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PHTY2101 EOS > B2 L31 Medical aspects of pain management > Flashcards

B2 L31 Medical aspects of pain management Flashcards

1
Q

What are the 4 steps in the standard medical perspective for symptom management?

A
  1. Diagnose cause (understand pathophysiology of problem)
  2. Develop management plan
  3. Review progress
  4. Re-evaluate
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2
Q

What are 2 features of acute pain?

A
  1. Indicates damage being inflicted NOW
  2. Demands action to prevent further damage
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3
Q

Acute main is one of the most ___ mechanisms. Why?

A

defensive mechanisms

  • feel pain when injury/damage is occurring
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4
Q

What are 3 features of chronic pain?

A
  1. Immediate damage not necessarily being done (“useless” pain- unlike acute pain)
  2. Persists in spite of appropriate action to prevent further damage
  3. Leads to behaviour that is very counter-productive
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5
Q

Explain the pathway from the start (damage to tissue) to the end (managing pain). 8 steps

A
  1. Damage to tissues
  2. Inflammation
  3. Nociceptors stimulated
  4. Input to anterior horn
  5. Cross midline (decussate)
  6. Goes up through contralateral spinothalamic tract
  7. Decussate (back to original side)
  8. Goes down through ipsilateral side to manage pain
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6
Q

What are 4 features of anterior horn synapse?

A
  1. Pain agonists
  2. Pain antagonists
  3. Noxious stimulus
  4. Quality of message to brain
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7
Q

What are 2 modifications to central pathways with chronic pain?

A

Persistent afferent impulses, esp slow fibres:

  1. New pathways laid down
  2. NMDA sensitisation,
    • damage to inhibitory neuronal paths
    • leads to “wind-up”
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8
Q

What is wind up? How does this have an effect on medication?

A

Pain accelerates for no particular reason

Medication stops working, need to use more for same effect

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9
Q

What is the modification of pain perception?

A
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10
Q

What are 2 forms of pain?

A
  1. Incident pain
    • Pain with an event – eg bathing
    • PREDICTABLE
  2. Breakthrough pain
    • Pain occurring when controlled analgesia already in place.
    • Related to sudden event – eg bleed into a tumour
    • UNPREDICTABLE
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11
Q

What is incident pain? How does that affect treatment?

A
  • Pain with an event – eg bathing
  • PREDICTABLE
  • Can give dose of medication before event
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12
Q

What is breakthrough pain? How does that affect treatment?

A
  • Pain occurring when controlled analgesia already in place.
  • Related to sudden/unexpected event – eg bleed into a tumour
  • UNPREDICTABLE
  • Have a generic plan ready (to manage pain)
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13
Q

What are the 2 types of assessment for pain?

A
  1. Nociceptive
  2. Non-nociceptive
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14
Q

What are the 2 types of nociceptive pain?

A
  1. Somatic
  2. Visceral
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15
Q

What is somatic nociceptive pain?

A

skin, muscle, connective tissue are damaged (nociceptors are in tissue)

  • pain is worse with movement
  • pain is localised
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16
Q

What are the 2 types of visceral nociceptive pain?

A
  1. Solid organs
  2. Hollow organs
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17
Q

What is visceral nociceptive pain of hollow organs/

A

obstruction of organ

  • always has muscle
  • tries to push through obstruction pain comes and goes
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18
Q

What are the 2 types of non-nociceptive pain?

A
  1. Neuropathetic
  2. Non-neuropathetic
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19
Q

What is neuropathetic non-nociceptive pain?

A

nerve is damaged and still perceiving pain

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20
Q

What is non-neuropathetic nociceptive pain?

A

panic, anxiety, anticipation/fear of pain

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21
Q

What is total pain?

A
  • Totality of suffering comprises physical, psychological and spiritual distress.
  • One element can’t be seen in isolation.
  • Each element affects the others
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22
Q

What are the 3 features nociceptive pain?

A
  1. Arising from stimulation of nociceptive pain receptors by “inflammatory soup”
  2. Found in connective tissue - skin, muscles, organ capsules, peritoneum
  3. Pain is locallised, worse with movement (internal movement)
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23
Q

What are the 4 features of neuropathic pain?

A
  1. Arises from damage to, compression of or invasion of nerves at any level of the CNS
  2. Burning, tingling, hypersensitivity
  3. Possibly dermatomal
  4. Not changed with movement
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24
Q

What are the 2 purpose of using validated tools for pain?

A
  1. Consistent reporting of pain
  2. Early warning of escalation
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25
What is the aim for pain?
control acute pain to minimise risk of progression to chronic pain
26
What are the 4 tasks of a consultation?
1. Presenting compliant(s) 2. Defining the problem(s)- (Diagnosis) 3. Understanding impact of problem on person 4. Negotiate a management plan
27
What are the 3 tasks of the reasoning process?
1. Developing a problem list 2. Defining pathological process(es) 3. Coming to a working diagnosis / diagnoses
28
In clinical medicine, what are 3 features that reasoning and hypothesis generation uses?
1. Knowledge * Basic sciences and pathology 2. Probability * What are the most prevalent conditions in people like this patient that have the relevant symptoms and signs? 3. Key questions * identifies major symptoms and signs that distinguish one condition from another (rule in or out a disease)
29
What are the 3 features in key questions for reasoning and hypothesis generation?
1. How to RULE IN or RULE OUT a disease 2. What are the KEY FEATURES that MUST be present to have that disease? 3. What are the KEY FEATURES that are NEVER present with that disease?
30
For example, what are the key questions for determining whether it is a migrane, neck-related headache or a space occupying lesion?
1. Does the head ache throb? (Quality of pain) 2. Where is the headache (Location of pain) 3. When is it worst (Time of pain)
31
What is triangulation? What are 2 features?
Seeks to confirm the presumed diagnosis by other evidence: 1. More features from the history that confirm or reject the initial hypothesis 2. Physical examination or investigations may support hypothesis or suggest competing hypotheses. (it is important not to rely on imaging for diagnosis, should be used to confirm)
32
What is the mapping grid for complex medical problems?
33
What are the 3 features in the mapping grid for complex medical problems?
1. Physiology and chemistry 2. Circumstances and environment 3. Personality strengths and weaknesses
34
What is the physiology and chemistry part in the mapping grid for complex medical problems? Give examples.
Diseases going on? * Depression or anxiety (chemical change) * Need medication to control pain Eg. * Musculoskeletal pathology * Allodynia- neuropathic pain * Lyrica – eliminated this pain * Anxiety/depression/panic (can do chemical treatment) * A role for SSRIs * Avoid benzodiazepines
35
What is the circumstances and environment part in the mapping grid for complex medical problems? Give examples
* Living space * Financial struggles Eg. * Moved from country town 4-5 yrs ago * Lives alone, no family support * Attends church in Brisbane, therefore usually miles from friends and support
36
#What is the personality strengths and weaknesses part in the mapping grid for complex medical problems?
Internal- that can't change * Family history * Personality Eg. Strengths * Likeable * Is teachable (even with low average intelligence- just repeat instructions) Weaknesses * Habitual Dependency * Anxiety (catastrophises) * Low average intelligence
37
What are some examples of management in regards to circumstances?
* nurse navigator training him and supporting good choices. * Recognition that a GP is there for him
38
What are some examples of management in regards to personality?
* Training him in self reliance * Rewarding good choices (praise) * Weekly consultations to sort out problems ( ED won’t do it for him)
39
What are some examples of management in regards to physiology/chemistry?
* Physiotherapy and exercises * Pregabalin for neuropathic pain
40
What are 4 considerations when choosing medication?
1. Nature of the pain 2. Timing of pain – Chronic? – Incident? – Breakthrough? 3. Predictable side effects 4. Unpredictable side effects
41
What are 4 non-pharmacological modalities for treatment?
1. splinting 2. positioning 3. physio 4. counselling
42
What are the 2 types of pharmacological treatments?
1. Analgesics 2. Adjuvants
43
What are analgesics? Give 3 examples.
Directly affect pain perception 1. Paracetamol 2. Aspirin 3. Opioids
44
What are adjuvants?
modify other processes, pain relief is secondary
45
What are 4 specialist modalities?
1. Radiotherapy –eg single bony metastases 2. Chemotherapy 3. Nerve blocks 4. Neurosurgical techniques.
46
What are the 3 steps to the W.H.O Analgesic Ladder?
Step 1- Non-Opioid+/- adjuvant Step 2- “mild/moderate” opioid +/- non-opioid +/- adjuvant Step 3- Opioid for moderate to severe pain +/- non opioid +/- adjuvant
47
What are the 5 limitations of the ladder approach?
1. only relates to pain intensity 2. does not identify causes and types of pain 3. Step 2 often omitted 4. adjuvants have increasing usefulness, but portrayed as second line treatments 5. no consideration of alternate routes of administration
48
What are 2 simple analgesics?
1. Paracetamol 2. Aspirin
49
What is the most important thing when prescribing opioids?
lowest dose and shortest duration
50
Opioids: "I'll make my patient addicted." True or false.
False Dependence NOT addiction in chronic pain
51
Opioids: "The patient won't have anything left for later on if I start them now." True or false
False Delayed control of pain allows pain preferred pathways to be laid down
52
Opioids: "Opioids cause respiratory depression". True or false.
False Only in overdose- not if titrated (slowly increase)
53
What are the 4 ways to administer opioids?
1. Oral * immediate release. * Slow release 2. Parenteral - s/c - syringe driver 3. Transdermal 4. Intrathecal, epidural
54
What are the 3 forms of morphine available in Australia?
Oral short -acting • Oral Long acting - slow release with peak levels after 12 hours, and 12-24 hrs duration (MS Contin, Kapanol) • Injectable - morphine sulphate, morphine tartrate
55
What are 3 characteristics of short-acting morphine?
1. 20 minute onset action 2. 4 hour duration 3. Forms: liquid, multiple concentrations, or tablets.
56
What are the 2 types of morphine?
1. Short acting 2. Long acting
57
What are 4 characteristics of long-acting morphine?
1. slow release 2. peak levels after 12 hours \12 (MS Contin) or 24 hrs duration Kapanol or MS Mono) 3. 48 hours to reach steady state
58
What are 4 alternatives to opioids? Why are these used?
1. Fentanyl – patches, less sedation, constipation, very strong 2. Hydromorphone- less constipation, hepatic metabolism 3. Oxycontin- less sedation, confusion 4. Buprenorphine – patches, weaker –ideal for older people
59
What are 5 processes to follow for the initiation of morphine?
1. Explanations to minimise opioid-phobia 2. Start liquid morphine with q4h dose (eg 5mg) plus prn breakthrough 3. Consider Short-term anti-emetic, and start laxative 4. Review at 48 hrs, calculate average dose per 24 hrs. 5. Start long acting opioid same dose per 24 hours
60
What is opioid rotation?
* Can be useful if dose escalates * Some opioids target NMDA (eg Methadone), but are hard to use
61
What are 5 alternatives to opioids? Why are they used?
1. Fentanyl - less sedation, constipation 2. Hydromorphone- less constipation, hepatic metabolism 3. Oxycontin- less sedation, confusion 4. Pethidine - short acting, toxic metabolites 5. Methadone – useful when windup – targets NMDA
62
What are 3 reasons why adjuvants are used for nociceptive pain?
1. Targeting the inflammatory soup * NSAIDS * Steroids 2. Skeletal muscle spasm * Benzodiazepines * baclofen 3. Smooth muscle spasm * Hyoscine butylbromide
63
What are 4 processes to follow with neuropathetic pain?
1. Assess severity. 2. If very severe, start morphine as before * Start an adjuvant simultaneously. 3. If not severe, start adjuvant slow response times – days to weeks 4. Regular review and titration upwards of BOTH opioids and adjuvants.
64
What are 3 adjuvants for neuropathetic pain?
1. Antidepressants * best evidence for amitryptaline 2. Anti-epileptics * pregabalin, gabapentin, valproate, carbamezepine 3. Anti- Arrhythmics (Xylocaine derivatives) * mexilitine, flecainide – rarely used
65
The _____ is the key element of determining pain management
diagnosis
66
Examination and investigations support the ___ but frequently do not make it.
diagnosis
67
Pain is complex and ____ treatment requires all elements to be managed
comprehensive

PHTY2101 EOS (22 decks)

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