Clin Med 4 Flashcards
challenges of txing pain
disparities in minorities/women/elderly/cog impair; undertx ca or end of life care; pain –> loss productivity or QOL; stigma for pain med seekers
what’s chronic pain?
> 3mo; from underlying dz/condition/injury or idio
addiction. 5 C’s? vs pseudoaddiction
primary, chronic, neurobio dz w/ genetic, psychosocial, environ factors. chronic, compulsive, no ctrl, cont despite harm, craving vs iatrogenic syndrome from misinterpreting relief-seeking behaviors for drug-seeking behaviors
physical dependence vs tolerance
both nml physio conseq d/t extended opioid for pain. adaptation manifested by w/drawal d/t abrupt cess, rapd dose reduction, dec blood drug lvl, antag admin; NOT addiction vs reduced effect from constant dose –> inc dose to produce desired effect
effective nonpharm vs nonopioid therapies. opioid OD depends on what? factors that inc risk for harm?
OMM, exer, cog behav therapy vs APAP, NSAID, anticonvul, anti dep. dose-dependent. preg, mental health d/o, old age, sleep breathing d/o
nociceptive vs somatic vs visceral pain
src –> periph n –> dorsal horn spinal cord –> decussate @ spinal cord –> ascend spinal cord via lat spinothal tract –> thal –> sensory cortex vs dull/achy pain from body surface or MSK tissue d/t inflamm, stretch, ctx/spastic; better w/ rest, worse w/ activity vs vague/diffuse internal organ pain
referred vs neuropathic pain
primary aff nociceptors –> DRG –> spinal cord –> mult sensory nn converge into ascending spinal nn of spinothal tract –> thal –> orig pain but along dermatome vs complex chronic pain w/ shooting/burning like phantom limb syndrome
APAP vs NSAIDs & corticosteroids vs antidep vs anticonvul vs LA w/ examples
noninflamm pain, Tylenol vs acute pain, flare ups w/ chronic pain; oral prednisone or cortisone injections vs TCA, cymbalta for fibromyalgia & neuropathy vs nerve pain; gabapentin for post herpetic neuralgia, pregabalin for fibromyalgia & diabetic neuroapthy
key things to consider for ER opioids
methadone should not be first choice for ER, do transdermal fentanyl, ER/long acting opioids should not be used for acute or intermittent pain
key things to consider when doing Morphine Milligram Equivalent
use mg dose & calculate w/ conversion factor; use lowest dose possible, avoid >50 MME/d (or else reeval, inc f/u, give naloxone), consider pain mgmt referral w/ doses >90-120 MME/d
how to rx opioids for acute pain not related to surgery or trauma?
start lowest dose & don’t give >3d worth (ie. don’t give more just in case); reeval pts w/in 1-4wks starting long term opioids or >q3mo; determine if opioids meet tx goals, cause AE, benefits > risks, dose can be taper to discont
tapering opioids sxs vs how to do it
drug craving, anxiety, tachy, insomnia, mydriasis vs taper 10-50% wkly or 2-3wks if AE
rx naloxone w/ opioids if:
h/o OD or substance use d/o, taking CNS depressants like benzos, >50 MME/d
how to tx OUD?
offer Medication Assisted Tx –> bupo + waiver, methadone, naltrexone
12 guidelines for opioids for chronic pain
- nonpharm/opioid therapy for chronic pain
- est realistic tx goals before opioid therapy for chronic pain
- discuss risks & benefits before opioid therapy, talk abt tapering
- rx IR, not ER/long acting for chronic pain
- rx lowest dose & inc slowly prn
- rx no greater quantity than needed for pain duration (3d = suff)
- eval benefits/harm w/in 1-4wks of starting opioid therapy
- eval risk factors for opioid-related harms (give naloxone based on hx)
- review pt hx & PDMP
- do urine test before opioid therapy
- don’t rx opioids w/ benzos –> taper off benzos first
- give evidence-based tx for pts w/ opioid use d/o like bupo & methadone
how to inform pt abt urine drug test
don’t test for substance that doesn’t affect pt mgmt; explain to pts that test is to improve safety, explain expected results, ask if there are “unexpected” results
risk factors vs etio of neonatal sz
premature, low birth wt, HIE vs asphyxia/hypoxia/ischemia encephalopathy, hypo/ernatremia, ICH, CNS malform, infxn
benign neonatal familial convulsion vs pyridoxine dependency/biotinidase defic vs benign neonatal sleep myoclonus
dom chrm 20, 2/3rd day of life, clonic/apneic sz w/o EEG marker vs various sz types vs EEG & PE nml, good prognosis
how to dx vs tx neonatal sz
observation +/- EEG vs determine cause of sz & give vent + glu, phenobarbital, phenytoin
simple vs complex febrile szs. how to tx?
b/w 6mo-5yo, can happen w/ common illnesses or vax; EEG nonspecific. <15min, lack focality –> generalized, tonic-clonic vs >15min, focal manifestations, recur w/in 24h. avoid prophylactic AEDs but can give oral diazepam; rectal diazepam for mult or prolonged attacks
benign partial epilepsy w/ centrotemporal spikes. tx? vs w/ occipital paroxysms. tx? assoc?
childhood; partial sz going to sleep affecting face, oropharynx, limbs; spikes = hallmark. first-line AED vs 4-12yo; visual halluc/distort, hemianopsia, amaurosis. first line AED. idio occipital epi, celiac dz, occipital calcifications
childhood absence epi. tx?
4-8yo, absence sz w/ 3Hz spike wave + hypervent, can have tonic-clonic in adulthood. valproate, ethos, lamto, levet, topiramate
west syndrome. tx?
3-8mo; triad: infantile spasm, Hypsarrhythmia EEG, psychomotor delay. pre/perinatal brain injury, metab d/o, degen d/o, neurocut d/o, cerebral malform; focal cortical dysplasia. benzos, val, corticosteroids/corticotropin, vigabatrin
lennox-gastaut syndrome. tx?
1-7yo; mult sz types (a/tonic, atypical absence, tonic-clonic > myoclonic), mental retard, slow spike-wave EEG. corticosteroid, ketogenic diet, val+lamot, felbamate but more AE
