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Final FRCA SOE > Pain > Flashcards

Pain Flashcards

1
Q

Definition of pain

A

Unpleasant sensory or emotional experience associated with actual or potential tissue damage

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2
Q

Classification

A

Acute
- noxious signally from recently damaged tissue
Chronic
- last or recurs for 3months +
- Subclassified
- chronic primary
- chronic cancer related
- chronic post-surgical
- chronic neuropthic
- chronic headache

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3
Q

Assessing acute pain

A

History - SOCRATES
Examination
Investigations
Assessment tools
- numerical rating scales
- visual analogue
- verbal ratiging
- facial pain scale (pads)

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4
Q

Assessing chronic pain

A

As above
Psychosical - sleep, mood, function, relationships
treatments received
ideas, concerns, expectations
Chronic pain assessment tools
- Mcgill pain questionnaire
- neuropathic pain scale
- brief pain inventory

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5
Q

Features of neuropathic pain

A

Spontaneous
- shooting, burning, electric shock, tingling, parasthesias
Allodynia
Hyperalgesia

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6
Q

Cancer pain

A
  • Compression of surrounding tissues
    • damage to nerves - neuropathic pain
    • damage to other tissue - nociceptive pain
  • consequence of treatment e.g. radiotherapy neuritis, chemo and peripheral neuropathy
  • related problems - infection, hypercalcaemia
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7
Q

Opioids in cancer pain

A

most patients require long acting background e.g. MR or TD
1/6 daily dose for breakthrough

WHO analgesic ladder
Adjuncts if appropriate - gabapentin, steroid, bisphosphonates

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8
Q

Opiod side effects

A

CNS
- Sedation
- tolerance
- addiction
Resp
- reduced respiratory rate
- Hypoventilation
CVS
- bradycardia
GI
- Nausea
- Constipation
Genral
- itch
- immunosuppression

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9
Q

CRPS

A

Pain disorder characterised by limb pain with associated sensory, vasomotor, trophy, sudomotr changes. Usually precipitated by surgery or trauma
type 1 - injury to tissues or bones but no nerve injury
type 2 - nerve injury without transection

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10
Q

Clinical features

A

Continuous pain disproportionate to inciting event
1 sign in 2 categories
1 symptom in 3
no other diagnosis
Sensory - severe continious pain, glove and stocking, allodynia, hyperalgesia
Vasomotor - colour change, temperature change
Sudomotor - eodema, sweating
Motor - decreased range of movement, power

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11
Q

Management

A

MDT
Physio, OT, psycho
Pain specialists
pharmacotherapy weak evidence
- simple analgesics
- TCAs
- Gabapentinoids
- topical capsaicin

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12
Q

Tolerance, dependance, addiction

A

tolerance = requiring increasing doses of drug for same pharmacodynamic effect
dependance - adaption by which withdrawal of drug leads to unpleasant withdrawal symptoms
addiction - pattern of behaviours seeking reward from drug despite physical, social, psychological harm

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13
Q

Methadone

A

racemic mixture of R and S enantiomers
R-methadone has mu receptor agonism
S-methadone has anti-NMDA and help with withdrawal
bioavailability is 35-100%, liver metabolism, reanal excretion, protein bound
can cause prolonged QT

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14
Q

Assessing post-operative pain

A

Systematic approach
- reviewing anaesthetic chart, operation notes, surgical notes and drug chart
- history of pain e.g. SOCRATES
- Physical examination

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15
Q

DDX of pain post amputation

A
  • Equipment issue (PCA) e.g pump failure, run out of drug, cannula tissued
  • Surgical complications - bleeding, haematoma, infection
  • stump pain
  • PLP
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16
Q

Phantom limb pain

A

Perception of pain or discomfort in limb that is no longer there.
Common
1st week post-op
cramping, burning, shooting
Risk factors
- high pre-op pain
- emergency surgical intervention
- Bilateral amputation
- stump pain
Management
- multimodal
- gabapentinoids
- ketamine iv
- local - lignocaine patch, IV lignocaine, nerve catheter

17
Q

Post herpetic neuralgia

A

chronic painful condition causing neuropathic pain within the sensory dermatome of a previous herpes zoster invection

18
Q

Pathophysiology of PHN

A
  • varicella zoster (chicken pox) remains dormant in DRG of sensory nerve
  • herpes zoster (shingles) is a painful vesicular skin rash confined to a dermatome caused by reactivation of VZV
  • sensory nerve becomes damaged by VZV leading to spontaneous discharge and neuropathic pain
19
Q

Clinical features PHN

A

Pain 3 months + beyond shingles healing
- single unilateral dermatome, thoracic or V1
- burning stabbing, lancinating
- allodynia and hyperalgesia
Risk factors
- pyrexia during shingles
> 50
- female
- psychosocial risk e.g. anxiety
Management
- antivirals within 72hrs of shingles - no effect on PHN
- topical capsaicin and lignocaine patches
- gabapentinoids, TCA, opioids

20
Q

Spinal cord stimulator

A

Implantable device using low voltage electrical stimulation to modulate nociceptive inputs into the spinal cord
MOA
- stimulations of dorsal column, dorsal roots
- inhibit nociceptive pathways - wide dynamic range neurones in dorsal horn, glial and immune cells
- activate descending pathways - GABA
- suppression of sympathetic fibres

21
Q

SCS indications

A
  • failed back surgery syndrome
  • CRPS 1
  • Chronic leg ischaemia
  • diabetic neuropathy
  • PLP
    Persistent 6mo+ neuropathic or ischaemic pain resistant to conventional treatment, positive trial
    insertion - theatre, sterile, epidural space, x-ray guidance, tuohy or surgical
    tonic stimulation, burst suppression, high frequency
22
Q

Management of SCS in periop

A

pre-op
- indication
- function
- pain team involvement
- deactivated (avoid interference, avoid risk of reporgrammin)
Intra-op
- positioning - mindful of device
- bipolar diathermy if possible
- if monopoly - avoid current path over SCS
- avoid neuraxial
post-op
- switch on
- pain team

NB. PPM and SCS - contraindicated (interference). deactivate in pregnancy

23
Q

gate control theory of pain

A

account for physical and psychological influences on pain transmision
interneurones modulate synaptic transmission between primary and secondary
inhibitory interneurones close the gate (either pre-synaptically or post-synaptically)
activation of inhibitory interneurones by non-painful stimuli
practical - rubbing sore spot, TENS

24
Q

Classification of trigeminal neuralgia

A

Classical
- women 50-60yrs
- neurovacqlar compression of the trigeminal nerve root near entry to pons resulting in local demyelination
- superior cerebellar artery, anterior inferior cerebellar artery, basilar artery
Seconary
- neurological disease such as MS, cerebellopontine angle tumours
Idiopathic
- no cause found

Final FRCA SOE (11 decks)

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