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FRCA CRQs > Pain > Flashcards

Pain Flashcards

1
Q

Give the classes of drugs used to treat post-amputation pain syndrome

A
  • Triyclic antidepressants e.g. amtitriptyline
  • Gabapentinoids e.g. gabapentin, pregabalin
  • Selective serotonin reuptake inhibitors e.g. duloxetine
  • TRPV1 receptor antagonists e.g. capsaicin cream
  • Opioids e.g. tramadol for acute control whilst awaiting specialist input
  • NMDA antagonists e.g. ketamine for acute control
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2
Q

Define neuropathic pain

A

Unpleasant sensation which arises as a consquence of lesion or disease affecting somatosensory system

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3
Q

Give characteristic features of neuropathic pain

A
  • Associated paraesthesia
  • Spontaneous episodes of pain
  • Allodynia
  • Shooting/electric shock/burning character
  • Hyperalgesia or hypoalgesia
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4
Q

Apart from diabetes, list possible causes for neuropathic pain in the feet

A
  • B12 deficiency
  • Alcohol excess
  • Spinal stenosis
  • HIV
  • Hypothyroidism

BASHHD (D for diabetes)

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5
Q

Give risk factors for development of peripheral neuropathy in patients affected by diabetes

A
  • Hyperlipidaemia
  • High BMI
  • Smoking
  • Hypertension
  • Poor glycaemic control
  • Longer duration of diabetes
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6
Q

Give the main mechanisms that result in peripheral nerve damage in diabetes

A
  • Hyperglycaemia damages microvascular supply to cause nervous tissue damage
  • Hyperglycaemia generates inflammatory mediators to cause nervous tissue damage
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7
Q

What is first line treatment for diabetic peripheral neuropathic pain

A
  • Amitriptyline, duloxetine, gabapentin or pregabalin
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8
Q

When would capsaicin be indicated in management of neuropathic pain

A

If pain is localised and
+ oral medication is not tolerated/patient refusal to take oral medication

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9
Q

What is the mechanism of action of capsaicin in the management of neuropathic pain

A
  • Stimulates TRPV1 receptors (type of calcium ion channel) in C-fibres
  • Causes initial release and then depletion of substance P
  • Reduces pain sensation transmission
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10
Q

List the diagnostic/clinical features of trigeminal neuralgia

A
  • Unilateral facial pain across distribution of trigeminal nerve or its divisions
  • Electric shock-like/shooting/stabbing character
  • Recurrent attacks of pain
  • Pain lasts from less than a second to two minutes each time
  • Precipitated by innocuous stimulation within distributon of trigeminal nerve
  • Severe intensity
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11
Q

Give differential diagnosis of trigeminal neuralgia

A
  • Cluster headache
  • Sinusitis
  • Post-herpetic neuralgia
  • Dental pain
  • TMJ disorder
  • Salivary gland stones

Ordered by location

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12
Q

What causes classical trigeminal neuralgia and how is it diagnosed

A
  • Compression of nerve root by local vascular structure causing morphological change
  • Clinical characteristics and MRI demonstrating compression of the nerve
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13
Q

Give four red flags that may suggest a serious underlying cause of trigeminal neuralgia

A
  • Optic neuritis
  • Opthalmic division pain only
  • Deafness
  • Skin or oral lesions
  • Sensory changes
  • Bilateral pain
  • Family hx MS
  • < 40 yrs at onset

Eyes and ears and mouth and MS

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14
Q

Give the management options for trigeminal neuralgia

A
  • First line: carbamazepine (anticonvulsant, inactivates voltage gated sodium channels)
  • Second line: gabapentinoid (inactivated voltage gated calcium channels), amitriptyline (TCA, multiple effects to inhibit reuptake of serotonin and noradrenaline - including on VG K, Na, Ca, alpha adrenergic receptors, dopamine receptors), phenytoin
  • Non pharmacological: microvascular decompression of trigeminal nerve root in posterior fossa, stereotactic radiosurgery, ablation of Gasserian ganglion
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15
Q

What pain control issues might chronic buprenorphine use cause perioperatively

A
  • Buprenorphine is a partial agonist at MOP
  • It is an agonist at KOP and DOP with high affinity and so prolonged duration of action
  • Continued buprenorphine may reduce maximal effect of other opioids administered perioperatively, causing analgesic failure
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16
Q

List six causes of pain in a patient with advanced cancer

A
  • Local mass effect
  • Treatment associated including acute and chronic post-surgical pain
  • Chemical release by tumour (e.g. prostaglandins) that sensitise nerve endings to painful stimuli
  • Paraneoplastic phenomena causing neuropathy e.g. anti-Hu
  • Associated conditions e.g. immunosuppression induced herptic reactivation, pathological fractures
  • Chronic pain development consequent to primary causes
  • Psychological state of patient exacerbating experience of pain
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17
Q

Give three approaches to minimise side effects from opioid medications in patients with advanced cancer

A
  • Minimise overal opioid dose by using WHO analgesia ladder and adjuvant therapies
  • Target management of specific side effects e.g. laxatives, antiemetics
  • Co-administration of antagonist e.g. naloxone
  • Rotation of opioid type
  • Expereinced clinician magaing prescription to maintain lowest possible dose
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18
Q

Give five pharmacological approaches to managing advanced cancer pain apart from opioid medications

A
  • WHO analgesic ladder: regular paracetamol, NSAIDs
  • Neuropathic pain medications e.g. gabapentinoids
  • Other adjuvant pain-relief e.g. ketamine
  • Treat underlying cause e.g. ansitspasmodics for colic pain
  • Manage associated depression or anxiety e.g. SSRO
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19
Q

Give four non pharmacological approaches to managing advanced cancer pain

A
  • Surgery e.g. treat pathological fractures
  • Radiotherapy
  • Physiotherapy e.g. graded exercise therapy
  • Psychological therapy e.g. CBT
  • Complementary therapy e.g. acupuncture
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20
Q

Give the diagnostic features of chronic post-surgical pain

A
  • Pain localised to surgical area or corresponding innervation
  • Pain that develops or increases after surgical procedure
  • Pain persists beyond healing process (more than or equal to 3 months)
  • Other causes of pain are excluded

Site, timing, character

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21
Q

List five surgical procedures commonly associated with chronic post-surgical pain

A

Top 3:
* Thoracotomy
* Mastectomy
* Amputation

By location:
* Craniotomy
* Thoracotomy
* Sternotomy
* Mastectomy
* Inguinal repair
* Cholecystectomy
* C-section
* Vasectomy
* Amputation
* Knee arthoplasty

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22
Q

Give four patient related risk factors for the development of chronic post-surgical pain

A
  • Younger age
  • Female
  • Higher BMI
  • Poor social support
  • Lower educational level
  • Psychological factors e.g. fear of surgery
  • Genetic susceptibility
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23
Q

Apart from the risk attributed to specific procedures or patient factors, list four risk factors for the development of chronic post-surgical pain

A

Surgical:
* Procedures that involve significant nerve/tissue damage
* Longer duration of surgery
* Surgical complications
* Repeated surgery

Anaesthetic:
* Poor post-operative pain control

Medical:
* Adjuvant radiotherapy/neurotoxic chemotherapy

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24
Q

List two anaesthetic interventions that may be employed to minise the risk of chronic postsurgical pain

A
  • Regional anaesthesia
  • Multimodal analgesia
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25
Q

State the peripheral and central nervous system changes that occur in the development of chronic post-surgical pain

A

Peripheral:
* Repeated nerve damage causes inflammation, activation of lymphocytes and release of inflammatory mediators
* Leads to increased sodium and calcium channel expression which reduces threshold for firing of peripheral nerves
* Neural sprouting at neurone terminals gives larger receptive field

Central:
* Increased glutamate release from first-order neurones at dorsal horn increases NMDA receptor density at postsynaptic membranes, increasing transmission
* There may be reduction in descending inhibitory pathway activity
* Microglia activated by nerve damage release substances that further sensitise neurones
* Increased activity in brain centres associated with perception of pain e.g. thalamus

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26
Q

Give three risk factors for the development of complex regional pain syndrome

A
  • Female
  • Prolonged immobility
  • Trauma
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27
Q

Give eight features you might find on clinical examination for CRPS

A
  • Sensory: hyperalgesia, allodynia
  • Vasomotor: temperature asymmetry, skin colour changes
  • Sudomotor: oedema, sweating changes
  • Trophic: decreased range of motion, motor dysfunction, trophic changes
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28
Q

Give other criteria apart from symptoms and signs that are required for the diagnosis of CRPS

A
  • Continuing pain disproportionate to inciting event
  • No diagnosis that can better explain clinical picture
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29
Q

Give four conservative treatment options in CRPS

A
  • Patient education
  • Physical therapies e.g. desensitisation
  • Oedema control strategies e.g. positioning
  • Occupational therapy e.g. pacing
  • Pyschological interventions e.g. CBT
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30
Q

Give five pharmacological options for the management of symptoms of CRPS

A
  • Corticosteroids e.g. prednisolone
  • TRPV1 receptor agonists e.g. capsaicin cream
  • Gabapentinoids e.g. gabapentin
  • Bisphosphonate e.g. alendronic acid
  • IV ketamine
  • Vasodilators e.g. CCB
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31
Q

Give three interventional techniques that may be considered in the management of CRPS

A
  • Spinal cord stimulation
  • TENS
  • Sympathetic nerve block
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32
Q

Give two preventative measures that may protect against the development of CRPS

A
  • Vitamin C 500mg OD for 50 days after wrist fracture
  • Early rehabilitation with viligance for abnormal pain response
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33
Q

State the mechanism of action of intrathecal opioids in the spinal cord

A
  • Intrathecal opiates stimulate opiate receptors in Rexed’s laminae, presynaptic to C and A-delta fibres, resulting in hyperpolarisation of the cell membrane and reduced release of excitatory neurotransmitters glutamate and substance P
  • Opioid receptors post-synaptically can also be activated which causes indirect activation of descending inhibitory pathways
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34
Q

State the mechanism of action of intrathecal opioids in the brain

A
  • Opioids spread cephalad and stimulate receptors in nucleus raphe magnus and periaqueductal grey, reducing GABAergic tone on descending inhibitory pathways, so they exert an antinociceptic effect at the spinal level
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35
Q

List six major side effects of intrathecal opioids

A
  • Nausea and vomiting
  • Respiratory depression
  • Pruiritus
  • Sedation
  • Delayed gastric emptying
  • Urinary retention
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36
Q

List five factors that may increase risk of post-operative respiratory depression following administration of intrathecal opioids

A
  • Use of hydrophilic opioids e.g. morphine
  • Concomittant use of long acting sedatives
  • Positive pressure ventilation
  • Increasing age
  • Co-existing respiratory disease
  • OSA
  • Obesity
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37
Q

List four regional anaesthesia techniques that may be used to support the post-operative pain management of a patient undergoing an elective laparotomy for resection of colonic tumour

A
  • Spinal
  • Rectus sheath block
  • Transversus abdominis plane block
  • Quadratus lumborum block
38
Q

Give two intravenous options that may reduce opioid requirements post-laparotomy, apart from paracetamol and NSAIDs

A
  • IV magnesium
  • IV ketamine
39
Q

Give two issues with buprenorphine transdermal patches

A
  • Unreliable absorption intraoperatively e.g. subject to temperature changes
  • Partial agonist at MOP receptors so may reduce effectiveness of other prescribed opiates
40
Q

Give four opioid sparing techniques that can be considered as part of post-operative management for a patient taking regular opioids

A
  • Regular patacetamol and NSAIDs
  • Regional analgesia
  • Neuraxial analgesia
  • Ketamine infusion
  • Use of gabapentinoids
  • IV magnesium
41
Q

List three clinical features of opioid withdrawal

A
  • Adrenergic hyperactivity e.g. tachycardia, sweating, piloerection
  • Abdominal cramps, diarrhoea
  • Lacrimation, rhinorrhoea
  • Yawning
  • Generalised malaise
42
Q

List three clinical features of opioid overdose

A
  • Respiratory depression
  • Sedation
  • Pin-point pupils
43
Q

Give the equivalent doses of the following to 10mg oral morphine:
Tramadol
Codeine
Oxycodone

A
  • Tramadol 100mg
  • Codeine 100mg
  • Oxycodone 6.6.mg

IV morphine would be 3.3mg

44
Q

List four perioperative implications of an existing spinal cord stimulator

A
  • Turn off SCS during surgery to avoid reprogramming or activation from electromagnetic interference
  • Care with positioning to avoid pressure damage and lead migration
  • Avoid neuraxial techniques which risk lead damage and infection
  • Use bipolar diathermy where possible
45
Q

List three perioperative considerations for a patient who has an intrathecal drug delivery system

A
  • Should only be accessed by clinicians with experience in use
  • Significant risk of infection, avoid spinal anaesthesia
  • Opioid dosing as for opioid-naive patient
  • No diathermy within 30cm of pump or catheter
46
Q

Preoperative management of a patient for elective surgery on regular opiates

A
  • Medication history including route, dose and frequency
  • Understand indication for opiate
  • Involve chronic pain team if complex pain
  • Formulate plan for post-operative pain relief including opiate conversions
  • Patient education about chronic versus acute pain management, advise to take regular analgesia on morning of surgery
  • Aim to reduce opiate requirements with multimodal analgesia if possible
47
Q

Intraoperative management of a patient for elective surgery on regular opiates

A
  • Use of pain modulating medications e.g. ketamine, magnesium, clonidine
  • May require higher doses of intraoperative opiates
  • Decision re patches
48
Q

Postoperative management of a patient for elective surgery on regular opiates

A
  • Acute pain team review
  • Higher boluses of opiate in PCA, consider mixed PCA with ketamine
  • Use pain scores
  • Be aware of signs of withdrawal or overdose
  • Aim to convert IV opiates to oral dosing as soon as is feasible
  • Make plan for de-escalation of opiates and include this in discharge paperwork
49
Q

You are called to see a 25-year-old man who suffered a traumatic below knee amputation 24 hours ago. He is using a morphine patient-controlled analgesia (PCA) and was comfortable until two hours ago, when he started to experience severe pain.

Give four reasons why his pain control may be inadequate

A
  • Failed delivery of PCA
  • New surgical complication e.g. wound dehiscence/infection
  • Neuropathic pain e.g. development of phantom limb pain
  • Regional/neuraxial block has worn off
50
Q

You are called to see a 25-year-old man who suffered a traumatic below knee amputation 24 hours ago. He is using a morphine patient-controlled analgesia (PCA) and was comfortable until two hours ago, when he started to experience severe pain.

Give four measures to re-establish pain control

A
  • Intravenous morphine titrated to effect, guided by anaesthetist with RR, BP, HR, O2 monitoring
  • Increase PCA bolus or background if considered safe (may require HDU)
  • Ensure regular paracetamol and NSAIDs
  • Initiate antineuropathic agent e.g. gabapentin
  • Ketamine infusion
  • Sciatic nerve catheter (femoral if above knee)
  • Epidural
51
Q

Give three features of post-amputation pain syndrome

A
  • Character of pain: shooting, burning, cramping
  • Location of pain is distal to stump
  • Disproportion between pain experienced and stimulus applied
52
Q

Give first line oral pharmacological options for long term management of post-amputation syndrome

A
  • Amytriptyline
  • Duloxetine
  • Gabapentin
53
Q

Give non-oral pharmacological options for long term management of post-amputation pain syndrome if first line treatment fails

A
  • Capsaicin 8% patches
  • Lidocaine 5% patches
54
Q

Give four risk factors for the development of post-amputation pain syndrome

A
  • Severe preoperative pain
  • Bilateral amputation
  • Repeated limb surgeries
  • Increasing age
55
Q

Give respiratory ploblems which could result from inadequate pain relief from rib fractures

A
  • Atelectasis
  • Pneumonia
  • Respiratory failure due to inadequate ventilation
  • Failed secretion clearance
56
Q

State two ways effectiveness of pain relief can be assessed

A
  • Pain scores e.g. visual analogue scores
  • Frequency of use of breakthrough pain medication
57
Q

List four factors which predict increased risk of mortality after rib fractures

A
  • Increasing age
  • Increasing number of rib fractures
  • Chronic lung condition
  • Lower oxygen saturations
  • Use of anticoagulants prior to injury
58
Q

State two pharmacological approaches to management of patient’s pain other than paracetamol and codeine

A
  • Consider NSAIDs
  • Oral morphine immediate release solution
  • Opioid PCA
59
Q

Give four regional analgesia options which may be considered for management of rib fracture pain

A
  • Thoracic epidural (bilateral fractures)
  • Paravertebral block (unilateral fractures)
  • Serratus anterior (anteriolateral fractures)
  • Errector spinae block (posterior fractures)
60
Q

Which ribs are most likely to be fractured as a consequence of trauma

A

Ribs 4-10

61
Q

State five complications that should be rapidly recognisable by healthcare professionals caring for patients having continuous epidural analgesia

A
  • Hypotension
  • Total spinal
  • Epidural haematoma or abscess
  • Local anaesthetic toxicity
  • Post-dural puncture headache
  • Nerve damage
62
Q

Give four organisational factors that are necessary to ensure safe management of continuous epidural analgesia in the ward setting

A
  • Adequate staff training
  • Inpatient pain service
  • Protocols for all aspects of CEA management
  • 24 hr anaesthetic service to manage any issues with CEA
  • Handover of CEAs for daily review
  • Resuscitation equipment, intralipid and naloxone readily available
63
Q

State two aspects of equipment monitoring that must be undertaken regularly throughout duration of continuous epidural analgesia

A
  • Patent venous access
  • Pump infusion rate, name and concentration of drug used
64
Q

State four aspects of patient monitoring that must be undertaken regularly throughout duration of continuous epidural analgesia

A
  • Heart rate
  • Blood pressure
  • Respiratory rate
  • Temperature
  • Pain score
  • Motor and sensory block
  • Sedation score
  • Visual inspection of epidural insertion site
65
Q

Give three safety features of the pump used for CEA

A
  • Preset limits for maximum infusion rate and bolus
  • Locked box containing drug
  • Code required for programming
66
Q

Give two safety features of the epidural infusion system used for continuous epidural analgesia

A
  • Closed system, no injection ports
  • Antibacterial filter
  • NRFit connections
67
Q

Give the names of the three nerves that contribute to the coeliac plexus

A
  • Greater splanchnic T5-10
  • Lesser splanchnic T10-11
  • Least splanchnic T11-12
68
Q

Give four anatomical relations of the coeliac plexus

A
  • Anterolateral to body of L1
  • Anterior to aorta and crura of diaphragm
  • Either side of the origin of the coeliac artery
  • Medial to IVC
69
Q

Give three indications for coeliac plexus block

A
  • Pancreatic cancer pain
  • Stomach cancer pain
  • Chronic pancreatitis pain
70
Q

Give two anatomical approaches used for coeliac plexus block

A
  • Posterior
  • Anterior
71
Q

Give specific complications associated with coeliac plexus block

A
  • Retroperitoneal bleeding (injury of aorta or IVC)
  • Intravascular injection into great vessels
  • Paraplegia if phenol injected into arterial supply
  • Intrathecal/epidural injection
  • Pneumothorax
  • Chlyothorax
  • Thrombosis
  • Sexual dysfunction if phenol spreads to sympathetic chain
72
Q

List eight factors in presentation of back pain that require referral or further investigation

A

Cancer:
* Age> 50 years
* Focal spinal tenderness
* Constitutional symptoms of weight loss and pyrexia

Fracture:
* Severe central spinal pain relieved on lying down
* History of major trauma
* Structural deformity of spine

Infection:
* Immunocompromise/HIV
* Recent infection
* Diabetes
* IVDU

Cauda equina:
* Perianal loss of sensation
* Loss of anal tone
* Urinary retention/incontinence
* Faecal incontinence
* Progression from unilateral to bilateral sciatic pain

Exam specific: pyrexia, focal tenderness, structural deformity of spine, perianal anaesthesia, loss of anal tone, motor weakness at legs or hips

73
Q

List four conservative options for the management of low back pain

A
  • Self management
  • Exercise
  • Manual therapy
  • Psychological therapy
  • Pain management programme
74
Q

Give three pharmacological options for the management of back pain

A
  • Paracetamol
  • NSAIDs
  • Short course weak opioid
75
Q

When is radiofrequency denervation considered for back pain

A
  • Pharmacological options not effective
  • Main source of pain identified from structures supplied by medial branch nerve
  • Moderate to severe localised back pain
76
Q

State the indication for considering caudal epidural for low back pain

A

Severe sciatic pain

77
Q

State a surgical option that may be considered when radiological findings are consistent with sciatic symptoms and non-surgical management has failed

A

Spinal decompression

78
Q

Define chronic back pain

A

Pain between the costal margins and gluteal folds, which persists beyond 3 months

79
Q

Risk factors for acute back pain to become chronic

A

Bio:
* Nerve root involvement
* Poor physical fitness
* Heavy smoking

Psycho:
* High levels of psychological distress
* Tendency towards depression

Social:
* Long time off work
* Ongoing compensation claim

80
Q

Signs of nerve root irritation in back pain

A

Straight leg raise, femoral stretch test

81
Q

Indications for spinal cord stimulation

A
  • Failed back surgery
  • CRP Type 1
  • Chronic leg ischaemia
  • Chronic angina refractory to treatment
82
Q

Complications from spinal cord stimulator implantation

A
  • Infection
  • CSF leak
  • Symptomatic haematoma
  • Lead migration
83
Q

Neuropathic features of chronic pain

A
  • Dyaesthesia: unpleasant touch or tingling sensation
  • Allodynia: pain to non-painful stimuli
  • Hyperalgesia: increased pain response to nociceptive stimuli
84
Q

Risk factors for trigeminal neuralgia

A
  • MS
  • Age
  • Previous stroke
  • Hypertension
  • Trauma
  • Trigeminal nerve root tumours
85
Q

Which base of skull structures do the branches of trigeminal nerve pass through?

A

V1: superior orbital fissure
V2: foramen rotundum
V3: foramen ovale

86
Q

List three cortical areas involved in processing nociceptive signals

A
  • Prefrontal cortex
  • Periaqueductal grey
  • Reticular formation
87
Q

Give symptoms and signs of sciatic back pain

A
  • Unilateral pain that radiates down side of hip to below knee, with leg pain more bothersome than back pain
  • Positive straight leg raise test
  • Dermatomal numbness/paraesthesia (lower leg except medial side) or motor weakness (thigh extension, knee flexion)
88
Q

Common sites for shingles (VZV)

A

Opthalmic division trigeminal nerve
Thoracic dermatomes

89
Q

Risk factors for post-herpetic neuralgia

A

Female
>60yrs
Pain before rash
Severe pain
Severe rash
Pyrexia

90
Q

Clinical features of post-herpetic neuralgia

A
  • Throbbing or stabbing pain across single dermatome (> 3 months duration)
  • May have allodynia and find it uncomfortable to wear clothes over area
  • May have autonomic features such as skin changes, temperature changes, sweating
  • May have sensory loss e.g. to heat
  • Systemic features including weight loss
  • Psychological features e.g. chronic fatigue and depression
  • Social features including depression

FRCA CRQs (9 decks)

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