Pain and other symptoms

Question 1

what types of different pain is there?

Answer 1

nociceptive pain - damage to body pain
neuropathic pain - damage to nerves or nervous system
visceral pain - internal organs pain
incident pain - related to movement

Question 2

what are 5 key principles of pain management?

Answer 2

• oral administration when possible
• regular intervals with duration supporting pain level
• prescribed at intensity characterised by patient free from clinical judgement
• start at lowest dose and titrate to response
• consistent vital for effective pain management

Question 3

what is the escalation of the WHO analgesic ladder?

Answer 3

• non-opioids like paracetamol or NSAIDs
• weak opioids like codeine or co-codamol
  reassess
• strong opioids like morphine, oxycodone, methadone, buprenorphine and fentanyl

Question 4

what are some side effects of opioids?

Answer 4

constipation
drowsiness and impaired consciousness
N+V
dry mouth
flushing
hallucination
headaches
risk of dependence

Question 5

what are some long term effects of opioids?

Answer 5

• falls
• erectile dysfunction
• amenorrhoea
• infertility
• depression
• fatigue
• opioid induced hyperalgesia

Question 6

what are some signs of opioid overdose or toxicity?

Answer 6

rhinorrhoea
needle track marks
pinpoint pupils
drowsiness
watering eyes
yawning

Question 7

what are some cautions with the use of opioids?

Answer 7

• renal impairment: oxycodone preferred
• elderly
• breastfeeding

Question 8

what do you understand by the term “breakthrough pain” in regards to cancer?

Answer 8

Unpredictable (spontaneous).
Predictable (incident) and related to movement or activity
influenced by physical, psychological, social, and spiritual factors

Question 9

what causes are there for malignancy related N+V?

Answer 9

chemo induced
gastric stasis
metabolic or chemical disturbances
raised ICP
constipation
malignant bowel obstruction
post-operative
psychological

Question 10

what is the best anti-emetic for chemo induced N+V?

Answer 10

• low risk: D2 antagonist metoclopramide
• high risk: 5HT3 antagonist like ondansetron combined with dexamethasone

Question 11

when might you suspect gastric stasis as a cause of N+V?

Answer 11

*locally advanced cancer, gastroentersotomy, morphine, ascites

reduced appetite, fullness, regurgitation, hiccups, epigastric pain, progressive nausea relieved by large volume vomits containing food

Question 12

what is the best management for gastric stasis?

Answer 12

Metoclopramide, domperidone (prokinetics)

Question 13

how do you manage N+V caused by raised ICP?

Answer 13

cyclizine (blocks conduction in vestibular-cerebellar pathway), dexamethasone

Question 14

how do you manage N+V caused by constipation?

Answer 14

laxatives, metoclopramide (prokinetics)

Question 15

how might you manage N+V caused by malignancy bowel obstruction?

Answer 15

• cyclizine (blocks conduction in vestibular-cerebellar pathway), dexamethasone
• consider stenting, chemo, surgery, gastrostomy, NGT

Question 16

how might you manage N+V caused by post-op?

Answer 16

ondansetron (inhibits serotonin release by bowel injury, chemo)

Question 17

how might you manage N+V caused by anxiety?

Answer 17

short term benzo (depending on stage of illness) like lorazepam

Question 18

how might you manage chemically mediated N+V?

Answer 18

*correct any abnormality
- ondansetron, haloperidol and levomepromazine

Question 19

how might you manage vestibular causes of N+V?

Answer 19

• cyclizine
• alt metoclopramide or prochlorperazine

Question 20

what is the preferred method of administration of anti-emetic?

Answer 20

*oral!

if vomiting, has issues with malabsorption, or there is severe gastric stasis,
- parenteral route of administration is preferred
- The intravenous route can be use if intravenous access is already established

Question 21

why might a patient present with intractable breathing?

Answer 21

• Subjective feeling of not getting enough oxygen, not the same as tachypnoea
• Can be caused directly by physical symptoms of illness or due to anxiety
• “death rattle” due to respiratory secretions that are not being adequately cleared

Question 22

how might you manage intractable breathing?

Answer 22

*treat underlying cause
- drains, anticoagulant, analgesia, blood transfusions, diuretics, antibiotics, stenting, benzo, pul rehab
- oxygen
- position, physio
- medications

Question 23

what medications can you prescribe to help with intractable breathing?

Answer 23

• oromorph and zormorph to reduce respiratory drive
• glycopyrronium for secretions
• lorazepam and midozalam
• hyoscine hydrobromide or butylbromide

Question 24

how might constipation present?

Answer 24

• hard faeces, uncomfortable or difficult to pass, reduced frequency
• other sx: incomplete evacuation after defecation, leakage of fluid, incontinence, colicky abdo pain, distention of abdomen, flatulence, N+V, anorexia, malaise, even urinary frequency and retention

Question 25

what could cause constipation?

Answer 25

• disease related
• fluid depletion
• weakness
• intestinal obstruction
• medication
• biochemical
• functional like pain on defecation, lack of privacy

Question 26

what medications can cause constipation?

Answer 26

opioids, diuretics, phenothiazines, anti-cholinergics, 5HT-antagonists

Question 27

how can you manage constipation?

Answer 27

• increase fibre intake
• increase motility
• stimulant - reduce bowel transit time
  
  • senna, bisacodyl
• softener - increase water penetration of stool
  
  • docusate
• osmotic
  
  • lactulose, movicol, laxido
• suppositories
  
  • glycerin, bisacodyl

Question 28

how would you manage chronic constipation in the frail?

Answer 28

1st line: softener
2nd line: add a stimulant
3rd line: add an osmotic

Question 29

how might you manage drug induced constipation?

Answer 29

1st line: stimulant
2nd line: add a softener
3rd line: add an osmotic
4th line: refer to specialists to start on co-danthramer, co-danthrusate and opioid antagonists

Question 30

how might you manage oncology related psychological distress?

Answer 30

• antidepressants and anxiolytics
• support groups
• spiritual guidance

Question 31

what could cause confusion and delirium in the context of cancer?

Answer 31

• metastatic spread to brain
• increased ICP with cerebral oedema
• chemo, radiotherapy s/e
• opioids, steroids, medications to prevent nausea etc
• hypoxia to brain
• anaemia
• electrolyte imbalance
• organ failure

Question 32

how would you manage acute confusion?

Answer 32

• maintain a reassuring and familiar environment
• manage underlying cause when possible - IVF, Abx
• medication optimisation
• antipsychotics