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Year 3 > Pain > Flashcards

Pain Flashcards

1
Q

Measure pain?

A

Pain scale 1-10

• faces for children

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2
Q

Non-opioid analgesia

A
  • Paracetamol
  • NSAIDs/COX-2 inhibitors
  • Topical treatments
  • Capsaicin
  • Lidocaine
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3
Q

Opioids analgesia for mild/mod pain

A
  • weak opioids - limited potency at mu receptor
  • Codeine
  • dihydrocodeine
  • tramadol
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4
Q

Opioid analgesia mod/severe pain

A
  • strong opioids
  • high potency at mu receptor
  • Morphine
  • diamorphine
  • oxycodone
  • fentanyl
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5
Q

Strong opioid eg

A
  • morhpine
  • diamorphine
  • oxycodone
  • fentanyl
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6
Q

Weak opioid eg

A
  • codeine
  • tramadol
  • dihydrocodeine
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7
Q

considerations surrounding opioid analgesia

A
  • metabolism
  • SE
  • renal function
  • dependence/addiction
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8
Q

opioid SE

A
  • Constipation
  • N&V
  • drowsiness
  • drowsiness
  • sedation
  • respiratory depression
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9
Q

Adjuvant therapy

A
  • anti-epileptic drugs
  • antidepressants
  • dexamethasone for bone pain in palliative care
  • non-pharmaceutical strategies
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10
Q

non pharmaceutical strategies for pain relief

A
  • physiotherapy
  • exercise
  • psychological therapy
  • acupuncture
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11
Q

chronic pain classification?

A
  • musculoskeletal
  • neuropathic
  • non-specific persistent pain
  • chronic headache syndrome
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12
Q

Musculoskeletal pain eg

A
  • mechanical pain
  • osteoarthritis
  • lower back pain
  • rheumatoid arthritis
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13
Q

Lower back pain/ sciatica

A
  • low back pain that is not associated with serious or potentially serious causes
  • sciatica - leg pain secondary to lumbosacral nerve root pathology
  • worldwide lower back pain causes more disability than any other condition
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14
Q

Sciatic is?

A

leg pain 2º to lumbosacral nerve root pathology

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15
Q

Lower back pain/sciatica treatment

A
  • continue normal activities
  • group exercise programs
  • manual therapies
  • psychological therapy
  • oral NSAID
  • if NSAID CI weak opioid +/- paracetamol for ACUTE pain only
  • surgical treatments
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16
Q

Surgical treatments for lower back pain/sciatica

A
  • radiofrequency denervation

* spinal cord stimulation

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17
Q

Sciatica specfic treament

A
  • epidural injections (local anaesthetic + corticosteroid),

* spinal decompression surgery

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18
Q

Ostheoarthritis

A
  • most common form
  • breakdown of cartilage in the joints, commonly hips, knees, hands, lower back and neck
  • symptoms
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19
Q

symptoms of osteoarthritis

A
  • joint pain during and after activity
  • initial limited range of of motion
  • clicking or cracking in joints
  • swelling around joints
  • muscle weakness around joint
  • instability of the joint
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20
Q

osteoarthritis treatment

A
  • exercise and manual therapy
  • weight loss if overweight/obese
  • paracetamol +/- topical NSAID
  • topical capsaicin
  • if the above are ineffective, consider oral NSAID/COX2 inhibitor
  • intra-articular corticosteroid
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21
Q

Rheumatoid Arthritis what?

A
  • autoimmune disease
  • inflammation of synovium
  • leads to erosion and deformation of the affected joints
  • can affect other tissues
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22
Q

Rheumatoid arthritis symptoms

A
  • symmetrical pain and swelling of small joint in hands and feet lasting >6weeks
  • spread to larger joints
  • joints may be warm and tender
  • stiffness on waking/after inactivity
  • fatigue, fever and loss of appetite
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23
Q

Treat to target monotherapy

A
  • methotrexate
  • leflunomide
  • sulfasalazine
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24
Q

treat to target in mild or palindromic disease

A

hydroxychloroquine as alternative to MTX/leflunomide

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25
Q

treat to pain step up strategy

A

• + DMARD (methotrexate) in combination where dose titration hasnt achieved remission/low disease activity

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26
Q

DMARD eg

A
  • methotrexate
  • leflunomide
  • sulfasalazine
  • hydroxychloroquine
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27
Q

If no response to conventional DMARD….

A
  • biologial DMARDs
  • infliximab
  • adalimumab
  • sarilumb
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28
Q

biological DMARD eg

A
  • upadacitinib
  • sarilumb
  • adalimumab
  • etanercept
  • infliximab
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29
Q

inadequate response to biological DMARD

A

• rituximab

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30
Q

neuropathic pain types

A
  • peripheral neuropathy
  • complex regional pain syndrome
  • central pain
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31
Q

Neuropathic pain treatment

A
  • amitriptyline
  • duloxetine
  • gabapentin
  • pregabalin
  • if one not work, try other.
  • tramadol for acute rescue therapy
  • consider capsaicin cream for localised pain
  • carbamazepine for management of trigeminal neuralgia
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32
Q

Carbamazepine for ?

A

management of trigeminal neuralgia

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33
Q

non specific persistent pain treatment

A
  • supervised group exercise program
  • psychological therapy
  • acupuncture
  • antidepressants - paroxetine
  • NOT recommend = paracetamol, opioids, NSAIDs, antiepileptic drugs, benzodiazepines
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34
Q

non specific persistent pain antidepressant eg

A
  • duloxetine
  • fluoxetine
  • paroxetine
  • citalopram
  • sertraline
  • amitriptyline
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35
Q

AVOID in non specific persistent pain

A
  • paracetamol
  • opioids
  • NSAIDs
  • antiepileptic drugs
  • benzodiazepines
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36
Q

Cluster type - chronic headache

A
  • idiopathic
  • intermittent
  • unilateral eye
  • lasts >2h
  • > 3days per week
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37
Q

Analgesic overuse - chronic headache what symptoms?

A
  • bilateral
  • constant
  • last 8 to 24hr
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38
Q

Tension-type - chronic headache

A
  • 1º headache
  • bilateral eye
  • constant
  • last 8-24hr
  • 7-9 days/month
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39
Q

Post-trauma - chronic headache

A
  • bilateral
  • constant
  • last 8 to 24h
  • 7 to 9 days/month
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40
Q

Chronic migraine - chronic headache, type? Lasts? Side?

A
  • 1º migraine
  • bilateral
  • last 1-4h
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41
Q

Acute pain what?

A
  • sudden onset
  • <6 months
  • spontaneous insult/trauma
  • planned surgery
  • spontaneous/trauma
  • childbirth
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42
Q

Spontaneous/trauma eg

A
  • broken bones
  • burns and cuts
  • tooth ache
  • headache
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43
Q

Management of Acute pain

A
  • OTC analgesia
  • Paracetamol
  • NSAIDs
  • low dose weak opioids
  • non-pharmacological
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44
Q

Palliative care is ?

A

• an approach to improve quality of life of pt and their families

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45
Q

Palliative care = end of life?

A

NO

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46
Q

Pain control in palliative care

A
  • WHO pain ladder
  • morphine commonly used as strong opioid.
  • no max dose of morphine
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47
Q

Opioids long acting & breakthrough

A
  • one long acting opioid/ prolonged release formulation
  • With short acting opioid/ immediate release formulation for breakthrough pain
  • breakthrough analgesia 1/10 to 1/6 of daily long acting dose
  • opioid equivalences when switching drug
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48
Q

In acute pain, breakthrough analgesia should be…?

A

1/10 to 1/6 of daily long acting dose

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49
Q

Syringe drivers

A
  • SC infusion
  • drugs & diluent set to infuse over (24h)
  • concern over stability of the contents.
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50
Q

PCA - what is it

A

Patient controlled Analgesia

51
Q

drug delivery PCA

A
  • loading dose (by nurse)
  • top ups (pt controlled)
  • lock out to prevent overdose
  • adjuncts for management of toxicity
52
Q

Drug deliver PCA monitoring the pt

A
  • pain scores

* AVPU - alert, voice, pain, unresponsive

53
Q

AVPU in PCA monitoring

A
  • Alert
  • Voice
  • Pain
  • Unresponsive
54
Q

Advantages PCA

A
  • Pt in control
  • Predictable pain relief
  • Active participants in their recovery
  • Faster alleviation of pain
  • Pt doesn’t have to wait for pain relief – reduced distress in waiting for pain relief
  • Less time consuming for nurse
  • Easy to titrate dose according to response or need of pain control
55
Q

Disadvantages PCA

A
  • Patient not responsive to use
  • May be scared of self administration
  • Poor dexterity
  • Reduced mobility
  • Potential to increase length of stay
  • Liable to abuse
  • Patients lack of understanding on how to use PCA
  • SIDE EFFECTS
56
Q

Loading dose in PCA is?

A

dose on initiation

57
Q

Commonly in PCA

A

morphine or fentanyl

58
Q

Bolus in PCA is?

A

dose administered on triggering

59
Q

Lockout in PCA is ?

A

min time between doses

60
Q

background rate in PCA is?

A

continuous infusion on top of which bolus dose given

61
Q

Monitoring during PCA use

A
  • BP
  • Pulse
  • Respiratory rate
  • sedation
  • pain score
  • nausea
  • hourly for 1st 8hr from initiation
  • 2hrly for 48h following
  • 4hrly until discontinuation
62
Q

PCA SE

A
  • N&V
  • Pruritis
  • Respiratory disease (RR <8)
  • Excessive sedation
63
Q

PCA SE N&V treatment

A

• cyclizine 50mg TDS

64
Q

PCA SE Pruritis treatment

A

• Chlorphenamine 4mg TDS PO

65
Q

PCA SE Respiratory depression treatment

A
  • O2
  • Turn off PCA
  • Monitor O2 SATs
  • Consider naloxone 200-400mcg IV
66
Q

PCA SE Excessive sedation treatment

A
  • Remove PCA handset
  • Monitor O2 SATs, pain, sedation scores
  • Ensure adequate non opiate analgesia prescribed regularly
67
Q

Post operative paracetamol

A

offered post operatively unless CI
• weight >50kg - 1g QDS
• weight <50kg - dose reduction

68
Q

Post operative analgesia Oral NSAID

A
  • Ibuprofen immediately post operative pain (except fractured hip)
  • IV NSAIDs not common
  • careful age, co-morbidities
69
Q

Post operative pain oral opioid

A
  • if pain mod-severe

* not with PA or opiate containing epidural

70
Q

Post operative neuropathic pain?

A

Gabapentin

71
Q

Post operative gabapentin?

A

Neuropathic pain

72
Q

Post operative analgesia - patient factors to consider

A
  • comorbidities
  • age
  • frailty
  • renal & liver fn
  • allergies
  • current meds
  • cognitive function
73
Q

Post operative analgesia - patient discussion

A
  • likely pain from procedure
  • pt preference
  • pt expectation
  • pain history
  • potential benefits and risks
  • long term risks
  • different types of pain relief
  • plans for discharge
74
Q

What is epidural analgesia

A

administration of analgesics into epidural space.
• allows injection near spinal cord and nerves
• powerful analgesic effect

75
Q

Epidural space in spine?

A
  • contains fat
  • above subdural space
  • which is above subarachnoid space - contains CSF
76
Q

Area of analgesic effect from epidural analgesia

A
  • thoracic
  • low thoracic/high lumbar
  • low thoracic
  • lumbar
77
Q

What is in epidural bag?

A
  • opioid analgesic &

* local anaesthetic

78
Q

Opioid in epidural does what?

A
  • diffuses into CSF
  • inhibits pain transmission in spinal cord
  • main site of action - spinal opiate receptors
  • no effect motor or sensory functions
  • reversible
  • doesnt migrate
79
Q

local anaesthetic in epidural does what?

A
  • diffuses across myelin sheath into nerve cell
  • inhibit Na+ channels, prevent Na+ influx, reduce cell membrane excitability
  • reversible
  • doesn’t migrate
80
Q

Epidural advantages

A
  • High quality pain relief
  • ↓ need for gaseous anaesthesia
  • Reduced incidence of DVT
  • Less sedation
  • Left in situ for post-op analgesia
  • Improved pulmonary function
  • Reduced cardiac morbidity
  • Reduced sepsis/chest infection
  • Faster re-establishment of oral intake
  • Tiny opioid dose compared to systemic analgesia
81
Q

Epidural disadvantages

A
  • Risk of permanent spinal damage
  • Accidental injection into spinal cord “total spinal block”
  • Infection risk
  • Accidental IV administration (bupivacaine very cardiotoxic)
  • Dural puncture headache
  • Epidural bleed/haematoma
  • Migration of drug leading to respiratory paralysis
82
Q

Accidental IV admin of bupivacaine in Epidural - rescue therapy

A
  • Intralipid 20% shown to reverse LA- induced cardiac arrest in animal models
  • recovery LA-induced cardiac arrest may take an hour
83
Q

Opioid toxicity in Epidural - rescue therapy

A
  • IV naloxone 100-400mcg

* short 1/2 life = repeat doses

84
Q

Severe hypotension in Epidural - rescue therapy

A

• ephedrine

85
Q

Epidural CI?

A
  • pt refuse
  • infection at proposed site
  • clotting abnormalities
  • severe respiratory impairment
  • uncorrected hypovolaemia
  • raised intercranial pressure
  • neurological disease
  • tattoos?
86
Q

types of pain

A
  • somatic
  • visceral
  • neuropathic
  • sympathetically maintained pain
87
Q

somatic pain is

A
  • From cutaneous / musculoskeletal tissue or peritoneal membranes
  • Post-operative, post-exercise, mild trauma
88
Q

Visceral pain is

A
  • The thoracic or abdominal organs

* Post-operative, cancer-related, traumatic injury

89
Q

Neuropathic pain is

A
  • From injury to the peripheral or central nervous system

* Amputation (surgical or traumatic), type 2 diabetes

90
Q

Sympathetically maintained pain is

A
  • Sensitisation of CNS causes neuropathic-like pain in distribution of a sympathetic nerve
  • Complex Regional Pain Syndromes (CRPS)
91
Q

Nociception is?

A
  • noxious stimuli with intensity enough to trigger reflex withdrawal, autonomic responses, pain
  • pain subjective
92
Q

Nociceptors

A
  • mechanical
  • thermal
  • polymodal
  • not protein receptors - naked nerve endings
  • dont up or down regulate in response to stimulation
  • pain perception is modifiable
93
Q

Peripheral nociception - A fibre subtypes

A
  • alpha
  • beta
  • gamma
  • delta
94
Q

A-alpha fibres?

A
  • efferent
  • motor
  • somatic
  • reflex activity
95
Q

A-beta fibres?

A
  • afferent
  • innervate muscle
  • touch
  • pressure
96
Q

A gamma fibres?

A
  • Efferent

* muscle spindle tone

97
Q

A delta fibres?

A
  • Afferent
  • pain
  • cold
  • temp
  • tissue damage
98
Q

Nerve fibres - myelinated ?

A

A yes
B yes
C no

99
Q

Nerve fibres - diameter? conduction velocity?

A

A to C
diameter - decreases
conduction velocity - decreases

100
Q

Nociceptors - which neurons carry noxious stimuli

A

A𝛿 fibres
C fibres

first pain: informative, move away

second pain: punishing pain, changes behaviour

101
Q

transmission - nociception

A
  • afferent pain fibres
  • dorsal horn spinal cord
  • brainstem
  • thalamus
  • cortex
  • higher brain
102
Q

detection - nociception

A
  • noxious stimulus
  • release chemical mediators
  • activate nociceptors
  • cell membrane become depolarised
  • AP generated
103
Q

perception - nociception

A
  • Brain activation
  • Reticular system
  • somatosensary cortex
  • limbic system
104
Q

modulation - nociceptors

A

Changing transmission of pain impulse in spinal cord via complex DMPP (descending modulatory pain pathways)

105
Q

DMPP

A

descending modulatory pain pathways

106
Q

Trauma releases which chemical mediators?

A 
ATP
Bradykinin
Prostaglandins
Histamine
5HT
H+

PHAB!

107
Q

Capsaicin - nociceptor pharmacology

A

TRPV1 receptor

108
Q

Bradykinin to ? pharmacology - nociceptor

A
  • B2 receptor
  • release Protein Kinase C
  • phosphorylates TRPV1
  • depolarisation
109
Q

Prostaglandins to ? - nociceptor pharmacology

A
  • prostanoid receptor
  • protein kinase A
  • Voltage gated Na channel
110
Q

Prostaglandins in nociception

A
  • PGE2 causes K+ channel inactivation and phosphorylation of TRPV1 via EP receptors
  • NSAIDs inhibit PG synthesis (COX) - analgesia
111
Q

TRPV1 activated by?

A
  • heat, chemicals, phosphorylation
  • capsaicin
  • allyl isothiocyanate - wasabe
112
Q

ASIC activated by?

A

H+

113
Q

P2X activated by?

A

ATP

114
Q

TRPV1 receptor role

A
  • peripheral detect body temp

* stimulated = burning sensation

115
Q

C fibre causes release of?

A
  • peripheral release of neuropeptides
  • substance P
  • CGRP (calcitonin gene-related peptide)
  • cause release inflammatory mediators and NGF - +ve feedback
  • sustained release thus can cause hyperalgesia
116
Q

Hyperalgesia

A

increased sensitivity

117
Q

NGF

A

nerve growth factor

118
Q

NGF acts on?

A
  • acts on TrkA receptors
  • causes upregulation of NaV channels
  • signals to increase activity TRPV1 via tyrosine kinase activity (phosphorylation)
119
Q

mutation to TrkA?

A

• congenital insensitivity to pain

120
Q

NaV channels & pain

A
  • essential for action potential propagation
  • 5 NaV subtypes
  • NaV 1.1, 1.6, 1.7, 1.8, 1.9
121
Q

Mutations in NaV1.7 lead to?

A
  • erythromelalgia & paroxysmal extreme pain disorder

* loss of activity of NaV 1.7 = no pain

122
Q

Afferent pain fibres enter dorsal horn in different laminae. Which Fibre - laminae?

A

A𝛿 - laminae I and V
Aß - laminae III, IV and V
C - laminae I and II

123
Q

Referred pain

A
  • visceral activation.
  • somatic perception
  • eg heart attack, pain down left arm.
124
Q

Perception by brain

A
  • somatosensory cortex - process information on location & intensity
  • cirgulate & insular cortices, amygdala - emotional components

Year 3 (4 decks)

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