Pain Flashcards
What elements of physical examination might assist in assessing palliative cancer pain?
Examine the patient to try and determine the cause of pain, for example tender hepatomegaly or abnormal sensation.
Look particularly for specific points of tenderness (which may indicate the site of origin of the pain) and signs of neurological deficit, which may suggest spinal cord compression.
A full examination is rarely appropriate in people who are very unwell and in the last stages of life.
Managing acute severe pain - palliative care
Immediately relieve pain using a subcutaneous or slow intravenous dose of a strong opioid.
Dose is Dependent on whether the person is already on a regular opioid - if so, calculate 4 hourly dose by taking the previous 24 hour dose and dividing that by 6 - give this dose subcutaneously
Managing non-emergent pain that is persistent in palliative care
Consider a stepwise approach using the WHO analgesic ladder
If pain is purely neuropathic and reversible conditions (for example vitamin B12 deficiency) have been excluded:
Consider offering a tricyclic antidepressant (such as amitriptyline) or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin).
Titrate the dosage according to response and tolerability.
Managing pain from intracranial pressure
Consider whether a treatable underlying cause is present.
Discuss with an oncologist regarding the need for radiotherapy.
Also consider a trial of dexamethasone at a dose of 8–16 mg daily (taken in the morning), titrated down to the lowest dose that controls symptoms
Managing intestinal colic in palliative care cancer patients
If symptomatic management is appropriate, consider hyoscine butylbromide (an antispasmodic), 20 mg immediately by subcutaneous injection, then 60–100 mg/24 hours via syringe driver continuous infusion.
Managing bone pain in palliative care patients
Consider whether there is a treatable underlying cause
Actual/imminent fracture = orthopaedic surgeon input
Symptomatic relief - hot/cold pack, standard analgesia in a stepwise approach, incident pain on movement = take a dose of breakthrough analgesia 20-30 minutes before anticipated movement
Managing muscle spasm pain in palliative cancer care
Consider whether there is a treatable underlying cause, try simple measures such as heat, massage, relaxation
Consider transcutaneous electric nerve stimulation over the trigger point if the pain is myofascial
If trigger points are multiple or the muscle spasm is widespread consider a muscle relaxant such as diazepam or baclofen
Suspecting spinal cord metastasis in palliative cancer care in the following features …
Pain in the thoracic or cervical spine, progressive lumbar pain, severe unremitting lower spinal pain, spinal pain aggravated by straining, localised spinal tenderness, nocturnal spinal pain preventing sleep
Suspecting spinal cord compression in palliative cancer care in the following features …
Neurological symptoms (radical ar pain, limb weakness, walking difficulty, sensory loss, bladder/bowel dysfunction)
Neurological signs of spinal cord or cauda equina compression
End of life care in palliative cancer pain
Individualised care plan should be made - including the areas of symptom control and anticipatory prescribing should be created.
Hyoscine butylbromide should not be administered to people with:
Myasthenia gravis.
Megacolon.
Narrow-angle glaucoma.
Tachycardia.
Prostatic enlargement with urinary retention.
Mechanical stenoses in the region of the gastrointestinal tract, or paralytic ileus.
Hyoscine butylbromide has a rapid onset of action and starts to take effect within 10 minutes of subcutaneous administration with a duration of action of up to …
Hyoscine butylbromide has a rapid onset of action and starts to take effect within 10 minutes of subcutaneous administration with a duration of action of up to 2 hours
Hyoscine butylbromide does it readily cross the blood-brain barrier?
Hyoscine butylbromide does not readily cross the blood-brain barrier and therefore does not produce central nervous system adverse effects.
Baclofen in palliative care - when to consider using diazepam instead?
Active (or history of) peptic ulceration, as baclofen stimulates gastric acid secretion.
Psychiatric disorders, such as psychosis, schizophrenia, depression, or mania, as baclofen may exacerbate these conditions.
Epilepsy, as baclofen may lower the seizure threshold; expert supervision is advised.
Urinary retention, which may be exacerbated in people with a hypertonic bladder sphincter.
