Essential Pain Management Flashcards
What is the difference between acute and chronic pain?
Acute: pain of recent onset and probable limited duration
Chronic:
* Lasts >3 months
* Lasts after normal healing
* Often no identifiable cause
What is the differnce between cancer and non-cancer pain?
- Cancer: Progressive, May be mix of acute and chronic
- Non-cancer: many different causes, acute or chronic
Define nonciceptive pain
**Obvious tissue injury/illness **
- Protective function
- Sharp +/- dull
- Well localised
(also called physiological/inflammitory pain)
Define neuropathic pain
Nervous system damage/abnormality
* Tissue injury may not be obvious
* No protective function
* Burning, shooting +/- numbness, pins and needles
* Not well localised
What are the different qualities upon which pain is classified?
What are the 4 basic steps that results in experince of pain for the patient in terms of physiology?
- Periphery (Injury to periphery) ->
- Spinal Cord (Signal to dorsal root ganglion -> ascending pathway)->
- Brain ( Thalamus) ->
- Modulation
What is the phsyiology of pain in the periphery?
Step 1
What chemical messengers are released from site of injury in periphery?
Setp 1
What is their function?
- Prostaglandins
- Substance P
Stimulate nonciceptive afferents in periphery
Via what type of fibres will nerve impulses from teh periphery be carried to the spinal cord?
- A delta fibres
- C fibres
They connect to dorsal root ganglion (spinal cord)
What is the phsyiology of pain in the spinal cord?
Step 2
What is the first relay station for pain?
Step 2
Dorsal horn of spinal cord
Via which spinal tract will the second nerve travel in to convey nerve impulse to the brain?
Step 2
Spinothalamic tract (opposite side of spinal cord from where the peripheral nerve entered)
What is the phsyiology of pain in the brain?
Step 3
Whta is the 2nd relay station of the pain pathway?
Step 3
Thalamus
Which parts of the brain does the thalamus directly connect with?
- Cortex
- Limbic system
- Brainstem
Which part of the brain does pain perception occur in?
Cortex
reason for patiernts being able to describe pain very accurately
How is pain modulated in the brain?
Step 4
What is the Gate theory of pain?
Theory of pain modulation
What are examples of neuropathic pain?
- Crush injury (nerve trauma)
- Peripheral neuropathy (diabetic pain)
- Dysfunction (Fibromyalgia, Chronic tension headaches)
What are some pathological mechanisms which can cause pain?
- Increased receptor numbers
- Abnormal sensation of nerves (exagerated): peripheral and central
- Chemical changes in the dorsal horn
- Loss of normal inhibitory moduclation
What are the classes of pharamacological medications used to terat pain?
- Simple analgesics
- Opioids : weak and strong
- Other
Give examples of simple anagesics used for pain management
- Paracetamol (acteaminophen)
- Non-Steroidal Anti-Inflammitory dugs (Diclofenac, Ibuprofen)
Give examples of weak and strong opioids used for pain management
- Weak: Codeine, Dihydrocodeine, Tramadol
- Strong: Mophine, Oxycodone, Fentanyl
Both have potential for addiction
What are some other classes of drugs used for pain management?
What are the treatments available for managing peripheral pain?
- Non-drug: Rest, Ice, elevation
- NSAIDS: (reduce inflammitory factors which stimlate nonciceptive afferents e.g prostaglandins in periphery)
- Local anaesthetic: (reduce nonciceptive afferent triggering)
What are the treatments available for managing spinal cord pain?
- Non-drug treatment: Acupuncture, massage TENS
- Local anesthetics: (Epidural, nerve blockade)
- Opioids: (epidural, intrathecal)
- Ketamine: (NMDA receptor anatagonist, modulates pain signal in decending pathway)
What are the treatments available for managing pain in the brain?
- Non-drug treatment: psychological
- Drug treatment: paracetamol, opioids, amitriptyline, clonidine
Paracetamol
Advantages and disadvantages
NSAIDs
Advantages and Disadvanatges
Codeine
Advantages and disadvantages
Tramidol
Advantages and disadvanatges
Morphine
Advantages and disadvanatges
Advanatages
* Cheap, generally safe
* Oral, IV, IM, SC, Intratgecally
* Effective if given regularly
* Good for:
- Mod-severe nonciceptive pain (e.g. post op)
- Cancer pain
Not advised for neuropathic pain
Disadvanatges
* constipation
* Respiratory depression in high dose
* Addiction and avoidance due to fear of addiction
* Controlled drug
Oral dose needs to be increased if changing from IV/IM/S/C routes as third pass metabolism reduces amount of morphine available
Amitriptyline
Advantages and disadvanatges
Anticonvulsant drugs
Advantages and disadvantages
What msut be concidered when thinking about route of administartion of pain treatment?
- Patient nil by mouth (NBM)?
- If IM or S/C: concider how many injection required a day (S/C cannula more tolerable?)
- Oral route preffered where possible
What are the delivery routes for pain treatment for local anaesthetics?
How is pain assessed in a clinical setting
What pain score is used for confused patients?
Abbey Pain Scale
What are available treatment options for pain management?
- Non- drug treatment
Physical: Rest, Ice, Elevation, Surgery, Acupuncture, massage, Physiotherapy
Psychological: Explanation, Reassurance, Councelling - Drug treatment:
Acute pain: WHO pain ladder
Neuropathic pain: alternative analgesics and/or psychological and non-drug treatments (not responsive to WHO pain ladder)
What are the steps in the WHO pain ladder for acute pain?
What pain medication should be administered to patient with mild-moderate pain according to WHO pain ladder?
Non-opioids:
* Aspirin
* NSAIDs
* Paracetamol
Rung 1
What pain medication should be administered to patient with moderate-severe pain according to WHO pain ladder?
Mild opioids:
* e.g. Codeine
* +/- non-opioid
Rung 1 and 2
What pain medication should be administered to patient with severe pain according to WHO pain ladder?
Strong opioids:
* E.g. Morphine
* +/- non-opioid
Rung 1 and 3 (miss out mild opioids)
Okay to start at top of ladder for severe/unbearable pain
How does pain management continue accoridng to WHO pain ladder as pain starts to resolve?
Move:
* From top -> middle (continue bottom rung drugs at all times)
* Lastly stop NSAIDs 1st -> Paracetamol 2nd ( dueto more adverse effects of NSAIDs)
Clear instructions given regarding reduction of all opioids
What is the RAT approach to pain management?
What does the R stand for in RAT assessment?
What are you looking for?
Recognise
* Ask if pt has pain
* Look (frowning?Moving easily? Sweating?)
* Do helathcare staff/ patinet’s family recognise pain in the patient
What does the A stand for in RAT assessment?
What are you looking for?
Assessment
1. Severity:
- Pain score at rest/with movement
- Pain affecting patient (can they move/cough/work?)
-
Type: (Nonceptive/neuropathic?)
Pain history (SOCARTES) -
Other Factors:
- Physical factors (otehr illness)
- Psychological and social factors: anger, anxiety, depression, lack of social support, previous drug use/addictive personality
What are features of neuropathic pain
RAT- Assessment
- Burning/shooting pain
- Phantom limb pain
- Other: pins and needles, numbness
What does the T stand for in RAT assessment?
What are you looking for?
**Treatment **
1. Non-drug
- RIE (rest, ice, elevation of injuries)
- Nursing care
- Surgery, acupuncture, massage, TENS etc.
- Psychological: explanation, rreassurance, input from socail owrker/pastor
-
Drug
- Nocicpetive (WHO pain ladder)
- Neuropathic pain:
Other non-drug treatments
Amitriptalyne, gabapentin, duloxetine
Following a RAT assessment, what should be your next steps?
Reasses patient:
* Is treatment working?
* Other treatments needed?
