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Orthopedic Surgery Ultimate > Ortho Pain Management > Flashcards

Ortho Pain Management Flashcards

1
Q

Patients that need sporadic pain control adjustments: such as? 4

A
  1. Toradol IM/IV
  2. Morphine IM/IV
  3. Dilaudid IM/IV
  4. Demerol/ Phenergan IM
    Most patients however can usually be controlled with oral mediations
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2
Q

What are your most common narcotics used? 7

A
  1. Codeine
  2. Hydrocodone
  3. Oxycodone
  4. Tramadol
  5. Hydromorphone
  6. Meperidine
  7. Fentanyl
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3
Q
  1. Describe schedule I drugs? 3

2. Examples? 5

A
  1. Schedule I
    - Use – Illegal/restricted to research. No accepted medical use.
    - Drug or other substance has a high potential for abuse.
    - Lack of accepted safety for use
    • Hallucinogens
    • Heroin
    • Peyote
    • Coca
    • Psilocybin mushrooms
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4
Q

Schedule II

  1. Requires what?
  2. abuse potential?
  3. WHat is not allowed for these?
  4. Examples? 8
A
  1. Requires a prescription
  2. High abuse potential
    - Psychological or Physical dependence
  3. No refills or verbal orders
    • Codeine
    • Hydrocodone
    • Hydromorphone
    • Morphine
    • Cocaine
    • Fentanyl
    • Methadone
    • Meperidine
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5
Q

Schedule III drugs

  1. Requires what?
  2. Abuse potential?
  3. Refills and verbal orders? 2
  4. Stimulants examples? 2
  5. Depressants? 4
A

Schedule III

  1. Requires a prescription
  2. Moderate abuse potential (Less than I&II)
    • Max 5 refills/6 mos
    • Verbal orders allowed
  4. Stimulants
    • Benzphetamine
    • Clortemine
  5. Depressants:
    • Ketamine
    • Pentobarbital
    • Secobarbital
    • Sulfomethane
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6
Q

Schedule IV drugs

  1. Requires what?
  2. Abuse potential?
  3. Refills/Verbal orders?
  4. Examples? 8
A
  1. Requires prescription
  2. Low abuse potential
    • Max 5 refills/6mo
    • Verbal orders allowed
  4. Examples – benzodiazepines, sedatives/hypnotics and now also tramadol
  • Alprazolam
  • Barbital
  • Clonazepam
  • Lorazepam
  • Midazolam
  • Phenobarbital
  • Diazepam
  • Tramadol
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7
Q

Schedule 5 drugs

  1. Requires?
  2. Abuse potential?
  3. Examples? 4
A
  1. Requires a prescription or may be OTC with restrictions in some states
  2. Low abuse potential

Currently accepted medical use in treatment

  1. Examples of Schedule V drugs:
    - Robitussin AC (antitussive)
    - Lyrica (anticonvulsant)
    - Lomotil (antidiarrheal)
    - Potiga (anticonvulsant)
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8
Q

Codeine/APAP

  1. Class of drug?
  2. Also used as?
  3. Schedule?
  4. Good choice for who?
A
  1. Opioid agonist (binds to opioid receptors)
  2. Used as an antitussive as well
  3. Schedule III
  4. Good choice for pediatric
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9
Q

Hydrocodone

  1. Class of drug?
  2. What are all the combo formations? 4
  3. Schedule?
A
  1. Opioid agonist (binds to opioid receptors)
  2. Many combo formulations(Vary in APAP)
    - Lorcet – 10/325
    - Vicodin– 5/325
    - Norco - 5/325, 7.5/325, 10/325
    - Lortab – 5/325, 7.5/325, 10/325
  3. Schedule II
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10
Q

Oxycodone

  1. What is oxycodone with APAP?
  2. What is it without APAP?
  3. What type of combo is used with chronic pain?
  4. Class of drug?
  5. Schedule?
  6. Which one has aspirin in it?
A
  1. Can be a combo drug or not
    Percocet…oxycodone with APAP
  2. OxyContin. No APAP
  3. MS-contin, oral morphine sulfate –chronic pain
  4. Opioid agonist (binds APAP to opioid receptors)
  5. Schedule II
  6. Cousin of percocet is percodan. Has aspirin
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11
Q

Tramadol (Ultram)

  1. APAP combo?
  2. Possible MOA?
  3. Caution with who?
  4. Schedule?
A
  1. APAP combo called Ultracet
  2. Mechanism of action unknown.
    binds to opioid receptors and inhibits norepenephrine/serotonin reuptake.
  3. Caution with seizure hx and can cause serotonin syndrome
  4. Schedule – IV
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12
Q

Hydromorphone(Dilaudid)

  1. MOA?
  2. Abuse potential?
  3. D/C instructions?
  4. Schedule?
A
  1. Mechanism of action the same as other opioids.
  2. High abuse potential and highly sedative
  3. Taper dose to D/C
  4. Schedule II
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13
Q

Meperidine(Demerol)

  1. Class of drug?
  2. SE?
  3. Risk?
  4. Which route of administration is the least effective?
  5. D/C instructions?
  6. Schedule?
  7. Often causes what? How can we prevent this?
A
  1. Opioid agonist(binds to opioid receptors)
  2. Very sedative
  3. Seizure risk over time and dose
  4. Oral route least effective
  5. Avoid abrupt cessation
  6. Schedule II
    Cost – 20 tabs about $30
  7. Often causes N/V….give with Phenergan
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14
Q

Fentanyl(Duragesic)

  1. For what?
  2. For who ONLY?
  3. Abuse potential?
  4. Need what with this?
  5. Schedule?
A
  1. For chronic pain.
  2. For opioid tolerant patients ONLY!
  3. Major abuse potential
  4. Need responsible patients and/or caregiver to administer
  5. Schedule II
    Cost – $100 for 5 patches. 1 patch = 3 day dose
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15
Q

NSAIDS

  1. Good in what field?
  2. What kind of properties?
  3. Caution with what?
  4. Some studies suggest that NSAIDS have what negative effect?
  5. All have warnings pertaining to what? 3
A
  1. Good use in orthopedics.
  2. Anti-inflammatory properties
  3. Caution with concomitant anticoagulation
  4. Some studies have suggested NSAIDS may slow down fracture healing
  5. All have warnings pertaining to
    - cardiovascular risk,
    - GI bleeding,
    - kidney risk.
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16
Q
  1. What NSAIDS are in the Acetic Acid group? 4
  2. MOA?
  3. Good for pain associated with what?
A
    • Diclofenac,
    • Etodolac,
    • Indomethacin,
    • Ketorolac
  2. Thought to inhibit cyclooxygenase, reducing prostaglandin and thromboxane synthesis
  3. for management of arthritis associated pain (rheumatoid, osteo, ankylosing spondylitis)
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17
Q

What are the most common OTC groupings?

A

Propionic acids

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18
Q

NSAIDS

  1. What are the propionic acids? 2
  2. MOA?
  3. Risks? 2
A
    • Naproxen,
    • Ibuprofen
  2. COX 1 and COX 2 inhibitor. Mess with prostaglandins
  3. Can cause
    - GI issues,
    - kidney issues.
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19
Q

COX 2 Inhibitors

  1. What drug is in this school?
  2. Where is this often used?
  3. Contraindication?
  4. Arguably less problems with?
A
  1. Celebrex – last man standing
  2. Many orthopedic surgeons use as an adjunct with narcotics following total joint surgery.
  3. Contraindicated in persons with sulfa allergy
  4. Arguably less of a GI profile
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20
Q

Steroids

  1. Oral drug commonly used in ortho?
  2. For what?
  3. Injectables? 3
A

Oral
1. Medrol-dose pack.

  1. Rheumatologic applications… longer duration, mostly use prednisone, need a taper.
  2. Injectable
    - Triamcinalone-kenalog
  • Celestone-betamethasone
  • Depo-medrol-methylprednisolone
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21
Q

Oral Muscle Relaxants
1. The aim of centrally acting skeletal muscle relaxants is to do what? 3

  1. Alters the balance of what? 2
  2. Primarily to elicit varying degrees of what?
A
  1. produce a
    - decrease in muscle tone and
    - involuntary movement
    - without loss of voluntary motor function or consciousness.
    • synaptic excitation and
    • inhibition the motor neuron receives
  3. skeletal muscle relaxation.
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22
Q

Indications for muscle relaxants? 3

A
  1. For relief of acute painful musculoskeletal conditions of local origin.
  2. As an adjunct to rest and physical therapy.
  3. For the relief of acute painful musculoskeletal conditions
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23
Q

Indications for muscle relaxants: For the relief of acute painful musculoskeletal conditions which include what?
5

A

which include

  1. muscle spasm secondary to trauma,
  2. radiculopathy,
  3. musculoskeletal strain or sprain,
  4. herniated intervertebral disc
  5. muscle spasm of osteoarthritis.
24
Q

Muscle relaxants

  1. All have what effects?
  2. Careful in who?
  3. Absorption?
A
  1. All are CNS depressants.
  2. caution with elderly
  3. All are well absorbed orally with quick effects.
25
Q

Muscle relaxants

  1. Caution with?
  2. What occurs with long term followup? 4
  3. Frequently used with what for abusive purposes?
  4. Cons? How to avoid this?
A
  1. Caution with renal and hepatic insufficiency.
    • Leukopenia,
    • thrombocytopenia,
    • hemolytic anemia,
    • bleeding agranulocytosis with long term use primarily so no initial or follow-up labs unless symptoms occur.
  3. Frequently used with alcohol or opioids for abusive purposes.
  4. Can have withdrawal from muscle relaxants. Taper off to avoid withdrawals.
26
Q

Muscle relaxants

  1. Not recommended for? 3
  2. Should be taken for how long?
A
    • Not recommended for use in pregnancy
    • Not recommended for use in children.
    • Should not be mixed with ETOH or other CNS depressants. This will potentiate the effects.
  2. Should only be taken for 10-14 days optimally.
    Must revaluate need
27
Q

Muscle relaxants
Guidelines for use?
4

A
  1. Combination muscle relaxant and an analgesic agent appear to be preferred.
  2. The most effective therapy should consider drugs in conjunction with various modes of physical therapy.
  3. All agents have the potential to cause drowsiness, headache, dizziness and blurred vision.
  4. Patients should not be treated with muscle relaxants for protracted periods.
28
Q

Muscle Relaxants:
1. _______ may be useful where pain predominates?

  1. For patients with anxiety, in whom sedation is desirable, what should be considered?
  2. Combination muscle relaxants/analgesics are available, equally effective and less costly. Example?
A
  1. NSAIDs
  2. Diazepam (Valium)
  3. Norgesic (asa/caffeine/orphenadrine)
29
Q

Muscle Relaxants:
Carisoprodol (Soma)
1. What makes this different?

  1. The mode of action in relieving acute muscle spasm of local origin has not been clearly identified, but may be related to what?
  2. In animals, has been shown to produce muscle relaxation by what?
  3. One of the products of metabolism, meprobamate, is active as a what?
A
  1. Centrally acting skeletal muscle relaxant that does not directly relax tense skeletal muscles in man.
  2. its sedative properties.
  3. blocking interneuronal activity and depressing transmission of polysynaptic neurons in the spinal cord and in the descending reticular formation of the brain.
  4. anxiolytic
30
Q

Muscle Relaxants:
Carisoprodol (Soma)
1. Should not be used for periods longer than what?

  1. Adverse effects?
    10
A
  1. 10-14 days.
    Evaluate need for further treatment.
    • Drowsiness, dizziness
    • Vertigo, ataxia
    • Nausea and/or vomiting
    • Hiccups
    • Epigastric distress
    • Tremor, agitation
    • Headache, insomnia
    • Tachycardia
    • Postural hypotension
    • Facial flushing
31
Q 
Muscle Relaxants:
Carisoprodol  (Soma)
1. Contraindications?
2. What is this?
3. What kind of symptoms? 3
  1. Precautions?
A

Contraindications

  1. Porphyria
  2. Inherited porphobilinogen deaminase mutation
    • Abdominal & urinary symptoms
    • Peripheral neuropathy
    • Systemic and central nervous system involvement
  4. Seizures
32
Q

Muscle Relaxants:
Cyclobebenzaprine (Flexeril)
1. Structurally similar to what?

  1. MOA?
  2. Onset of action?
  3. Has what kind of affect?
  4. Should not be used for periods longer than what?
A
  1. Tricyclic antidepressants.
  2. Relieves skeletal muscle spasm of local origin without interfering with muscle function.
  3. is approx 1 hour, effects last up to 12 hours.
  4. anticholinergic effect.
  5. 10-14 days.
    Evaluate need for further treatment.
33
Q

Muscle Relaxants:
Cyclobebenzaprine (Flexeril)
1. Contraindications? 4

  1. Most common adverse effects? 4
  2. Less common adverse affects? 5
A
  1. Contraindication:
    -With concurrent use of MAOI’s
    -Acute phase of MI
    -Arrhythmias
    Heart block
  2. Most common adverse effects:
    - Drowsiness
    - Dry mouth
    - Fatigue
    - Headache
  3. Less common adverse effects:
    - Constipation
    - Abdominal pain
    - Acid regurg
    - Dizziness
    - Nausea
34
Q 
Muscle Relaxants:
Diazepam (Valium)
1. Used as?
2. MOA?
3. It is the only agent in this class to be approved for what?
A
  1. Used as a centrally acting skeletal muscle relaxant.
  2. Diazepam depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition medication by GABA.
  3. treatment of muscle spasm or musculoskeletal disorders.
35
Q

Muscle Relaxants:
Methocarbamol (Robaxin)
-Advantage of this medication?

A

Less sedating than some other muscle relaxants

36
Q

Muscle Relaxants:
Methocarbamol (Robaxin)
1. How many grams of day are recommended for the first 48 to 72 hours of tx?

  1. Thereafter?
  2. Should not be used longer than?
A
  1. 6 grams/day are recommended for the first 48 to 72 hours of treatment. (For severe conditions 8 grams a day may be administered.)
  2. Thereafter, the dosage can usually be reduced to approximately 4 grams/day.
  3. Should not be used for periods longer than 10-14 days.
    - Evaluate need for further treatment.
37
Q

Muscle Relaxants: Others? 3

A
  1. Metaxalone (Skelaxin)
  2. Tizanidine (Zanaflex)
  3. Baclofen (Lioresal)
38
Q

Ortho Pain

What classes of meds can be used? 7

A
  1. NSAIDs
  2. Muscle Relaxers
  3. Narcotics
  4. Steroids
  5. TCA’s
  6. GABA Analog (ex: Gabapentin, valproic acid)
  7. OTC i.e. Glucosamine, Omega 3’s
39
Q

Ortho Pain
Non-pharmaceutical mangement?
8

A
  1. Ice/Heat
  2. Patientt handouts on stretches/exercises
  3. Consider Physical Therapy/Occupational Therapy
  4. Consider plain films then MRI
  5. Osteopathic Manipulation/Chiropractor
  6. Behavioral Health for chronic pain
  7. Biofeedback/hypnosis/anti-inflam diet
  8. Splinting/bracing/immobilization
40
Q

Ankle Sprain Medications
Grade I ankle sprain post inversion injury with immediate pain then some swelling.
No significant past history
Consider? 2

A

NSAIDS
1. Motrin (Ibuprofen) 800mg 1 po tid-qid
Or
2. Naproxen 250mg 1-2 po bid

41
Q

How would you consider treating this grade II-III ankle sprain:
-What are some anti-inflammatories and dosing?
NSAIDS? 3

A 
1. Motrin (Ibuprofen)  800mg 1 po tid (wf)
Or
2. Naproxen 250mg 1-2 po bid  (wf)
Or
3. Indocin 25mg 1 po tid  (wf)
42
Q

Grade II-III ankle sprain:
How painful do you think this would be?
Would you consider something for a couple of days or maybe something to take at night to help sleep?

A

I would consider something stronger for night time ie:
-Vicodin #10 1-2 po every evening prn pain
Percocets are probably a little too strong but can consider.

43
Q

Vicodin (hydrocodone tartrate and acetaminophen) 5mg/500mg

SE? 7

A
  1. Constipation
  2. Shallow breathing, slow heartbeat
  3. Feeling light-headed, fainting
  4. Confusion, fear, unusual thoughts or behavior
  5. Seizure (convulsions)
  6. Problems with urination
  7. Nausea, upper stomach pain, itching, loss of appetite, dark urine, clay colored stools, jaundice

Diversion is a real problem

44
Q

What would you do for this patient?

Was lifting heavy object when had sudden sharp, non radiating LBP. No bowel, bladder, fever or saddle parasthesia. DTR’s 2+ BL, Neg SLR, No CVA tenderness

Tx?
3

A

How about starting with an NSAID?
1. Ibuprofen 800mg 1 po tid x 3-5 days then prn
Or
2. Naproxen 250-500mg bid

  1. How about a muscle relaxer?
    Robaxin 500mg 1-2 po qid x 3 days then prn
    Can combine with an NSAID
45
Q

Fibromyalgia

  1. What is it?
  2. What do researchers believe that is the PP of FM?
A
  1. Widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
  2. Researchers believe that fibromyalgia amplifies painful sensations
46
Q

Fibromyalgia Risk Factors? 3

A
  1. Genetics
  2. Rheumatic Diseases
  3. Physical or emotional trauma
47
Q

Fibromyalgia Medications? 3

A
  1. Pain relievers
  2. Antidepressants
  3. Anti-seizure drugs
48
Q

Fibromyalgia Medications

Pain Relievers? 6

A

Pain relievers

  1. OTC meds
  2. Acetaminophen (Tylenol)
  3. Ibuprofen (Motrin, Advil)
  4. Naproxen (Aleve)
  5. Tramadol (Ultram)
  6. Narcotics not advised
49
Q

Fibromyalgia Medications

Antodepressants that you would use? 3

A
  1. Amitriptyline
    Initial dose 10mg qhs (may increase to 150mg)
  2. Duloxetine (Cymbalta)
    30mg qd x 1 week then increase to 60mg qd as tolerated

Upon discontinuation of antidepressant therapy, gradually taper the dose

  1. As an alternative to Amitriptyline
    Cyclobenzaprine (Flexeril)
    Immediate release: Initial 5mg tid; may increase to 10mg tid prn

Does not treat depression

50
Q

FBM meds: Anticonvulsants that you would use? 2

A

Anticonvulsants:
1. Gabapentin
300mg starting dose

  1. Pregabalin
    75mg starting dose
51
Q

Fibromyalgia Medications
Combination treatment
Unresponsive to monotherapy

Get psych, phys therapy, physicao medicine involved
-Directed at reducing the major symptoms: Such as? 4

A
  1. Chronic widespread pain
  2. Fatigue
  3. Insomnia
  4. Cognitive dysfunction
52
Q

Reflex Sympathetic Dystrophy

  1. Disorder of what?
  2. Characterized by?
  3. Inciting events? 4
A
  1. Disorder of a body region…. usually extremities
  2. Characterized by severe pain, swelling, limited range of motion, and skin changes
  3. Inciting event:
    - Soft tissue injury in 40%
    - Fractures in 25%
    - MI 12%
    - Cerebrovascular accidents 3%
53
Q 
Reflex Sympathetic Dystrophy
Tx
1. Topical tx?
2. Glucocorticoids?
3. NSAIDS? 2
4. Sympathetic blockers?
5. Alpha 1 adrenoceptor antagonist? 2
6. Opioids?
A
  1. Topical treatment:
    Capsaicin cream qid
  2. Glucocorticoids:
    Prednisone 30-80mg/day may be effective
  3. NSAIDS:
    - Motrin,
    - Naproxen
  4. Sympathetic blockers:
    Propranolol
  5. Alpha 1 adrenoceptor antagonist:
    - Terazosin
    - Prazosin 1.6mg/day as tolerated
  6. Opioids: For severe pain
54
Q

Drug Seeking Behavior

Characteristics? 4

A
  1. Requests for early refills
  2. Multisourcing
  3. Intoxicated behaviors
  4. Pressuring behaviors
55
Q

Drug seeking behavior
Characteristics:
Multisourcing? 3

A
  1. Visiting multiple physicians (“doctor shopping”)
  2. Recruiting surrogates to obtain the medication
  3. Purchasing drugs from illicit drug dealers or over the internet
56
Q

Drug seeking behavior
Characteristics:
Intoxicated behaviors? 3

A
  1. Slurred or disinhibited calls to the office
  2. Presenting to pharmacies under the influence
  3. Emergency department visits for repeated falls, other traumatic injuries, accidental overdose
57
Q

Drug seeking behavior
Characteristics:
Pressuring behaviors? 4

A
  1. Begging or pleading
  2. Excessive compliments
  3. Breaching boundaries
  4. Threats of harm to self or others

Orthopedic Surgery Ultimate (88 decks)

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