioid induce respiratory depression and how does it manifest

Respiratory Center becomes less responsive to Carbon dioxide causing progressive respiratory depression that manifest as decreased respiratory rate. This effect is dose dependent

What effect does opioid have On cough reflex

Opioids depresses it

What is the antidote for opioid induced respiratory depression

Naloxone - increase patient's respiratory rate

True/ false: naloxone can precipitate withdrawl sx

True

What is the natural occuring opioid

Morphine

What is the gold standard for severe pain

Morphine

Activate histamine release the most

Morphine Meperidine

Precipitate histamine release at a lesser degree

Hydromorphone Oxycodone Fentanyl

Does not precipitate histamine release

Hydrocodone

What effect can morphine induce

Vasodilation Decrease myocardial oxygen demand Sphincter of Oddi spasms

Why should morphine be dosed cautiously m patient with renal impairment

Active metabolite are cleared really and can accumulate

What are the semi synthetic opioids

Hydromorphone Hydrocodone Oxycodone

Which have similar effect as morphine but with fewer side effect

Hydromorphone

Which is available as combination product only

Hydrocodone

Which comes as a single or combination drug

Oxycodone

Used for moderate to severe pain

Hydrocodone Oxycodone

Which have similar effect to morphine but is less potent and have shorter duration of action

Meperidine

Caution in elderly and renal impaired patient

Meperidine

Which has a metabolite that is venally cleared and accumulation and can cause CNS excitability such as tremor, myoclonus, seizures

Meperidine

Which opioid has no analgesic advantage

Meperidine

Which opioid is the most potent, lipophilic and shorter acting

Fentanyl

Gold standard for ICU or OR

Fentanyl

Caution in dosing errors but safe for renal impairment

Hydromorphone Fentanyl

Severe pain opioid

Morphine Hydromorphone Meperidine Fentanyl

By mouth only closed at 5-10mg every 4-6hours

Hydrocodone Oxycodone

IM only dosed at 50-150mg every 3-4hours

Meperidine

IV and IM only dosed in micrograms

Fentanyl

Steps 1 of WHO analgesic ladder for mild pain

Non-opioids with or without adjuvants for neuropathic or bone pain

Step 2 of WHO analgesic ladder for mild to moderate pain

As needed opioid Codeine Combination opioids with acetaminophine or ibuprofen Tramadol

Step 3 of WHO analgesic ladder for moderate to severe pain

Around the clock dosing Morphine Oxycodone Hydrocodone Fentanyl Hydromorphone