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a13. Specialities: Anaesthetics (Medical knowledge) > Essential Pain Management > Flashcards

Essential Pain Management Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the difference between acute and chronic pain?

A

Acute: pain of recent onset and probable limited duration
Chronic:
* Lasts >3 months
* Lasts after normal healing
* Often no identifiable cause

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2
Q

What is the differnce between cancer and non-cancer pain?

A
  • Cancer: Progressive, May be mix of acute and chronic
  • Non-cancer: many different causes, acute or chronic
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3
Q

Define nonciceptive pain

A

**Obvious tissue injury/illness **

  • Protective function
  • Sharp +/- dull
  • Well localised

(also called physiological/inflammitory pain)

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4
Q

Define neuropathic pain

A

Nervous system damage/abnormality
* Tissue injury may not be obvious
* No protective function
* Burning, shooting +/- numbness, pins and needles
* Not well localised

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5
Q

What are the different qualities upon which pain is classified?

A
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6
Q

What are the 4 basic steps that results in experince of pain for the patient in terms of physiology?

A
  • Periphery (Injury to periphery) ->
  • Spinal Cord (Signal to dorsal root ganglion -> ascending pathway)->
  • Brain ( Thalamus) ->
  • Modulation
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7
Q

What is the phsyiology of pain in the periphery?

Step 1

A
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8
Q

What chemical messengers are released from site of injury in periphery?

Setp 1

What is their function?

A
  • Prostaglandins
  • Substance P

Stimulate nonciceptive afferents in periphery

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9
Q

Via what type of fibres will nerve impulses from teh periphery be carried to the spinal cord?

A
  • A delta fibres
  • C fibres

They connect to dorsal root ganglion (spinal cord)

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10
Q

What is the phsyiology of pain in the spinal cord?

Step 2

A
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11
Q

What is the first relay station for pain?

Step 2

A

Dorsal horn of spinal cord

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12
Q

Via which spinal tract will the second nerve travel in to convey nerve impulse to the brain?

Step 2

A

Spinothalamic tract (opposite side of spinal cord from where the peripheral nerve entered)

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13
Q

What is the phsyiology of pain in the brain?

Step 3

A
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14
Q

Whta is the 2nd relay station of the pain pathway?

Step 3

A

Thalamus

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15
Q

Which parts of the brain does the thalamus directly connect with?

A
  • Cortex
  • Limbic system
  • Brainstem
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16
Q

Which part of the brain does pain perception occur in?

A

Cortex

reason for patiernts being able to describe pain very accurately

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17
Q

How is pain modulated in the brain?

Step 4

A
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18
Q

What is the Gate theory of pain?

A

Theory of pain modulation

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19
Q

What are examples of neuropathic pain?

A
  • Crush injury (nerve trauma)
  • Peripheral neuropathy (diabetic pain)
  • Dysfunction (Fibromyalgia, Chronic tension headaches)
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20
Q

What are some pathological mechanisms which can cause pain?

A
  • Increased receptor numbers
  • Abnormal sensation of nerves (exagerated): peripheral and central
  • Chemical changes in the dorsal horn
  • Loss of normal inhibitory moduclation
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21
Q

What are the classes of pharamacological medications used to terat pain?

A
  • Simple analgesics
  • Opioids : weak and strong
  • Other
22
Q

Give examples of simple anagesics used for pain management

A
  • Paracetamol (acteaminophen)
  • Non-Steroidal Anti-Inflammitory dugs (Diclofenac, Ibuprofen)
23
Q

Give examples of weak and strong opioids used for pain management

A
  • Weak: Codeine, Dihydrocodeine, Tramadol
  • Strong: Mophine, Oxycodone, Fentanyl

Both have potential for addiction

24
Q

What are some other classes of drugs used for pain management?

A
25
Q

What are the treatments available for managing peripheral pain?

A
  1. Non-drug: Rest, Ice, elevation
  2. NSAIDS: (reduce inflammitory factors which stimlate nonciceptive afferents e.g prostaglandins in periphery)
  3. Local anaesthetic: (reduce nonciceptive afferent triggering)
26
Q

What are the treatments available for managing spinal cord pain?

A
  1. Non-drug treatment: Acupuncture, massage TENS
  2. Local anesthetics: (Epidural, nerve blockade)
  3. Opioids: (epidural, intrathecal)
  4. Ketamine: (NMDA receptor anatagonist, modulates pain signal in decending pathway)
27
Q

What are the treatments available for managing pain in the brain?

A
  1. Non-drug treatment: psychological
  2. Drug treatment: paracetamol, opioids, amitriptyline, clonidine
28
Q

Paracetamol
Advantages and disadvantages

A
29
Q

NSAIDs
Advantages and Disadvanatges

A
30
Q

Codeine
Advantages and disadvantages

A
31
Q

Tramidol
Advantages and disadvanatges

A
32
Q

Morphine
Advantages and disadvanatges

A

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

33
Q

Amitriptyline
Advantages and disadvanatges

A
34
Q

Anticonvulsant drugs
Advantages and disadvantages

A
35
Q

What msut be concidered when thinking about route of administartion of pain treatment?

A
  • 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
36
Q

What are the delivery routes for pain treatment for local anaesthetics?

A
37
Q

How is pain assessed in a clinical setting

A
38
Q

What pain score is used for confused patients?

A

Abbey Pain Scale

39
Q

What are available treatment options for pain management?

A
  • 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)
40
Q

What are the steps in the WHO pain ladder for acute pain?

A
41
Q

What pain medication should be administered to patient with mild-moderate pain according to WHO pain ladder?

A

Non-opioids:
* Aspirin
* NSAIDs
* Paracetamol

Rung 1

42
Q

What pain medication should be administered to patient with moderate-severe pain according to WHO pain ladder?

A

Mild opioids:
* e.g. Codeine
* +/- non-opioid

Rung 1 and 2

43
Q

What pain medication should be administered to patient with severe pain according to WHO pain ladder?

A

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

44
Q

How does pain management continue accoridng to WHO pain ladder as pain starts to resolve?

A

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

45
Q

What is the RAT approach to pain management?

A
46
Q

What does the R stand for in RAT assessment?
What are you looking for?

A

Recognise
* Ask if pt has pain
* Look (frowning?Moving easily? Sweating?)
* Do helathcare staff/ patinet’s family recognise pain in the patient

47
Q

What does the A stand for in RAT assessment?
What are you looking for?

A

Assessment
1. Severity:
- Pain score at rest/with movement
- Pain affecting patient (can they move/cough/work?)

  1. Type: (Nonceptive/neuropathic?)
    Pain history (SOCARTES)
  2. Other Factors:
    - Physical factors (otehr illness)
    - Psychological and social factors: anger, anxiety, depression, lack of social support, previous drug use/addictive personality
48
Q

What are features of neuropathic pain

RAT- Assessment

A
  • Burning/shooting pain
  • Phantom limb pain
  • Other: pins and needles, numbness
49
Q

What does the T stand for in RAT assessment?
What are you looking for?

A

**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

  1. Drug
    - Nocicpetive (WHO pain ladder)
    - Neuropathic pain:
    Other non-drug treatments
    Amitriptalyne, gabapentin, duloxetine
50
Q

Following a RAT assessment, what should be your next steps?

A

Reasses patient:
* Is treatment working?
* Other treatments needed?

a13. Specialities: Anaesthetics (Medical knowledge) (7 decks)

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