CHAPTER 35: Acute Pain Management Flashcards by Lyn Ong

Is the most common presenting symptom for patients coming to the ED

Pain (70% to 80%)

How well did you know this?

Not at all

Perfectly

Undertreatment of pain

Oligoanalgesia

How well did you know this?

Not at all

Perfectly

Ethnicity, gender, age (very young, very old)
Diminished cognitive function
Fear of meds: addiction, side effects
Acceptance of pain as being inevitable
Unwillingness to bother healthcare providers

Patient related barriers to adequate ED pain control (Table 35-1 p. 230)

How well did you know this?

Not at all

Perfectly

Is the physiologic response to a noxious stimulus

Pain

How well did you know this?

Not at all

Perfectly

Is the expression of pain, it is modified by the complex interaction of cognitive, behavioral, and sociocultural dimension

Suffering

How well did you know this?

Not at all

Perfectly

Is considered the gold standard for quantifying the severity of a patient’s pain

Self-reporting

The patient’s subjective reporting of pain, not the healthcare provider’s impression, is the basis for pain assessment and treatment.

How well did you know this?

Not at all

Perfectly

Easily localized pain

Somatic pain

How well did you know this?

Not at all

Perfectly

Visceral pain

Poorly localized pain

How well did you know this?

Not at all

Perfectly

Opioid receptor with significant structural homology

Nociceptin

How well did you know this?

Not at all

Perfectly

Opioid receptor produces supraspinal analgesia

Mu-1 (μ1) receptor

How well did you know this?

Not at all

Perfectly

Opioid receptor results in euphoria, miosis, respiratory depression, and depressed GI motility

GERM:
GI motility depression
Euphoria
Resp depression
Miosis

Mu-2 (μ2) receptor

How well did you know this?

Not at all

Perfectly

Opioid receptor produces analgesia and also exerts an antidepressant effect

Delta (δ) receptor

How well did you know this?

Not at all

Perfectly

Opioid receptor produces Dysphoria, along with Dissociation, Delirium, and Diuresis

4Ds

Kappa (κ) receptor

How well did you know this?

Not at all

Perfectly

TRUE or FALSE?

Opioid receptors are linked to addiction

FALSE

Opioid receptors are NOT linked to addiction, which is much more closely linked to the cannabinoid-1 receptor

How well did you know this?

Not at all

Perfectly

TRUE or FALSE?

There’s a weak correlation bet nonverbal signs & px’s report of pain

TRUE

There is a weak correlation between nonverbal signs and the px’s report of pain, so DO NOT rely on these to det the seve of a px’s pain

How well did you know this?

Not at all

Perfectly

Quantitate pain severity, guide the selection and administration of an analgesic agent, and reassess the pain response to determine the need for repeated doses or alternative analgesics

Pain scales

How well did you know this?

Not at all

Perfectly

Is the preferred pain assessment tool when there are language difficulties or cross-cultural differences because it is the least affected by these factors

Visual Analog Scale (VAS)

How well did you know this?

Not at all

Perfectly

Is the mainstay of acute pain management

Administration of pharmacologic agents

How well did you know this?

Not at all

Perfectly

Pain reliever that should be considered for mild to moderate pain or when targeting severe pain originating from smooth muscle spasm such as renal or biliary coli

NSAIDs

In specific instances such as renal and biliary colic, although parenteral NSAIDs may control severe pain, combination therapy with an opioid is usually superior.

How well did you know this?

Not at all

Perfectly

Pain Scale method (Table 35-2 p. 230):
Ordered list of pain descriptors (no pain to worst possible pain)
Easy to administer

Adjective rating scale

How well did you know this?

Not at all

Perfectly

Pain Scale method (Table 35-2 p. 230):
10-cm linear scale
Measured in millimeters

Visual analog scale (VAS)

How well did you know this?

Not at all

Perfectly

Is the minimum clinically significant change noticeable by patients in VAS

13mm

How well did you know this?

Not at all

Perfectly

Is the average decrease of change as the minimum acceptable change for pain control

30 mm

How well did you know this?

Not at all

Perfectly

Pain Scale method (Table 35-2 p. 230):
Scale of 0 to 10 WITH descriptors
Used in patients with visual, speech, or manual dexterity difficulties by using upheld fingers

Numeric rating scale

How well did you know this?

Not at all

Perfectly

Pain Scale method (Table 35-2 p. 230): Rates pain as:0 = none1 = a little2 = some3 = a lot4 = worst possible Decrease of 1 point is a large change

5-Point global scale

Pain Scale method (Table 35-2 p. 230): Sccale of 0 to 10 WITHOUT descriptors Most commonly used scale

Verbal quantitative scale

Are the cornerstone of pharmacologic management of moderate to severe acute pain

Opioid analgesics

Refers to agents that are structurally related to natural alkaloids found in opium, the dried resin of the opium poppy

Opiate

Describes any compound with pharmacologic activity similar to an opiate, regardless of chemical structure

Opioid

TRUE or FALSE? | Variation in pain reduction is related to body mass and gender

FALSE Variation in pain reduction is related to age, initial pain severity, and previous or chronic exposure to opioids, but NOT body mass or gender

TRUE or FALSE? | Opioid hypersensitivity is uncommon

TRUE Opioid hypersensitivity is uncommon, and true allergic reactions are extremely rare

There is minimal evidence of clinical cross-sensitivity within opioid classes EXCEPT among the —?—

Phenylpiperidines: Fentanyl Alfentanil Sufentanil

Not a reliable analgesic, and it produces more nausea, vomiting, and dysphoria than other opioids

Codeine

Opioid which is extensively metabolized by cytochrome P450 enzymes

Tramadol

Opioid which is considered to produce more elation than other opioids

Meperidine (Pethidine)

Metabolite of meperidine which has neuroexcitatory properties and a long elimination half-life (24 to 48 hours) Seizures in elderly or CKD: >48 hrs or >600mg/day

Normeperidine

Opioid with histamine may produce transient hypotension or nausea and emesis (neither requires routine adjunctive treatment) Table 35-4 page 232

Morphine

Opioid more euphoria inducing than morphine | Table 35-4 page 232

Hydromorphone

Opioid less cardiovascular depression than morphine | Table 35-4 page 232

Fentanyl

Dose of Fentanyl that can cause chest wall rigidity

High doses (>5 micrograms/kg IV)

Opioid used for breakthrough pain in opioid-tolerant cancer patients Table 35-4 page 232

Fentanyl (nasal spray & buccal mucosa tablet)

Opioid contraindicated when patient has taken a monoamine oxidase inhibitor within the past 14 d to avoid precipitating serotonin syndrome Table 35-4 page 232

Meperidine (Pethidine)

Opioid with lower incidence of nausea than others | Table 35-4 page 232

Oxycodone & Hydrocodone/acetaminophen

Opioid with high incidence of GI side effects | Table 35-4 page 232

Codeine

Opioid with common CNS side effects | Table 35-4 page 232b

Tramadol

Medications that are sometimes used to enhance the analgesic effect, reduce the amount of opioid required, and prevent side effects

Adjuncts

Medications that are used to minimize some of the adverse effects of pure opioid agonists and have major benefit of ceiling on respiratory depression but may precipitate withdrawal symptoms in opioid-addicted patients

Opioid agonists-antagonists

Is an effective analgesic for acute mild to moderate pain | No dosage change is required for renal or mild hepatic impairment

Acetaminophen (Paracetamol)

Are both anti-inflammatory agents and analgesics | Have significant opioid dose-sparing effects

Aspirin & NSAIDs

A phencyclidine derivative produces analgesia and/ or dissociative anesthesia with the advantage of causing minimal respiratory depression at usual doses

Ketamine

Is a fast-onset, short-acting analgesic and sedative inhalational agent

Nitrous Oxide

Nitrous oxide/oxygen mixture that is consistently effective

70/30

Nitrous oxide is contraindicated in patients with —?—

Perforated abdominal viscus Altered mental status Suspected pneumothorax Head injury

Topical analgesic effective for treating acute soft tissue injuries such as sprains and strains and also for treating chronic joint pain from osteoarthritis

Topical NSAIDs

Topical analgesic effective for patients with postherpetic neuralgia and diabetic neuropathy

Topical lidocaine

Topical analgesic effective for postherpetic neuralgia, but requires professional application and removal to minimize side effects

Topical capsaicin (8% capsaicin topical patch)

The primary adverse reaction of topical medications

Local burning

Hypotension effect of opioids is almost always due to —?— release with the first dose of medication

Histamine

Is the misuse of a medication or drug to the detriment of the patient's well-being

Addiction

Infers that abrupt cessation of a medication will result in acute withdrawal symptoms Requires regular daily usage for 4 to 6 weeks

Dependence

Are the preferred opioids in patients with renal failure

Hydromorphone & Fentanyl

Drugs contraindicated when patient has taken a monoamine oxidase inhibitor within the past 14 d to avoid precipitating serotonin syndrom

Monoamine Oxidase Inhibitors (MAOIs)

Cyclic antidepressants that may increase morphine levels and potentiate the opioid effects

Clomipramine & Amitriptyline CA = Cyclic antidepressants

Medications when combined with opioids carries a high risk of central sleep apnea and should be used with caution

Benzodiazepines

The opioid of choice in trauma patients

Fentanyl