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year three exam 2 > pain clinical > Flashcards

pain clinical Flashcards

1
Q

what is pain

A

unpleasant sensory and emotional experience associated with actual or potential tissue damage

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2
Q

how is pain classified

A

duration - acute or chronic
mechanism- nociceptive, neuropathic or neoplastic

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3
Q

what is acute pain

A

sudden onset
resolved by treating cause
<6m
OTC/WHO ladder for treatment

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4
Q

what is chronic pain

A

gradual onset
usually the result of a condition that is heard to diagnose/treat
>6m duration
musculoskeletal pain

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5
Q

what is nociceptive pain

A

pain preventing or in response to tissue damage

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6
Q

what is neuropathic pain

A

malfunction of the nervous system or nerve damage

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7
Q

what is oncoplastic pain

A

altered nociception in the absence of tissue or nerve damage

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8
Q

what are the 3 rules of the WHO pain ladder

A

by the clock - as often as possible
by the mouth - unless not possible
by the ladder

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9
Q

what are the steps on the WHO pain ladder

A
  1. non-opioid (paracetamol, NSAIDs, COX)
  2. mild opioid (codeine, dihydrocodeine, tramadol)
  3. strong opioid (morphine, oxycodone, fentanyl)
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10
Q

what adjuvant therapies can be used for pain

A

neuropathy - AEDs (gaba, pregab and carba)
- TCAs/SSRIs
palliative bone pain - dexamethasone
non-pharmacolog - physio, exercise, physological treatment, acupuncture

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11
Q

what are opioids used for

A

acute pain and palliative care

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12
Q

opioid metabolism

A

CYP2D6 - varies between patients

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13
Q

opioid side s/e

A

N&V - may settle
constipation - co prescribed w/ laxatives
drowsiness/sedation
resp depression
renal function
addiction

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14
Q

what are the signs of opioid overdose

A

pinpoint pupils
hypoxia
resp depression
NEWS2
- RR <8
- O2 <85% on air
- tachycardia
- sedation

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15
Q

what are the non-pharmacological interventions for lower back pain and sciatica

A
  • exercise and manual therapies
  • psychological activities
  • return to work programs
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16
Q

pharmacological treatment for lower back pain

A
  • NSAIDS (GI/renal/age - PPI and stop date)
  • weak opioids if NSAID C/I or not tolerated
  • paracetmol alone not recommended
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17
Q

pharmacological treatment of sciatica

A
  • no gabapentinoids, AEDs, benzos - stop if on
  • limited evidence for NSAIDs
  • no opioids
  • epidural injections or surgery
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18
Q

how is osteoarthritis treated

A
  • exercise/weight loss
  • manual therapies
  • oral/topical NSAID
  • paracetamol/weak opioids considered
  • intraarticular steroids
  • joint replacement
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19
Q

how is neuropathic pain treated

A
  • if initial C/I or not tolerated
    amitriptyline/duloxetine/gaba/pregab
  • tramadol only for acute rescue therapy
  • capsaicin can be used for local if oral not tolerated
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20
Q

what is palliative care

A

aim is to improve QoL at end of life

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21
Q

what pain relief is used in palliative care

A

24 hr simple analgesia or weak opioid
- PRN injection but if >3 then syringe driver
naloxone for toxicity

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22
Q

what is used to treat breathlessness in palliative care

A

opioid or midazolam

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23
Q

what is PCA

A

patient controlled analgesia - usually 1mg/ml morphine but if renal function reduced give fentanyl

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24
Q

monitoring for PCA

A

BP
pulse
RR
sedation
pain score
- hourly for 8
- every 2 for 8-24
- every 48 hours after

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25
PCA s/e
N&V - cyclizine pruritis - chlorphenamine RR <8 - O2, monitor and stop - consider naloxone excess sedation - stop, monitor, non-opioid analgesia
26
what is an epidural
delivery of analgesics with or without adjuvants o epidural space
27
where are epidurals given
epidural space
28
epidural space physiology
dorsal route ganglion - cell bodies from afferent and efferent nerves, communication between peripheral and central nervous systems - Spinal meninges - dura mater is outer layer (arachnoid mater and then pia mater) - tough and strong to protect the spine ○ Subarachnoid space - space between the subarachnoid mater and the pia mater - filled with CSF, accessed for lumbar punctures ○ Epidural space between dura mater and bone - fatty matter and space for epidural to be injected
29
what are the components of epidural
opioid analgesic - inhibits pain transmission at spinal cord - reversible, no migration anaesthetic - diffuses across myelin sheath into nerve - inhibits sodium channel preventing depolarisation ephedrine for hypotension naloxone cyclizine for sickness
30
what are the advantages of epidural
- better relief for smaller doses - reduced DVT incidence - less sedation - covers post-op - improved pulmonary function - reduced cardiac and sepsis issues
31
what are the disadvantages of epidural
- Accidental injection into spinal cord - total spine block - Risk of permanent damage - Accidental IV administration - Dural puncture headache - Epidural bleed - Drug migration can lead to respiratory paralysis - Infection risk - Requires informed consent
32
s/e of epidural
- resp arrest (C3-C5) - resp depression - hypotension/hypothermia - reduced cardiac output - reflex tachycardia - overdose/IV - myocardial depression - reduced hepatic/real perfusion - dural headache - tinnitus - pruritis - N&V - sedation
33
what rescue therapies are used for epidurals
- IV bupivacaine - reverse cardiac arrest or toxicity - opioid toxicity - naloxone - hypotension - ephedrine - dural puncture headache - CSF leakage causes drop in pressure
34
C/I for epidurals
- Refusal - Infection at site - Clotting abnormalities - Severe respiratory impairment - Uncorrected hypovolaemia - Raised intracranial pressure - Neurological disease - Injury or deformity changing anatomy - Tattoos - site of injection would be up to clinician (could cause ink leakage/bleeding)
35
what is a tension headache
most common form, thought to be due to neck/scalp muscle spasm - can be due to stress
36
symptoms of a tension headache
mild to moderate pain non-throbbing and vice like unilateral may worsen throughout the day
37
what is a cluster headache
sudden onset lasting 10m to 3hr
38
what are the symptoms of a cluster headache
* Excruciating- severe pain on one side of the head * Nasal or eye symptoms * Accompanied by red eye, lacrimation, nasal congestion, rhinorrhoea, facial sweating, miosis, droopy eye lids and eye lid oedema
39
what are the differential diagnosis for cluster headaches
meningitis - non blanching rash, light sensitivity bleeding - trauma, confusion cranial arteritis - pre-existing joint issues
40
what are medication overuse headaches
Pain is oppressive - worse in morning caused by painkiller overuse
41
how are medication use headaches treated
stop therapy pain gets worse before it gets better gp for prophylaxis
42
what medications put patients at risk of medication overuse headaches
using analgesics or triptans for more than 15 days/month
43
how should painkillers be used for headaches
<15 days a month 3-4 doses / 2 days no consecutive use avoid codeine
44
what are the symptoms of migraines
prodrome - pre-headache - aura headache - lateralised and pulsing - N&V - dislike for bright light and loud noises
45
what are the theories for pathophysiology of migraines
- vascular theory - disproven - brain hypothesis - increased extracellular potassium causing decreased flow and neuronal inhibition - inflammation - activation of trigeminal nerve 5HT implicated in pathogenesis - metabolites present in urine
46
what are the three types of migraine
classical common abdominal
47
what are the symptoms of a classical migraine
aura slurred speech visual phenomena
48
what are the symptoms of common migraines
no aura
49
what are the symptoms of abdominal auras
usually in children headaches GI symptoms withdrawing from play not liking loud noises cyclic
50
what are some trigger factors of migraines
certain foods hormonal changes environmental issues change in standard routine
51
how are migraines diagnosed
repeated attacks lasting 4-74 hours with at least TWO - unilateral pain - throbbing pain - aggravated by movement - moderate or severe intensity and ONE - nausea and vomiting - phono/photophobia
52
which migraine patients need to be referred to GP
>24 hrs no nausea but vomiting in the morning unsteadiness under 12s suspected ADRs
53
how are migraines managed
elimination of triggers acute intervention for breakthrough if >4/month offer prophylaxis
54
what is the acute treatment of migraines
1. dispersible or effervescent ibuprofen 400, aspirin 900 or paracetamol 1g 2. OTC prochlorperazine or triptans
55
what are the triptans
5HT1B and 1D agonists C/I in IHD, HT, 65 + s/e dizziness, tiredness, tight chest and throat 1 tab - 2nd dose if goes away ad comes back
56
which medications can be used for migraine prophylaxis
beta blockers pizotifen methysergide TCAs topiramate valproate
57
beat blockers s/e
fatigue bronchoconstriction cold extremities
58
what is methysergide and its s/e
5HT antagonist N&V rare fibrotic conditions
59
what is pizotifen and its s/e
5HT agonist weight gain sedation
60
what issue needs to be accounted for when using valproate and topiramate for migraines
teratogenic
61
what are the trigger factors for migraines and how to reduce them
anxiety - coping strategies change of habits - reversal to normal foods - exclude bright lights and noise - avoid strenuous exercise - avoid
62
when is migraine prophylaxis indicated
- functional impairment - >2 headaches a week - patient compliance

year three exam 2 (38 decks)

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