CHAPTER 35: Acute Pain Management Flashcards
Is the most common presenting symptom for patients coming to the ED
Pain (70% to 80%)
Undertreatment of pain
Oligoanalgesia
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)
Is the physiologic response to a noxious stimulus
Pain
Is the expression of pain, it is modified by the complex interaction of cognitive, behavioral, and sociocultural dimension
Suffering
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.
Easily localized pain
Somatic pain
Visceral pain
Poorly localized pain
Opioid receptor with significant structural homology
Nociceptin
Opioid receptor produces supraspinal analgesia
Mu-1 (μ1) receptor
Opioid receptor results in euphoria, miosis, respiratory depression, and depressed GI motility
GERM: GI motility depression Euphoria Resp depression Miosis
Mu-2 (μ2) receptor
Opioid receptor produces analgesia and also exerts an antidepressant effect
Delta (δ) receptor
Opioid receptor produces Dysphoria, along with Dissociation, Delirium, and Diuresis
4Ds
Kappa (κ) receptor
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
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
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
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)
Is the mainstay of acute pain management
Administration of pharmacologic agents
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.
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
Pain Scale method (Table 35-2 p. 230):
10-cm linear scale
Measured in millimeters
Visual analog scale (VAS)
Is the minimum clinically significant change noticeable by patients in VAS
13mm
Is the average decrease of change as the minimum acceptable change for pain control
30 mm
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
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
