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essential pain management Flashcards

1
Q

what is pain

A

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

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2
Q

6 key notes - looking after patients with pain

A
  • pain is a personal experience influenced by biological, psychological and social factors
  • pain and nociception are different phenomena
  • individuals learn the concept of pain through life experiences
  • a person’s report of pain should be respected
  • pain serves an adaptive role but may have adverse effects on function and psychological wellbeing
  • verbal description is only one of several behaviours to express pain
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3
Q

how many people live with persistent pain

A

1 in 4

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4
Q

why is pain important to treat

A

persistent pain is common
basic human right
66% of people attending A&E seeking help w/ pain had made ~ 3 visits to HCP in proceeding weeks

pain results in poor QOL as bad as other neurological diseases

low back pain is the number 1 disease for yrs lost to disability worldwide

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5
Q

physical benefits of treating pain for the patient

A

improved sleep
better appetite
fewer medical complications e.g. MI, pneumonia

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6
Q

psychological benefits of treating pain for the patient

A

reduced suffering

less depression, anxiety

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7
Q

benefits of treating pain for the family

A

improved functioning as a family member e.g. as a parent

able to keep working

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8
Q

benefits of treating pain for society

A

lower health costs e.g. shorter hospital stay

able to contribute to the community

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9
Q

3 ways to classify pain

A

duration - acute, chronic, acute on chronic
cause - cancer, non-cancer
mechanism - nociceptive, neuropathic

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10
Q

what is acute pain

A

pain of recent onset and probable limited duration

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11
Q

what is chronic pain

A

pain lasting >3mths
pain lasting after normal healing
often no identifiable cause

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12
Q

what is cancer pain

A

progressive

can be a mixture of acute and chronic

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13
Q

what is non-cancer pain

A

many different causes

acute or chronic

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14
Q

what is nociceptive pain

A

obvious tissue injury or illness
aka physiological or inflammatory pain
protective function
description: sharp +/- dull, well localised

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15
Q

what is neuropathic pain

A

nervous system damage or abnormality
tissue injury may not be obvious
doesn’t have a protective function

description:

  • burning, shooting +/- numbness, pins and needles
  • not well localised
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16
Q

what are the 4 steps in pain physiology

A

periphery
spinal cord
brain
modulation

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17
Q

4 steps in pain physiology - periphery

A

tissue injury
release of chemicals e.g. prostaglandins, substance P
stimulation of pain receptors - nociceptors
signal travels in Adelta or C nerve to spinal cord - dorsal ganglia

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18
Q

4 steps in pain physiology - spinal cord

A

dorsal horn is the first relay station for pain
Adelta or C nerve synapses with 2nd nerve (usually in the spinothalamic tract)
2nd nerve travels up opposite side of spinal cord into the thalamus

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19
Q

4 steps in pain physiology - brain

A

thalamus is the 2nd relay station
connections to many parts of the brain - cortex, limbic system, brainstem
pain perception occurs in the cortex

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20
Q

what is the result of the pathway from the cortex to the thalamus

A

produce an expectation of pain

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21
Q

4 steps in pain physiology - modulation

A

descending pathway from brain to dorsal horn

usually decreases pain signal

done through many different types of neurotransmitters

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22
Q

what is the result of a very active descending pathway in pain modulation

A

less pain experience than those who have a less good descending inhibition

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23
Q

what is the gate theory of pain

A

by rubbing/massaging/application of heat etc stimulates the large peripheral Abeta fibres

this stimulates an inihibitory neurone

this switches off the nociceptive afferent signal from going into the dorsal horn

modulation pathway occurs at the periphery and at certain levels within the brain and spinal cord to modulate the pain pathway

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24
Q

what causes neuropathic pain

A

abnormal processing of pain signal
nervous system damage or dysfunction

needs to be treated differently

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25
examples of neuropathic pain
nerve trauma, diabetic pain (damage) | fibromyalgia, chronic tension headache (dysfunction)
26
pathological mechanisms of neuropathic pain
increased receptor numbers - enhances pain signal and keeps it going for longer abnormal sensitisation of nerves (peripheral, central) - pain signal is exaggerated all through the pathway chemical changes in the dorsal horn - enhanced pain signal loss of normal inhibitory modulation
27
drug classification for treating pain
simple analgesics: paracetamol (acetaminophen) NSAIDs - diclofenac, ibuprofen opioids: weak - codeine, dihydrocodeine, tramadol strong - morphine, oxycodone, fentanyl other
28
which opiates have the potential for addiction
both weak and strong
29
other analgesics
tramadol - mixed opiate and 5HT/NA reuptake inhibitor antidepressants - amitriptyline, duloxetine anticonvulsants - gabapentin ketamine - NMDA receptor antagonist local anaesthetics topical agents - capsaicin
30
treatments for pain - periphery
non-drug - rest, ice, elevation NSAIDs - reduce amount of prostagland local anaesthetic
31
treatments for pain - spinal cord
non-drug - acupuncture, massage, TENS local anaesthetics - epidural, nerve block opioids - epidural, intrathecal, into CSF ketamine - modulates pain signal in descending pathway
32
treatments for pain - brain
non-drug - psychological | drug - paracetamol, opioids, amitriptyline, clonidine
33
advantages of paracetamol
cheap safe route: oral, rectal, IV good for: mild pain by itself, mod-severe pain with other drugs
34
disadvantages of paracetamol
liver damage in overdose
35
examples of NSAIDS
aspirin ibuprofen diclofenac
36
advantages of NSAIDs
cheap generally safe good for nociceptive pain - best given regularly with paracetamol (synergism)
37
disadvantages of NSAIDs
GI side effects renal side effects - reduced blood flow bronchospasm in some patients with asthma
38
advantages of codeine
cheap safe good for mild-moderate acute nociceptive pain - best given regularly w/ paracetamol
39
disadvantages of codeine
constipation | not good for neuropathic pain
40
how does tramadol work
weak opioid effect | plus inhibitor of serotonin and noradrenaline reuptake
41
advantages of tramadol
less respiratory depression can be used w/ opioids and simple analgesics less constipating than opioids
42
disadvantages of tramadol
N+V can be poorly tolerated by some pts, esp at bigger doses controlled drug
42
disadvantages of tramadol
N+V can be poorly tolerated by some pts, esp at bigger doses controlled drug
43
advantages of morphine
cheap generally safe route: oral, IV, IM, SC, PR, intrathecally effective if given regularly good for: mod-severe nociceptive pain (e.g. post-op), cancer pain not advised for neuropathic pain
44
disadvantages of morphine
constipation respiratory depression in high doses addiction and avoidance due to fear of addiction controlled drug oral dose needs to be increased if changing from IV/IM or SC routes as 3rd pass metabolism reduces the amount of morphine available
45
how does amitriptyline work
tricyclic antidepressant | increases descending inhibitory signals
46
advantages of amitriptyline
cheap safe in low dose good for neuropathic pain also treats depression, poor sleep
47
disadvantages of amitriptyline
anti-cholinergic side effects e.g. dry mouth, glaucoma, urinary retention long term use might be linked with cognitive decline and dementia
48
examples of anti convulsant drugs
carbamazepine sodium valproate gabapentin also called membrane stabilisers
49
how do anti-convulsants work
reduce abnormal firing of nerves good for neuropathic pain
49
how do anti-convulsants work
reduce abnormal firing of nerves good for neuropathic pain
50
how do anti-convulsants work
reduce abnormal firing of nerves good for neuropathic pain
51
gabapentin and addiction
pretty addictive cocaine like effect only start w/ good evidence for neuropathic pain
52
choosing route of delivery
patient may be NBM if prescribing IM/SC consider how much the patient might require and if that is acceptable S/C cannula might be more tolerable oral route preferred where possible
53
types of delivery routes
``` oral rectal sublingual subcutaneous transdermal IM IV - boluses, possibly patient controlled systems or nurse administered intrathecal/epidural ```
54
delivery routes for LA
``` epidural (+/- opiates) intrathecal (+/- opiates) wound catheters nerve plexus catheters lidocaine patches for some neuropathic pain conditions ```
55
how do we assess pain
``` verbal rating score numerical rating score visual analogue scale smiling faces abbey pain scale (for confused patients) functional assessments ```
56
non-drug treatments for pain
physical: - rest, ice, elevation - surgery - accupuncture, massage, physio psychological: - explanation - reassurance - counselling
57
choosing drug treatments for pain
acute pain: WHO pain ladder | neuropathic pain: alternative analgesics +/or psychological and non-drug treatments; not responsive to WHO ladder drugs
58
WHO analgesic ladder
``` step 1 (mild-mod pain): - non-opioids: aspirin, NSAIDs or paracetamol ``` step 2 (mod-sev pain): - mild opioids: e.g. codeine - w/ or w/o non-opioids step 3 (severe pain): - strong opioids: e.g. morphine - w/ or w/o non-opioids
59
Link pain assessment to prescribing for acute nociceptive pain
mild pain - start at bottom of pain ladder moderate pain - bottom of ladder plus middle rung severe pain - bottom of ladder plus top, miss out the middle it is okay to start at the top of the ladder for severe/unbearable pain
60
what to do as pain resolves
move from top to middle of ladder continue bottom rung at all times lastly, stop NSAIDs first then paracetamol (NSAIDs have more side effects) clear instructions must be given regarding reduction of all opiates
61
RAT approach to pain management
Recognise Assess - severity, type, other factors Treat - non-drug and drug
62
recognising pain
does the patient have pain? - ask - look - frowning, moving easily, sweating - functional ability e.g. move easily, cough, deep breath etc do other people know the patient has pain - other health workers - family
63
Assessment of pain - severity
what is the pain score - at rest - with movement how is the pain affecting the patient - can the patient move, cough, can the patient work
64
assessment of pain - type
take a pain hx nociceptive or neuropathic look for neuropathic features: burning or shooting pain phantom limb pain other features - pins and needles, numbness
65
assessment - are there any other factors
- things that might make the patient more susceptible to pain or more difficult to treat w/ analgesia - physical factors - other illness etc - psychological and social factors - anger, anxiety, depression; lack of social support; prev drug use/addictive personality
66
what to do after RAT
reassess the patient is the treatment working are other treatments needed

Y3 - anaesthetic s (5 decks)

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