Headache, fever, MSID Flashcards
1
Q
Tension type headache
A
Location: bilateral Nature: diffuse ache to tight pressing, constricting pain Onset: gradual Duration: minutes to days Non-headache symptoms: scalp tenderness
2
Q
Migraine headache
A
Usually unilateral Throbbing; may preceded by an aura Onset suddenly Hours to 2 days Nausea
3
Q
Sinus headache
A
Face, forehead or preorbital area
Pressure behind eyes or face; dull; bilateral pain, worse in the AM
Onset simultaneous with sinus symptoms, including nasal discharge
Duration Days Resolves with sinus symptoms
Nasal congestion
4
Q
Secondary headaches (medications that cause headaches)
A
Blood-pressure lowering medication Antibiotics Oral contraceptives Vasodilators Over of medications: ergot derivatives, opioids, nonopiod agents, triptans Caffeine withdrawal
5
Q
Secondary headache ( medication overuse symptoms and treatment)
A
Frequent use >3 month and from stopping medication
Continuous HA: waking, increase with frequency
TX: need to taper the medication to eliminate
6
Q
Exclusions for self treatment HA
A
Severe head pain
Headache that persists for 10 days with or without treatment
Last trimester of pregnancy
<8 years of age
High fever or signs of serious infection
History of liver disease disease or consumption of 3or more alcoholic drinks per day
Secondary headache ( except minor sinus headache)
Symptoms consistent with migraine without formal diagnosis
7
Q
General treatment for episodic tension type headaches
A
Apap
NSAID
Salicylate
8
Q
General treatment for chronic tension type headaches
A
Candidates for prescription medications
If using OTC, limit to 3 days per week
Benefit from non pharmacologic treatment
9
Q
General treatment for migraine headaches
A
Medical diagnosis is required before self treatment
Treat with NDAID or salicylate
10
Q
General treatment for sinus headache
A
Decongestant and/or OTC analgesic
11
Q
Nonpharmacologic therapy of chronic tension headaches
A
Relaxation exercise
Physical therapy focused on stretching and strengthening of head and neck muscles
12
Q
Nonpharmacological treatment for migraines
A
Regular sleeping and eating schedule
Methods for coping with stress
Ice+pressure to forehead or temple are
Dietary: Avoid Food that triggers; avoid hunger or low blood glucose; magnesium supplements; avoid food with nitrates, tyramine, phenylalanine, monosodium glutamate ( msg), caffeine and theobromine
13
Q
MOA of APAP
A
Inhibitors of prostaglandins synthesis centraly
Not an anti inflammatory
Not considered NSAID
14
Q
Indications for APAP
A
Analgesic ( mild to moderate pain of non visceral origin)
Antipyretic
15
Q
Onset of APAP
A
30 minutes
16
Q
Duration of APAP
A
Four hours, 6-8 hours with ER formulation
17
Q
DI with APAP
A
Alcohol
Warfarin
18
Q
APAP Dosing
A
Adult dosing:
325 mg - 1000 mg 4-6 hours ( MDD 4000mg)
New dosing: extra strength tablets (500mg): 2tab every 6 hours ( MDD 3000 mg)
Regular strength tablets (325mg): MDD 3250 mg
19
Q
APAP pediatrics dosing
A
10-15 mg/kg
20
Q
Acute overdose of APAP
A
One time dose 10g or more leading acute liver failure
21
Q
Chronic overdose of APAP
A
Daily dose more than 4 g for several weeks leading acute liver failure
22
Q
Prevention of overdose of APAP
A
Follow dosing instructions and max daily dose exactly as on package labeling
Read labels of all medications to avoid excess APAP
Conservative dosing (2g/day or less) in patients at risk for hepatotoxicity:
-Concurrent use of other potential hepatotoxic drugs
-Poor nutrition intake
-Ingestion of 3 or more alcoholic drinks per day
23
Q
Symptoms of overdose of APAP
A
Early symptoms: nausea, vomiting, drowsiness, confusion, abnormal pain. Or no symptoms
Serious clinical manifestation: begin 2-4 days after acute ingestion; increased liver enzymes ( alt/ast); increased plasma bilirubin w/jaundice; prolonged prothrombin time; obtuntation
Majority of cases, hepatic damage is reversible over week-months but fatal hepatic necrosis can occur
Refer to poison control center/ER
24
Q
NSAID salicylate
A
ASA
25
NSAID non acetylated salicylate
Magnesium salicylate
| Choline salicylate
26
Non salicylate nsaid
Ibuprofen
Ketoprofen
Naproxen
27
NSAID MOA
Anti inflammatory: nsaid decreases prostaglandins synthesis via inhibitions of cox1 and cox2 ( non selective)
- ASA irreversibly binds to receptors
- Ibuprofen, ketoprofen, naproxen reversible binds to receptors
Analgesic and antipyretic Activity: inhibit the production of prostaglandin synthesis resulting in reduced nonciceptor sensitization and increase pain threshold.
- temperature-inhibition of PGE2
- Analgesic-inhibition of PGE and PGF
Platelet Effect: the inhibition of platelet aggregation
28
Indications for no salicylate nsaid
Fever
Minor pain from headaches, common cold, toothache, muscle aches, backache, arthritis, menstrual cramps
Mild-moderate pain of non visceral origin
Inflammation
29
Non salicylate nsaid ADR:
GI: dispepsia, heartburn, nausea, anorexia, epigastric pain, peptic ulcer, bleeding
Dizziness, rash, fluid retention, renal failure
30
Non salicylate nsaid CI
-increased risk for MI,heart failure, hypertension, stroke
-patients at risk for CV should avoid: hyperlipidemia, HTM, DM
All patients, use lowest dose for shortest duration:
-history of GI bleeds
-asthma
-impaired renal/hepatic function
31
Non salicylate nsaid DDI
NSAID and ASA ( cardio protection): take ASA 30 min before or 8 hr after: allowing ASA time to bind irreversible
PHenytoin:displacement from protein binding sites
Bisphosphonates: increased risk of GI irritation
Digoxin: inhibition of digoxin renal clearance
Anti hypertensive effects inhibited ( BB, ACE-I, Vadodilators, diuretics)
Anticoagulant: increased risk of bleeding
Alcohol:increased risk of bleeding
Methotrexate: decreased clearance
32
Ibuprofen dosing
>12 yo 200-400 mg Q 4-6 hr 1200mg/day
33
Naproxen dosing
12-65 220 mg Q 8-12 hr max 660mg/day
>65 yo 220mg Q 12 hr max 440 mg/day
Aspirin 650-1000mg Q 4-6 hr 4000 mg/ day
Not recommended younger than 12 years old
34
ASA dosing
650-1000 mg Q 4-6 hr max 4000mg/day
35
Ibuprofen pediatric dosing
5-10 mg/kg
36
Salicylate indications
Treatment of symptoms Of osteoarthritis, rheumatoid arthritis
Temporary relief of minor aches And pains from backache and muscle aches
Mild-moderate pain from musculoskeletal conditions/fever
ASA: prevention of thromboembolic events ( MI and Stroke)
37
Salicylate drugs interactions
Nsaid and ASA
Valporic acid: Displacement from protein binding site And incubation of metabolism
Nsaid and anticoagulants, alcohol: increased GI bleeding
Antihypertensive effect inhibited ( BB, ACE I, vasodilator, diuretic)
Methotrexate: decreased clearance
Sulfonylureas: increased risk of hypoglycemia
38
Salicylate ADR
GI : dyspepsia, epigastric discomfort
Gastritis ulceration of upper GI tract
- penetrates protective mucous and bicarbonate layers of gastric mucosa, allowing back diffusionof acid leading to cellular and vascular erosion: local irritant effect from medication contacting gastric mucosa and systemic effect from prostaglandins inhibition
GI blood loss is dose dependent
Aspirin intolerance:
-urticaria-angioedema and bronchi spastic ( risk factor: asthma with nasal polyps )
39
ASA CI
Discontinue 3 days before fecal occult blood testing
Discontinue 2-7 days Before surgery
Do not use to relive pain after any surgery
In patients with hypothrombinemia, vitamin K deficiency, hemophilia, history of bleeding disorder, history of peptic ulcer disease
40
Sodium salicylate CI
Does not affect platelets but can increase prothrombin time
| Avoid in patients who are sodium restricted ( heart failure, HTN, renal failure)
41
Magnesium salicylate CI
Caution in patients with renal impairment ( accumulation of magnesium)
42
All Salicylates CI
Avoid in history of gout or hyperuricemia ( does of 1-2 g inhibit Uric acid secretion)
43
Salicylates : Reye’s syndrome
Acute illness occurring exclusively in children <15 yo
Progressive neurologic they damage, fatty liver with encephalopathy, hypoglycemia
Mortality as high as 50%
Cause unknown onset follows viral infection with influenza or varicella zoster
Warning:aspirin and other salicylate Should be avoided in children and young adults who have influenza and chickenpox
44
Regular aspirin
Non ionized drug absorbed in the stomach and small intestine
45
Enteric coated aspirin
Absorbed only in small intestine
Absorption slowed by food
Hypochlorhydria may cause dissolution in the stomach
Not for patients who need rapid pain relief
46
Salicylate suppository
Absorption slow and unreliable
47
Buffered aspirin
```
Buffers to decrease GI irritation:
Aluminum hydroxide
Magnesium carbonate
Calcium Carbonite
Sodium bicarbonate
Absorbed more rapidly than non buffered, but time to onset is not improved much
More expensive
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48
Sustained-release aspirin
ProlongsDuration of action by slowing dissolution and absorption
49
Salicylates Toxicity
Salicylism: mild salicylate intoxication
- 90-100mg/kg for at least 2 days
- HA, confusion, dizziness, difficulties hearing, vision changes, n/v, sweating
Acute intoxication:
- Mild (<150mg/kg) to severe( >300mg/kg)
- lethargy, tinnitus, tachypnea, pulmonary edema, convulsions, coma, n/v, acid-base disturbance, dehydration, hemorrhage, hypoglycemia
50
Choline salicylate dosing
870 mg q3-4h ( 5220mg/d)
| Do not give for patients younger than 15 years old
51
Ketoprofen dosing
12.5-25 mg q4-6 hr( 75mg/d)
| Not recommended for patients younger than 16 years old
52
Normal body temperature
Between 97.5-98.9
53
Fever
Regulated rise in the body temperature maintained by the hypothalamus in response to a pyrogen
Increase in the body thermoregulatory set point
54
Hyperthermia
Uncontrolled elevation invited temperature without elevation of hypothalamic set point
55
Hyperpyrexia
Body temperature >106f resulting in mental and physical consequences
Caused by pyrogen or hyperthermia
56
Causes of fever
```
Idiopathic
Microbial infections
Tissue damage
Malignancies
Antigen antibody rnx
Dehydration
Heatstroke
CNS inflammation
Metabolic disorders
Drug fever from 98.9 to 109f
Pyrogens:
-exogenous (microbes toxins): did not independently increase hypothalamic set point; stimulate release of endogenous pyrogens
-exogenous ( immune cytokines): causes production of PGE2; PGE2 elevates thermoregulatory st point
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57
Complications of fever
Most fevers are self-limiting and nonthteatening:
-headache, diaphoresis, generalized malaise, chills, tachycardia, arthralgia, myalgia, irritability, anorexia
-disorientation and delirium
Major risk: seizures, dehydration, change in mental status
58
Rectal thermometer
Normal range: 97.9-100.4
Fever: > 100.4
Gold standard, most accurate
59
Oral thermometer
Normal range: 95.9-99.5
| Fever: >99.5
60
Axillary thermometer
Normal range 94.5-99.3
| Fever >99.3
61
Temporal thermometer
Normal range97.9 -100.1
Fever: > 100.7for two months old
>100.3 for 3-4 months old
> 100.1 for >4 months old
62
Tympanic thermometer
Normal range 96.3 - 100
| Fever more than 100
63
Exclusions to self care of fever
Children older than six months with rectal temperature more than 104 or equivalent
Infants younger than six months with rectal temperature more than 101
Severe symptoms of infection that are not self-limiting
Risk of hyperthermia
Impaired oxygen utilization( sever Copd, respiratory distress, heart failure)
Impaired immune function HIV cancer
CNS They Mitch head trauma Stroke
Children with history of febrile seizures
Fever persists more than three days three days with or without treatment
Child who: develops spot or rash; refuses to drink fluids , is sleepy , irritable or hard to wake up; Is vomiting and cannot keep fluids down
64
Recommended nonpharmacologic treatment for fever
Adequate fluid intake:
-children: increased by 30-60 ml of fluid per hour
-adults: Increased by 60-120 ml Of fluids per hour
-Caution recommending fruit juice in patients with diarrhea
Wear lightweight closing
Remove blankets
Maintain comfortable room temperature of about 68f
65
Did not recommend nonpharmacological treatment
Sponging or baths= Limited utility
Icewater bath
Sponging with hydroalcoholic solutions
66
Pharmacologic therapy
Antipyretic: inhibit pge2 synthesis => Decreasing hypothalamic set point
APAP: Takes 30 min to 1 hour to begin did you please temperature or discomfort; Reaches maximum temperature reduction at two hours
Ibuprofen: Text half an hour to an hour to degrees temperature or discomfort ; reaches maximum temperature reduction two hours
67
Monitoring fever
In Most patients reduction in temperature seen after each individual dose
In some patients Pharmacologic therapy may take up to one day to result in decrease in temperature
Monitor temperature 2-3 times a day
68
Referral to medical provider ( fever)
If fever or discomfort persists or worsens after three days of Drug treatment
69
MSID
Musculoskeletal injuries and desorders
70
Somatic pain( MSID)
Arise from: Bone, Joint, muscle,connective tissue
| Symptoms: Aching , squeezing stabbing, throbbing ; well localize patient then identify the source
71
Visceral pain( MSID)
Arise from internal organs
Symptoms dull and crumpy
Injury it to organ capsule or other structure pain more localized and sharp
72
Neuropathic pain ( MSID)
Abnormal processing of sensory input by peripheral or CNS: Spontaneous pain transmission
Symptoms Burning, tingling shock like shooting
73
Acute pain( MSID)
10 days or less
Triggered by tissue damage
Ex. Tendinitis ,sprain, strain
74
Chronic pain(MSID)
Six months or longer
More than 14 days if you have been trying to Treat
Continued pain after the injury is healed
Associated with ongoing or progressive disease
Ex: degenerative joint disease ( DJD) or osteoarthritis
75
Common musculoskeletal disorders
```
Myalgia
Tendinitis
Bursitis
sprain
Strain
Osteoarthritis ( APAP is first line
Low back pain: acute: candidates for self care
Chronic: Medical Evolation first
Overexertion
```
76
Exclusions for self-care ( MSID)
Moderate to severe pain score more than six
Pain that lasts more than 10 days
Pain that continues more than seven days after treatment with topical analgesics
Increased intensity or change in character of pain
Pelvic or abdominal pain other than dysmenorrhea
N/V or fever or other signs of infection
Visually deformed Joint, Abnormal movement weakness in any Limb or suspected fracture
Third trimester of pregnancy
Less than two years of age
77
General treatment considerations ( MSID)
Use scheduled doses of non-prescription strength analgesics early in course of injury
Quickly taper dose and dosing interval as the injury improves ( 1-3 days)
Follow up: If plane has not improved in 10 days seek medical attention
78
Nonpharmacologic therapy MSID
RICE: rest ice compression elevation
Preventing sports exercise injuries: warming up or stretching; proper hydration
Muscle cramps: Stretching and message and the affected area immediately then the rest or reduced activity
Chairs with back support and Ergonomic keyboards
Heat therapy
79
Heat therapy MSID
For noninflammatory pain (acute low back pain ) and Osteoarthritis:
-Did not apply to recent injuries less than 48 hours or inflamed area( will intensify vasodilation and exacerbate vascular leakage and tissue damage)
Did not use Waze other topical agents or over broken skin
Did not to use heating devices on area of skin with decreased sensation
Warm wet compresses heating pads or hot the water bottles:
-apply heat for 15 or 20 minutes 3 to 4 times a day
Heat-generating adhesive and wrap products:
- Warn for up to eight hr to 12 hours for arthritis products
- thermacare products should not be used on the palm of the hand, back of the knee or bend of the arm
- remove patch immediately if pain , discomfort, itching, or burning
Heat wraps:
- should be warn over clothing in patients over 55 yo
- should not be used while sleeping
80
Counterirritants
Paradoxical pain-relieving effect achieved by producing a less severe pain to counter a more intense one
Psychological component:
- met exert placebo effect through pleasant odors or sensations of warmth/coolness
Indications:
- temporary relief of minor aches and sprains of muscles and joints
- simple backache, arthritis pain, strains, bruises and sprain
81
Rubefacients ( increase blood flow)
Methyl salicylate 10-60%
Turpentine 6-50%
Allyl isothiocynate 0.5-50%
Ammonia water 1-2.5%
Applying no more often then 3 to 4 times a day for up to seven days
82
Counterirritants produced cooling sensation
Camphor 3-11%
Menthol 1.25 -16.0 %
Apply no more often than 3 to 4 times a day for up to seven days
83
Counterirritants caused vasodilation
Menthyl nicotinate 0.25-1
Histamine dihydrochloride 0.025-0.1
Apply no more often than 3 to 4 times a day for up to seven days
84
Counterirritants: irritation without rubefaction
Capsicum, capsaicin 0.025-0.25%
Acute pain: apply no more often then 3 to 4 times a day for up to seven days
Chronic pain: Apply 3 to 4 times a day for duration of pain
85
Methyl Salicylate
Occurs naturally as wintergreen oil or sweet birch oil: also known as gaultheria oil, teaberry oil, or mountain tea
MOA: rubefacient: Causes vasodilation of cutaneous vasculature producing hyperemia
Also inhibits prostaglandins synthesis peripherally and centrally, acting as anti-inflammatory agent
Direct tissue penetration suggests local effect
86
Methyl Salicylate ADR
Skin irritation or rush
Erythema, blistering, neurotoxicity , thermal hyperalgesia
Salicylate Toxicity
87
Methyl Salicylate Precautions
Absorption increases with: Heat pads or heat exposure, exercise
Avoid in children
Avoid in patients with severe asthma or nasal polyps
Avoid in patients with sensitivity to aspirin
88
Camphor MOA
Concentrations 0.1-3% depress cutaneous receptors( Used as analgesic,antipyretic, anesthetic)
Concentrations more than 3% stimulates nerve endings in the skin and induce pain relieve and discomfort by Making Moderate-severe deeper visceral pain with a milder pain arising From the skin at the level of innervation
When applied vigorously, it produces a rubefacient rxn
89
Camphor precautious
CNS Toxicity ( tonic-clonic seizures) Following ingestion
Placing in Nostrils of infants can cause respiratory collapse
Caution with vapo-rub products
90
Menthol MOA
Extracted from peppermint oil or prepared synthetically
Concentrations less than 1% acts as anesthetic and depresses cutaneous response
Concentrations more than 1.25% stimulates cutaneous receptor response ( counterirritants)
Triggers cold sensation that travels along pathways similar to somatic pain sensations from that affected muscle or joint, which distracts from the pain sensation
Initial feelings of coolness followed by sensation of warmth
91
Menthol CI
Hypersensitivity or Sensitization
92
Methyl nicotinate MOA
Causes vasodilation and elevation of skin temperature
| Partially mediated by prostaglandins Biosynthesis
93
Methyl nicotinate ADR
Blood pressure decrease decrease in Pulse rate
| Syncope From generalized vascular dilation
94
Capsicum MOA
Naturally occurring
Depletes substance P from sensory neurons implicated in mediating cutaneous Pain
Causes burning pain or sensation
95
Capsicum Indication
Reduces pain Butts not inflammation of rheumatoid arthritis, osteoarthritis
Also used in postherpetic neuralgia, psoriasis, diabetic neuropathy
96
Capsicum dosing
Need to use every day 3 to 4 times a day for efficacy
Duration of action 4 to 6 hours
Pain relief takes 14 days up to 4 to 6 weeks
Apply With gloves or applicator and wash hands following use
Do not touch sensitive areas (eyes) or apply to Wounds for damage skin
Discontinue temporarily of skin breakdown occurs (Read, weeping, small ulcers).
97
Trolamine Salicylate MOA
Category three: Insufficient data are available to establish safety and efficacy during pregnancy
Salicylate salt
Absorbed through the skin lead-in to salicylate concentrations in synovial fluid slightly below those of oral aspirin
98
Trolamine Salicylate dosing
10-15% concentration applied to affected area not more Than 3 to 4 times a day
For adults and children more than two years old
Same drug interactions and CI As other salicylates
Avoid Contact with eyes and mucous membranes
