Pain Flashcards
0
Q
Pain WHO definition:
An unpleasant sensory and emotional experience associated with actual or potential ___ ___.
-Pain is a ___ ___.
A
Tissue damage
-Protective mechanism
1
Q
This was originally defined as pain that has lasted 6 months or longer. It is now defined as “the disease of pain” ?
A
Chronic Pain
2
Q
Pain Management - Applies to the entire discipline of Anesthesiology:
Includes ~
1) ___ = recovering from surgery or with acute medical conditions
2) ___ = diverse group of people in the outpatient setting
3) ___ = short or long term therapy both in and out of the hospital
A
1) Acute
2) Chronic
3) Cancer
3
Q
With anesthesia ___ is one of our biggest specialties.
A
Pain
airway first, then pain
4
Q
Any abnormal sensation described as unpleasant by the patient?
A
Dysesthesia
5
Q
Exaggerated pain response from a normally painful stimulus, usually includes aspects of summation with repeated stimulus of constant intensity and aftersensation?
A
Hyperalgesia
6
Q
Abnormally painful and exaggerated reaction to a painful stimulus?
*This is related to?
A
Hyperpathia
*Hyperalgesia
7
Q
Exaggerated perception of touch stimulus?
A
Hyperesthesia (hypesthesia)
8
Q
Abnormal perception of pain from a normally non-painful mechanical or thermal stimulus; usually has elements of delay in perception?
A
Allodynia
9
Q
Decreased sensitivity and raised threshold to painful stimuli?
A
Hypoalgesia (hypalgesia)
10
Q
Reduced perception of all sensation, mainly touch?
A
Anesthesia
11
Q
Loss of perception of vibration?
A
Pallanesthesia
12
Q
Reduced perception of pain stimulus?
A
Analgesia
13
Q
Mainly spontaneous abnormal sensation that is not unpleasant; usually described as “pins and needles”?
A
Paresthesia
14
Q
Burning pain in the distribution of one or more peripheral nerves?
*Usually what ___ have.
A
Causalgia
*Diabetics
15
Q
Pain-Receptors:
1) Perception depends on the specialized neurons that function as ___.
2) ___ detect a stimulus (temp, pain, pressure).
3) ___ - very little adaptation, or not at all
4) Stimulus is transduced and conducted to the ___.
5) Sensation is then felt; *____ = noxious (painful)
* ____ = non-noxious, ex: pressure, light touch, temp discrimination
A
1) receptors
2) Neurons
3) Non-adaptive
4) CNS
5) *Protopathic
* Epicritic
16
Q
Two Types of Pain - each with different pathways & specific qualities:
1) _____ = _________ fibers *Felt about 0.1 sec after stimulus; felt on surface of body (sharp, pricking, electric pain). Very precise, prick finger with needle will know exactly where you pricked it.
2) _____ = _________ fibers *Felt at 1 sec after stimulus; felt in deeper tissue and surface tissue (slow burning, aching, throbbing, chronic). Ex: visceral pain (slower).
A
1) Fast pain
Thinly myelinated Type A delta fibers
2) Slow pain
Unmyelinated Type C pain fibers
17
Q
1) Both pain pathways fast pain and slow pain are involved with ___ & ___.
2) ____ only has slow pain.
A
1) Mechanical & Thermal
2) Chemical
18
Q
Painful Stimuli - Chemical (SLOW pain ONLY)
* *___, ___, ___, ___, & ___ - increase permeability to ions
ex: potassium
A
**Bradykinin Acetylcholine Prostaglandins Substance P Proteolytic enzymes
19
Q
Perception that something is painful?
A
Nociception
20
Q
4 Physiologic processes to Nociceptive Stimuli:
1) ___ = noxious stimuli converted to electric activity at the sensory nerve endings (at the afferent nerve)
2) ___ = propagation of impulses thru the sensory nervous system
3) ___ = process of transmission modified by neural influence
4) ___ = above 3 interact with the psychology of the pt to create what is perceived as pain
A
1) Transduction
2) Transmission
3) Modulation
4) Perception
21
Q
- Noxious stimuli causes cell damage with the release of sensitizing chemicals (Prostaglandins, Bradykinin, Serotonin, Substance P, Histamine)?
- These substances activate ___ and lead to generation of ___.
A
*Transduction
Nociceptors
Action potential
22
Q
Action potential continues from site of injury to spinal cord > spinal cord to brainstem & thalamus > thalamus to cortex for processing?
A
Transmission
23
Q
Neurons originating in the brainstem descend to the spinal cord and release substances (ex: endogenous opioids) that inhibit nociceptive impulses (dampening or rampening)?
A
Modulation
24
Conscious experience of pain?
Perception
25
1) _____ = first order neurons send their axons into the SC via the dorsal (sensory) root, may synapse with interneurons, sympathetic neurons, and ventral horn (motor) neurons
2) _____ = in gray matter of ipsilateral dorsal horn
1) Primary afferent neurons
| 2) Second order neurons
26
Axons of most second order neurons cross midline and form the ???
^This is the major pain pathway to the thalamus, reticular formation, nucleus raphe magnus & periaqueductal grey.
*Lies ___ in ___ ___ of spinal cord.
Spinothalamic tract
| *Anterolaterally in white matter of spinal cord
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These are located in the thalamus and send fibers to somatosensory areas I & II in the parietal cortex, and the superior wall of the sylvian fissure.
*They are responsible for ?
Third order neurons
| *Perception & localization of pain
28
Alternate Pain Pathways: (these are actually stimulated by the ?)
1) Responsible for insomnia due to pain?
2) Activates anti-nociceptive, descending pathways?
(your own opioid system is essentially what gets going here)
3) Activate the hypothalamus and evoke emotional behavior?
Slow pain pathway
1) Spinoreticular tract
2) Spinomesencephalic tract
3) Spinohypothalamic & Spinotelencephalic tracts
29
Pain-Inhibition & Pain-Facilitation in the Dorsal Horn:
Neuronal circuitry within the dorsal horn. Primary afferent neuron axons synapse onto ___ ___ and onto ___ & ____ neurons.
- spinothalamic neurons
- excitatory
- inhibitory
30
~Within the spinal column itself we have ___ that help with modulation of pain.
~Majority of modulation occurs in the ___. However, we have the capacity to also modulate pain to some degree in the ___.
~interneurons
~Brain
~Spinal cord
31
The slow pain pathway is known as? This uses what type of fibers?
Paleospinothalamic Pathway
| C fibers
33
Fast Pain Pathway Summary: NEOSPINOTHALAMIC TRACT
1) First order neurons via type ___ fibers-enter lamina ___ & ___ (aka?)
of the dorsal horn of the spinal cord. Synapse with second order neurons.
2) Second order neurons cross the midline through the ___ and pass upwards in the ____.
3) Few of these fibers terminate on the ___.
4) MOST - travel to ___ of the ___.
5) Third order neurons communicate with the ___.
```
1) A delta
lamina I & V
lamina marginalis
2) anterior white commissure
anterolateral columns
3) reticular formation
4) Ventrobasal complex (VBC) of the thalamus
5) somatosensory cortex
```
34
Fast Pain Pathway - Neospinothalamic tract:
These communicate with the somatosensory cortex so we know where the pain is and can perceive it?
Third order neurons
35
Slow Pain Pathway: PALEOSPINOTHALAMIC PATHWAY:
1) First order neurons via ___ fibers enter lamina ___ & ___ of the dorsal horns (aka?) & synapse with second order neurons.
2) Second order neurons make synaptic connections in ___, can go up ___!!
3) Most second order neurons join fibers from the ___, crossing to the opposite side traveling upwards through the ___.
4) They terminate widely in the ___, with 1/10 of fibers stopping in the ___, and the rest stopping in the ___, ___, ___ of midbrain mesencephalon & _____.
```
1) type C fibers
lamina II & III
substantia gelatinosa
2) lamina IV-VIII
without crossing
3) fast pathway
anterolateral pathway (aka spinothalamic tract)
4) brainstem
thalamus
medulla
pons
tectum of midbrain mesencephalon
periaqueductal grey
```
36
The second order neurons of this pathway will CROSS the midline through the anterior white commissure and pass upwards in the anterolateral columns?
Neospinothalamic tract
37
The second order neurons of this pathway can make synaptic connections in lamina IV-VIII, can go up without crossing?
Paleospinothalamic Pathway
* **But most second order neurons in the slow pain pathway will join the fibers from the fast pathway, crossing to the opposite side traveling upwards through the anterolateral pathway
* **Just realize the slow pain pathway can have fibers going up that DO NOT CROSS
38
____ can either ramp pain up or dampen pain down.
Interneurons
39
Localization of Pain:
1) FAST pain can be localized easily if A delta fibers are ___ ___ with ___ ___.
2) SLOW pain is ?
1) stimulated together
tactile receptors
2) poorly localized
40
The Analgesia System is Mediated by 3 Major Components:
1) ??? (this is located in the ____)
2) ??? (this is located in the ____)
3) ??? (these are located within the ____).
```
1) Periaqueductal grey matter
midbrain
2) Nucleus raphe magnus
medulla
3) Nociception (pain) inhibitory neurons
dorsal horns of the spinal cord
```
41
Brain Analgesia Systems:
| This is the biggest one, known as the epicenter of analgesia?
Periaqueductal grey matter (in the midbrain)
42
Brain Analgesia Systems:
These act to inhibit nociception (these are the only ones located in the spinal cord)?
*transmitting neurons also located in the ???
Nociception (pain) inhibitory neurons
| *spinal dorsal horn
43
Periaqueductal Grey Matter:
* This is located in the ___ ___ within the midbrain.
* Plays a role in the ___ ___ of pain and in ___ ___.
*cerebral aqueduct
*descending modulation
defensive behavior (guarding/not moving affected extremity)
44
Brain Analgesia Systems: Nucleus Raphe Magnus
This is afferently stimulated from ___ in the ___ & ___.
- axons
- spinal cord
- cerebellum
45
The main function is mostly pain mediation?
| *In fact it sends projections to the dorsal horn of the spinal cord to directly inhibit pain.
Nucleus Raphe Magnus
46
This plays a HUGE role in the descending modulation of pain?
Periaqueductal grey matter
47
Nucleus raphe magnus projects throughout the ?
Cortex
48
Pain Cellular Physiology: Chemical Mediators
1) ____ = released slower, building over few minutes
* Involved in what type of pain?
2) ____ = acts instantly; only lasts a few milliseconds (main excitatory chemical in your brain)
* Involved in what type of pain?
3) ____
1) Substance P
* slow chronic pain
2) Glutamate
* fast pain
3) Calcitonin gene-related peptide (CGRP)
49
Pain Cellular Physiology: Modulators
1) Occurs peripherally at the ___, in the ___ ___ or in ___ ___. This modulation can suppress or aggravate pain.
2) One of the biggest modulators we have?
1) nociceptors
spinal cord
supraspinal structures (meaning in the brain)
2) NMDA receptor role
50
___ is the only induction agent that we have in anesthesia that is also an analgesic.
Ketamine
51
Pain Cellular Physiology-ACUTE: Information about noxious stimuli arrives from the periphery along ___ & ___.
1) ___ & ___ (ex: glutamine) are released.
2) Activation of ___ receptors by Substance P & activation of ___ receptors by EAAs cause ___ ___ of the pain neurons.
3) These are relayed to ?
4) ___ ___ ___ are inoperative as they are chronically 'plugged' by ?
A delta & C fibers
1) Substance P & Excitatory amino acids (EAAs)
2) neurokinin-1 (NK-1) receptors
AMPA receptors (amino-3-hydroxy-5-methyl-4-isoxazol propionic acid)
-transient depolarization
3) higher brain areas
4) NMDA-linked channels (N-methyl-D-aspartate)
-magnesium ions
52
Newer research shows that administration of ____ can be beneficial for pain management.
Magnesium
53
Pain Cellular Physiology: CHRONIC state = In response to intense and/or prolonged barrages of incoming nociceptive information, the neurons become sensitized & ___ to subsequent incoming nociceptive signals.
1) This barrage depolarizes the neurons such that the ___ ___ exit the ?
2) Results in influx of ___ - activates ___, causing conversion of ___ to ___. Because it is a gas, ___ rapidly diffuses out of the neurons.
3) This NO acts presynaptically to cause exaggerated release of ___ & ___.
4) Postsynaptically, NO causes the neurons to become ___ releasing ___, ___ etc.
```
Over-respond
1) magnesium ions
NMDA-linked channels
2) calcium ions
nitric oxide synthase (cNOS)
L-arginine to nitric oxide (NO)
NO
3) Substance P & EAAs
4) hyperexcitable
Substance P & Acetylcholine
```
54
Need to give adequate medications (narcotics, ketamine) to prevent people from going from acute pain to chronic pain. The 2 most common types of chronic pain are headache and back pain, the third most common chronic pain is ?
*Once it becomes chronic ____ is knocked off.
Surgical pain
| *magnesium
55
Physiologic Responses to Acute Pain: Neuroendocrine Response
1) Increase secretion of ___ ___
2) ___ response
3) Decrease ___ ___, ___, ___
4) ___ release
5) ___ (if their diabetic, want to really monitor what their blood sugar is doing)
1) Catabolic hormones
2) Stress response
3) anabolic metabolism
insulin
testosterone
4) ACTH release
5) Hyperglycemia
56
Physiologic Responses to Acute Pain: Cardiac Responses
1) Increased __, __, __, __
2) ___, ___, ___ (tachyarrhythmias)
3) Decrease ___ ___ secondary to pulmonary dysfunction = ___
4) Coronary artery ___ - high ___ *Release of serotonin may induce ?
5) Increase plasma viscosity = ___ ___ ___
1) Increased BP, HR, SVR, CO
2) MI, CHF, dysrhythmias
3) Decrease myocardial oxygenation
atelectasis
4) constriction - high catecholamines
*coronary vasospasm
5) Platelet induced occlusion
57
Physiologic Responses to Acute Pain: Pulmonary Responses
1) Increased total body ___ ___
2) Increased ___ ___
3) Increased ___ ___ (patient compensating)
4) Pulmonary function decreased with ___ or ___ ___.
1) Increased total body oxygen consumption
2) Increased CO2 production
3) Increased minute ventilation
4) Abdominal or thoracic incisions (splinting)
58
Physiologic Responses to Acute Pain: Pulmonary Responses
***Increased MINUTE VENTILATION as a result of decreased ___, ___, ___ = most detrimental alteration in post surgical lung volume. As ___ decreases, resting lung volume approaches closing volume, as it continues, ___ results, ___ ___, & ___ ensues.
- decreased TV, FRC, VC
- FRC
- atelectasis
- V/Q mismatch
- hypoxemia
59
Other Responses to Acute Pain:
1) Vascular system = stress mediated due to ___ & ___ (DVT, Pulmonary edema)
2) Visceral pain is referred to ___ ___ (ex: patient with laparoscopic procedures can have referred shoulder pain)
3) Muscle spasms = ___ & ___ ___ initiates reflex motor response leading to muscle spasm
1) platelet adhesion
hyper-coagulability
2) Somatic sites
3) Periosteal & Somatic irritation
60
Other Responses to Acute Pain:
~GI & Urinary Systems = Increased sympathetic tone, increased sphincter tone, decreased gastric motility promoting ___ & ___
*Nausea and vomiting common
*___ ___ can occur = increased gastric juices
ileus & urinary retention
| *Stress ulcers
61
If lack of pain control ___ & ___ can result.
Anxiety & anger
62
Methods to Relieve Pain: Take into Consideration~
1) ___ of pain relief
2) Patient history
3) Goals of management (talk to patient - "You may wake up with some pain")
* ___ ___ goal is they are not going to have any pain
4) Acute vs Chronic pain (chronic pain patients will have an exaggerated response to acute surgical pain)
1) Duration of pain relief
| * epidural anesthesia
63
Release of ___ in response to the pain = this may induce coronary vasospasm.
Serotonin
64
Methods to Relieve Pain:
1) ___ ___ = BEST POSTOPERATIVE PAIN MANAGEMENT BEGINS PREOPERATIVELY
2) ___ & ___ in General anesthesia
3) Regional blocks
4) ___ ___ at the ___ ___ could be used to control acute pain (hernia repair, tonsilar bed)
1) Preemptive Analgesia
2) Opioids & NSAIDs
4) Local infiltration at the surgical site
65
Slow Pain Pathway: Paleospinothalamic Pathway:
Majority of the second order neurons ____, join the fast pain pathway and go up the ____ to the ____ and end there. They can communicate and excite the rest of the brain.
- cross over
- Spinothalamic tract
- thalamus
66
Slow Pain Pathway - Paleospinothalamic Pathway:
* These do not synapse with third order neurons therefore they are poorly localized?
* One of the areas where the local anesthetics work, very well known area?
* C fibers
| * Substantia gelatinosa
67
The fast pain pathway is known as? This uses what type of fibers?
Neospinothalamic tract
| A delta fibers
68
```
***___ ___ patients do better overall.
~less morbidity
~less CV failure
~less infections
~less ___ ___ = ___ significant effect on the neuroendocrine response to surgery
~lower overall post-op complication rate
```
***Regional Anesthesia patients
~less urinary cortisol
>L1
69
Methods to Relieve Pain: MAXIMUM ANALGESIA
~Opioids ~NSAIDs
1) ___ ___ (___ ___) = inhibits prostaglandin synthesis
2) Two Types of Cox recognized:
*___ = constitutive & widespread through the body
*___ = expressed primarily with inflammation (___ ___ ___ ___ is great for inflammatory states)
1) Cyclooxygenase inhibitors (COX inhibitors)
2) *COX 1
*COX 2
(Vioxx - COX 2 inhibitor)
70
_____: Advantages to this are; they are cost effective, higher degree of patient satisfaction. Total drug consumption is less than IM. Harder to overmedicate self.
Patient Controlled Analgesia (PCA)
71
Patient Controlled Analgesia (PCA) - Features:
* Reservoir
* ___ ___ = pushbutton to be operated BY THE PATIENT ONLY (not family & visitors)
* Delivers a ___ ___
* ___ (minimal intervals btw doses)
* ___ ___ (background infusion)
* Infusion controller
* Specific dose
* Lockout
* Basal infusion
72
PCA prevents the ???
PCA findings = patients consume less drug, males use more than females, shortens hospital stay
"Pain no pain cycle"
73
PCA = Prescription - it is crucial that you?
relieve the pain before starting PCA
74
PCA:
1) ___ ___ each hit discourages the patient.
2) If the ___ ___ is ___ ___ could cause adverse reactions that also discourage the patient (distrust).
1) Too little
2) demand dose
too much
75
PCA - Side Effects:
* Onset of ___ ___ parallels analgesia and is more rapid with ___ ___.
* Nausea, vomiting, constipation, pruritis.
* **Nearly all overdoses have been to errors in the ???
*Respiratory depression
lipophilic opioids
***Programming of the Parameters
76
This is associated with musculoskeletal disorders, chronic visceral disorders, lesions of peripheral nerves, nerve roots, dorsal root ganglia (including causalgia, phantom limb pain), lesions of the CNS and cancers invading the nervous system?
Chronic Pain
77
*Chronic Pain has no time limit, often has no apparent cause and serves no apparent biological purpose.
Chronic pain can trigger multiple ___ ___ that confound both patient and health care provider, leading to feelings of helplessness & hopelessness.
Psychological problems
78
The most common causes of Chronic Pain include ___ (this is #1), followed very closely by ___, recurrent facial pain, cancer pain & arthritic pain.
*And sometimes chronic pain can have a ___ or ___ cause.
1) Low back pain
2) Headaches
* psychosomatic or psychogenic cause
79
Chronic Pain Causes:
~Chronic pathology in somatic or visceral structures
~Psychological mechanisms
~Peripheral mechanisms = Chronic pain syndromes associated with chronic inflammations in the periphery respond to ___ & ___ which prevent synthesis of prostaglandins.
~Aspirin & NSAIDs
80
____ = in chronic pain can create excessive muscle tension & tendon stretch. ___ ___ can create local ischemia and persistent disruption of the microcirculation.
Reflex role
| Sympathetic hyperactivity
81
Chronic Pain - Causes:
1) ____ = Lesions of peripheral nerves, dorsal roots or dorsal ganglion cells. Found in causalgias, and other reflex sympathetic dystrophy, phantom pain.
2) ____ = Suggests that intense stimulation of nerve fibers in the cord activate internuncial neurons creating an abnormal reverberatory activity in a closed loop.
3) ____
1) Peripheral-Central Mechanism
2) The Circle Mechanism
3) Chronic Nerve Compression
82
Chronic Pain:
1) ____ = Found in lesions to the thalamus and spinal cord injury as in paraplegia.
2) ____ = Severe stress, usually seen in chronic tension headaches and chronic pain due to muscle spasms in the shoulder, back and chest.
3) ____ = Secondary gain. These patients frequently develop reactive depression and hypochondriasis.
1) Central Pain Mechanisms
2) Psychophysiologic Mechanisms
3) Learned Mechanisms
83
Effects of Chronic Pain:
___ & ___ become depleted, so minor injuries become intolerable.
*Very important to do preemptive pain management on these patients!
Serotonin & Endorphins
84
Chronic Pain - Psychologic Profiles:
1) The chronic pain patient shows significant differences on the MMPI (Minnesota Multi-phasic Personality Inventory), neuroticism. However, when the pain is relieved the neurotic features dissipate. The longer the duration of the pain, the ???
greater the psychological changes
85
Treatment of ??? = must not only remove the pain and the cause of the pain but also rehabilitate the patient and family physically, psychosocially & psychologically
Chronic Pain
86
Chronic Pain = Examples of Pain Control include:
1) ___ ___ ___ with or without trigger point injections
2) ___ ___ ___ with neurolytics (cutting off afferent sensory nerves)
3) ___
* ****Often require more ?
1) Steroid Epidural Injections
2) Peripheral Nerve Blocks
3) Acupuncture
* ****analgesics
87
Approximately 19 million people worldwide experience cancer pain every year.
Causes:
*Direct tumor involvement
1) This is the most common cause of cancer pain?
2) The next most common cause?
*Cancer pain can also be due to ___
1) Tumor invasion of the bone
2) Tumor compression of peripheral nerves
* Treatment
88
Cancer Pain Effects:
1) ____ = worse than for chronic pain due to loss of sleep, appetite, nausea & vomiting
2) ___ = heightened anxiety, separation & loss, self esteem, life's goals, effect on the family, disfigurement
1) Physical
| 2) Psychological
89
___ patients with pain had more emotional disturbances and died sooner than those whose pain was controlled.
Cancer patients
90
Cancer Pain:
| This results from lack of knowledge of Pharmacology of analgesics, fear of addiction and respiratory depression?
Poor Pain Treatment
91
Cancer Pain Management:
Start with this (it will not last very long) for mild pain - inhibit prostaglandin synthetase, and some anti-tumor effects in bone metastases?
*Problem - ___ ___ on analgesia
Nonopioid analgesic
| *Ceiling effect
92
Cancer Pain Management - WHO Recommendations (3 Step):
1) Nonopioid analgesic (mild pain) Name 3???
2) "Weak" oral opioids (moderate pain) Name 2??
3) "Stronger" opioids (severe pain) Name 2??
1) Aspirin, acetaminophen, NSAIDs
2) Codeine, oxycodone
3) Morphine, hydromorphone
93
Cancer Pain Management: ADJUNCTS
1) ___ = prevent release of prostaglandins and stimulate appetite
2) ___ = elevate mood, help with sleep, block reuptake of serotonin, potentiate narcotic analgesics
1) Corticosteroids
| 2) Antidepressants
94
Cancer Pain Management:
1) ___ = normal for opioids, especially IV administered. Terminally ill can require ___ of IV morphine.
2) ___ = Rare event in cancer pain patients.
3) ___ = Intensity & duration of pain. Physical, mental & nutritional state. Pharmacology. Route of administration.
* They build tolerance, but are not necessarily addicted
1) Tolerance
200 mg/hr
2) Addiction
3) Drug choice
95
Cancer Pain Management:
* Goal of this is sustained ___ ___ with minimal ___ ___.
* Cancer patients build tolerance, but are not necessarily addicted to opioids
*Pain relief
| side effects
96
Other Treatment Modalities for Cancer Pain Management:
1) ___ = local anesthetics, peridural narcotics
* Disadvantage = ?
2) ___ = permanent destruction of the nerve, rare to not get some motor loss as well
1) Regional Analgesia
* Short term relief
2) Neurolytics
97
Pain which persists one month longer than expected?
Chronic pain
98
This helps with perception?
Modulation
