Flashcards MD
Define the mechanism of action of tiagabine.
Tiagabine is an antiepileptic drug that acts as a selective GABA reuptake inhibitor.
Define the primary means of assessing pain in children under four years old.
behavioral scales such as the CHEOPS, FLACC, CRIES
Define the superior hypogastric plexus and its significance in pain management.
The superior hypogastric plexus contains sympathetic nerves from various pelvic organs and can help alleviate pain in regions such as the descending colon, rectum, and reproductive organs.
Drugs that increase and decrease methadone levels
Increase: cipro azoles prozac
phenobarbital carb
Decrease: rifampin ART phenytoin
Describe the method for converting morphine to methadone for doses less than 100 MEDDs.
For doses less than 100 MEDDs, it is recommended to divide the morphine dose by 4 to obtain the equivalent dose of methadone.
Describe the pediatric Memorial Symptom Assessment Scale.
The pediatric Memorial Symptom Assessment Scale is a tool available for children in two age ranges: 7-12 years and 10-18 years, measuring multiple symptoms in addition to pain.
Describe the relationship between visceral pain and the celiac plexus.
Visceral pain, such as that originating from the liver, can be managed with a celiac plexus block, which is located in front of the aorta at the L1 level.
Mechanism of benzodiazepines, zolpidem, and baclofen
They are selective GABA agonists.
Describe the role of sympathetic stimulation in post herpetic neuralgia.
Intense sympathetic stimulation and activation of adrenergic receptors may contribute to both acute zoster pain and chronic post herpetic neuralgia, potentially leading to decreased neuronal blood flow and ischemia.
Describe the role of the pain thermometer in pediatric pain assessment.
The pain thermometer is a color visual analog scale used by children to express their pain levels, aiding in effective pain assessment.
Discuss the safety of using opioids in patients with renal failure.
In patients with renal failure, the accumulation of oxycodone and its metabolites can lead to neurotoxic effects, making morphine, hydromorphone, and codeine unsafe or requiring caution.
Do behavioral scales play a role in pain assessment for young children?
Yes, behavioral scales such as the CHEOPS are the primary means of pain assessment for children under the age of four and for those with developmental disabilities.
Explain the anatomical location of the superior hypogastric plexus.
The superior hypogastric plexus is located anterior to the vertebral column between the lower third of L5 and the upper third of the S1 vertebral bodies.
venlafaxine dose for polyneuropathy.
At a dosage of 150 mg or greater, venlafaxine, a selective serotonin-norepinephrine reuptake inhibitor, is effective in treating painful polyneuropathy, including diabetic neuropathy.
How do children ages 3-7 typically rate their pain?
Children ages 3-7 typically use versions of the faces scale, such as the Oucher or Baker Wong scale, and color visual analog scales like the pain thermometer to rate their pain.
How do gabapentin and pregabalin work?
They bind to voltage-gated calcium channels and decrease the release of glutamate, norepinephrine, and substance P.
How does morphine-6-glucuronide differ from morphine-3-glucuronide?
Morphine-6-glucuronide is an agonist at μ-opioid receptors and exerts antinociceptive activity, while morphine-3-glucuronide has no antinociceptive effect.
How does the stellate ganglion block relate to pain management?
The stellate ganglion block is used to cover pain regions of the face and upper extremity.
How should a patient with an allergic reaction to phenanthrene opioids be managed?
If a patient has an allergic reaction to phenanthrene opioids (like morphine or codeine), it is recommended to try an opioid from a different class, such as phenylpiperidines (e.g., fentanyl) or phenylheptylamines (e.g., methadone).
Identify the areas where the ganglion impar is effective for pain relief.
The ganglion impar is effective for pain originating in the rectal area.
What are the common opioids that belong to the phenanthrene class?
Common opioids in the phenanthrene class include morphine, codeine, hydrocodone, hydromorphone, oxycodone, and oxymorphone.
What is the function of the celiac plexus in pain management?
The celiac plexus helps manage pain originating from the lower esophagus to the mid-transverse colon.
What is the significance of methadone in the context of renal failure?
Methadone and its metabolites are excreted into the gut, making methadone a safer option in the presence of renal failure.
What is the significance of the splanchnic nerve block in pain management?
The splanchnic nerve block is appropriate for managing pain from upper abdominal viscera and is located at the anterolateral part of the T12 vertebra.
What role does CYP3A4 play in drug metabolism?
CYP3A4 is responsible for the metabolism of approximately 60% of all clinically used drugs, including many opioid analgesics, with significant variability in metabolism among individuals.
Metabolized at least in part by 3A4 (7)
Codeine, oxycodone
fentanyl, buprenorphine, methadone
Tramadol and dextromethorphan
Morphine and hydromorphone are metabolized mainly by
Glucuronidation
UGT 2B7 polymerizations impact metabolism of
Morphine and hydromorphone
Lumbar sympathetic block
Sympathetic leg pain
Psoas compartment black
Lower extremity, L1,2 3
A major contributor to opioid neurotoxicity
Dehydration
WHO step 2, mild opioids
Hydrocodone, codeine and tramadol
NMDA receptor molecule
Glutamate (excitatory)
Major methadone metabolizers
3A4, then 2D6
Death is temporary and reversible
Ages 2-6
GFR in neonates
Reduced. In renally cleared meds, lower doses, longer intervals
Liver size in ages 2-6
Increased, need higher
Constipation and confusion, rule out
Hypercalcemia
How reglan increases motility
Blocks serotonin receptors, increasing gut tissue response to acetylcholine, increasing peristalsis
ACC/AHA heart failure stages
A: risk of developing, B: structural abnormalities or reduced EF without symptoms, C: Prior or current symptoms D: needs transplant, LVAD or chronic pressers
LVAD prognosis
1-2y versus 6 months without
Physical symptoms, depression and spiritual well being are lower
in advanced CHF than in cancer
Survival in stage 4 CHF
10 months
Survival in stage 4 CKD
2-3 years
Survival in COPD w/FEV1 35%
2-4 years
Survival from death rattle, mandibular breathing, cyanosis, radial pulselessness
In hours: 57, 7, 5 and 2
Death rattle grading
0 Inaudible, 1 near patient, 2 end of bed, 3 at the door
Worst grief symptoms
Yearning then depression, depression peaks at 6 months
Increased risk of EPS from reglan
Young male patients, prolonged use
Anticholinergics like TCAs and Reglan
Don’t mix—cancels out pro kinetic effects
Home oxygen in COPD
Improves survival, but not proven to improve dyspnea
BiPAP in COPD
Does not improve QoL (does in ALS)
Vegetative or minimally conscious?
In MCS, patients track, follow commands, have purposeful movements (like scratching an itch)
GOLD/ABCD
Prognosis in COPD, includes # of hospitalizations, mMRC dyspnea scale and COPD assessment test
2 drugs good for pruritus but not cholestatic
Antihistimines (allergy only) and gabapentin (uremic pruritis)
Alginate dressings
Wounds with exudates or bleeding
Hip fracture rehab in hospice
Yes if it was mechanical, no if it was metastatic/pathological
Respite care for symptom management
Nope. 5 days rest when symptoms are well controlled
FTF waved
in an emergency (do later), if patient dies within 2 days (waived)
Is failure to thrive a hospital diagnosis
no
Does hospice pay for medication for chronic conditions (e.g. synthroid?)
Nope. Medicare Part D
Hospice criteria for HIV
End stage complication (refractory cancer or infection), CD <25, persistent viral load > 100,000
HIV cancer prognoses
Hodgkins prognosis is same, NSCLC and anal cancer have shorter prognoses in HIV
Olanzapine receptors blocked
serotonin, dopamine, acetylcholine and histamine
Acupuncture proven benefits
Acute and chronic pain, post-operative pain, nausea and vomiting,
Metabolic causes of nausea via
CTZ
Sacral plexopathy symptoms
Sensory loss, sphincter control loss, dull aching and neuropathic pain
Risks of licorice
Glycyyrhizic acid, which causes pseaudohyperaldo (hypertension, fluid retention, hypokalemia)
Do antivirals or antibiotics prevent mucositis
No
Best treatment for pediatric bereavement and trauma
Play therapy
Alprazolam metabolizer and common interaction
3A4, inhibited by diltiazem
Opioids activated by 2D6 (4) and their metabolites
codeine, oxycodone, hydrocodone and tramadol (to morphine, oxymorphone, hydromorphone and O-desmethyl tramadol)
codeine, oxycodone, hydrocodone and tramadol activated forms
morphine, oxymorphone, hydromorphone and O-desmethyl tramadol
Auto induction of methadone metabolism
Causes spontaneous sudden loss of efficacy of methadone dosing due to increased metabolism
Who is billed for radiation on hospice?
Medicare A, if physician has agreement with hospice
Who is billed if attending is a covering or is serving as attending but not affiliated with hospice
Medicare B.
Nonopioid cough treatments
Sodium cromoglycate, brachytherapy, high intrathoracic vagotomy
