Pain Exam 1-S4 Flashcards
A drug that in moderate doses dulls the senses, relieves pain and induces profound sleep, but in excessive doses causes stupor, coma or convulsions. Potential for abuse?
Narcotic
Narcotic analgesic derived from an opium poppy?
Morphine
Codeine
Opiate
A narcotic analgesic that is at least part synthetic, not found in nature?
Heroin
Fentanyl
Opioid
What created the 5 schedules (classifications) of drugs which control the manufacture, importation and use/distribution of substances?
Controlled Substances Act (CSA)
Established federal us drug policy
Which Schedule has the highest potential for abuse and is no current accepted medical use?
Schedule I
This schedule has
-Highest potential for abuse
- NO current accepted medical use
- Lack of accepted Safety for use of the drug.
- No prescriptions may be written
- Heroin
-LSD
-Marijuana
-MDMA
Schedule I
This schedule has
- High potential for abuse
- Currently accepted medical use w/ restrictions
- May lead to severe dependence
- 7 day prescription only
- NO refills
- Cocaine, Opium, Fentanyl, Oxycodone, Morphine, methadone
Schedule II
Which schedule of drugs can have 7 day prescriptions with up to 90 day supply?
Schedule II
This schedule has
- Potential for abuse less than I and II
- Accepted medical use
- Lead to low physical dependence or high psyschological dependence
- Ketamine
- Anabolic Steroids
Schedule III
This schedule has
- Low potential for abuse
- Accepted medical use
- May lead to limited physical dependence.
- Benzos
- Tramadol
- Chloral hydrate
Schedule IV
This schedule has
- Low potential for abuse
- Accepted medical use
- May lead to limited physical dependence
- Pregabalin
- Cough suppressants
- Atropine (lomotil)
Schedule V
APRN (Except psych NP) can prescribe Schedule II controlled substances for how many days?
7 days
APRN must complete how many hours of CE every 2 years for prescription authority and is required?
3 hours
In 2001 who issued pain management standards that instructed hospitals to measure pain and prioritize its treatment?
5th Vital sign
Join Commission
> 60% of drug overdose deaths are caused by what?
78 Americans die every day
Record in 2014
Now more than 28k Americans yearly
Fentanyl
T/F
More people die annually of opiod ovderdose than MVA?
True
SRNA and CRNA substance abuse rate?
Now more than 15%
One of the strongest NSAD pain reliever combinations available is what?
Stronger than oxycodone and percocet
200mg ibuprofen and
500mg acetaminophen
Max dose of tylenol daily?
3000mg daily or
3 grams
Advil is a combination of ibuprofen 125mg and acetaminophen 250mg.
What is the max dose of Advil Qd?
3200mg daily
Uncontrolled chronic pain can lead to what?
Disability and despair
Loss of awareness is called ___?
Hypnosis
Loss of memory is called ___?
Amnesia
Loss of pain is called ___?
Analgesia
Loss of movement is called ___?
Akinesis
Persistent post-surgical pain is chronic pain that continues beyond the usual healing period of ?
1-2 months following surgery
Smoking cessation is to stop smoking __ weeks before procedure?
8 weeks
Heat loss caused by IV fluids and laying on the cold table is called?
Conduction
(most)
Heat loss caused by oxymask and betadine drying is called?
Evaporation
Heat loss caused by cold temperature in the OR coming across the patient?
Convection
Heat loss caused by skin exposure in the OR is called?
Radiation
What is the average patient temperature decrease in the first 20 mins after induction?
1.5 C decrease
Ondasetron(Zofran) works on which receptor?
Serotonin 5HT-3
Antagonist
Metoclopramide(Reglan) and Chlorpromazine work on which receptor?
Dopamine D2
Antagonist
Scopolamine and hydroxyzine work on which receptor?
Anticholinergic and Antihistamine
Antagonist
PONV prophylaxis
Dexamethasone dose?
4-12mg IV
PONV prophylaxis
Ondansetron dose?
50-200 mcg/kg
4-8mg typical
PONV prophylaxis
Metoclopramide dose?
100-250 mcg/kg
What 3 things can minimize postoperative ileus?
Hydration
Movement (early movement post-op)
Minimize or remove opioids
Administration of what can ensure better preservation of
- pulmonary function
- early ambulation
- early physical therapy
- lowers risk post operative DVT
Local anesthetics
PCA- self administer small doses of narcotics and have
- Lock out periods
- Max PCA dosage
- Basal Rate per Hour
The use of PCA allows what?
To objectively assess pain level by number of PCA dose and attempts.
PCA by proxy is used by activating the pump by someone other than the patient and utilized with what patients?
Pediatric
Hospice
This headache is a tight band-like pain that is associated with tightness in neck muscles. Gradual and fluctuates
Lasts hours to days.
- Frontal
- Temporal
- Occipital More bilateral than unilateral
Associated with emotional stress or depression.
Tension Headache.
This headache is a throbbing or pounding and associated with photophobia, scotoma, N/V.
Lasts 4-72 hours.
Often has localized transient neurological dysfunction (AURA)
- Unilateral pain often
- Frontotemporal location
Migraine headache
_____ migraines are preceded by an aura whereas _____ migraines are not?
Classic migraine have aura
Common migraine do not
Migraines primarily affect
- Children
- Young adult females
- Family history
- provoked by odor, foods, menses and sleep deprivation.
Sleep typically relieves the headache.
-Oxygen
-Sumatriptan(Amitrex) 6mg subq
-IV lidocaine 100mg
- sphenopalatine block
are abortive treatments for what?
Rapid abortive treatment for migraines
- adrenergic blockers
- CCB
- Valproic acid
- amitriptyline
are prophylactic treatment for what?
Prophylactic treatment for migraines
This headache is classically unilateral and periorbital
-one to three attacks a day over 4-8 weeks
- burning or drilling sensation
- can awaken from sleep
- lasts 30-120 mins
- ptosis (horner’s syndrome)
- red eye
- tearing
- nasal stuffiness
- treated with prednisone or lithium
Cluster Headache
Which headache affects males (90%) and typically episodic but can become chronic?
Cluster headaches
Inflammatory disorder of the extracranial arteries?
- Headache can be bilateral/unilateral
- Dull and boring in quality
- Temporal region
- develops over few hours and lancinating(stabbing)
- worse at night and cold weather
Temporal arteritis
Which disorder can lead to blindness if not treated?
Temporal arteritis
How is temporal arteritis diagnosed?
Temporal artery biopsy
This disease is a vesicular dermatomal rash that lasts 1-2 weeks.
- severe pain
- Affects T3-L3 dermatomes
- Most common in elderly
- can go blind if affects eye
Herpes zoster virus
Treatment for Herpes zoster includes?
Supportive
Oral analgesics
acyclovir or valacyclovir to reduce the duration
Which type of patients affected by herpes zoster virus require IV acyclovir therapy?
Immunocompromised patients
Post-herpetic neuralgia (PHN) is difficult to treat, but ____ and _____ may decrease the incidence of PHN in patients older than 50 yo?
Oral corticosteroids
Transdermal lidocaine patch
What is the most common type of neuropathic pain?
Diabetic neuropathy
The most common syndrome associated with diabetic neuropathy is ___ _____?
Which results in symmetric numbness “stocking and glove”
Peripheral polyneuropathy
Isolated mononeuropathies associated with diabetic neuropathy are ____ ___can have a sudden onset and last a few weeks are reversible?
Wrist/Foot drop
Cranial nerve palsy
What affects the gastrointestinal track causing diarrhea, delayed gastric emptying, and delayed esophageal motility?
Autonomic neuropathy
The combination of gabapentin and amitriptyline are particularly effective in treating what condition?
Possibly Tramadol for analgesia
Diabetic neuropathy
A positive Patrick’s sign is associated with what?
Hip pain rather than lower back pain.
Constant pain with localized tenderness over vertebrae, bony destruction, and neural or vascular compression are associated with what?
Spinal tumors
What can present like a herniated disk and may rapidly progress to flaccid paralysis if not treated?
Epidural or Intradural tumor
Patients with what condition present with chronic back pain without fever or leukocytosis?
Spinal tuberculosis
Patients with what condition present with acute back pain, fever and leukocytosis?
Epidural abscesses
Patients with what condition present with low back pain associated with early morning stiffness?
Pain is insidious onset, improves with activity but can progress to restricted movement within months/years?
Ankylosing spondylitis
Radiographic evidence of sacroiliitis is used to diagnose what condition?
“Bamboo- like” appearance
Ankylosing spondylitis
Indomethacin is an NSAID that can reduce early morning stiffness and used to treat what?
Ankylosing spondylitis
This disease is associated with symptoms of conjunctivitis, urethritis, and arthritis?
Reiter’s syndrome
What disorder is commonly characterized by pain radiating in a fixed pattern that does not follow dermatomes and tight ropy bands over trigger points from acute injury?
Myofascial syndrome
Gross trauma or repetitive microtrauma plays a role in initiating what?
Myofascial syndromes
The diagnosis of what is pain and palpation of discrete trigger points that reproduce it?
Myofascial syndromes
Myofascial syndromes are treated with the use of what two things?
Topical cooling with ethyl chloride to cause muscle relaxation and
Local anesthetic injection of trigger area
Cancer pain involves a 3 step approach using what?
1.
2.
3.
- Nonopioids for mild pain
- Weak oral opioids for moderate pain
- Stronger opioids for severe pain
A fixed schedule rather than PRN and Antidepressants and other modalities should be used liberally with patients who have this condition?
Cancer pain
Clavicle dermatome?
C4
Nipple dermatome?
T4
Xiphoid dermatome?
T6
Umbilicus dermatome?
T10
Tibia dermatome?
L4-L5
Perineum dermatome?
S2-S5
TENS stimulation causes conduction block in which fibers?
Conduction block in small afferent pain fibers
The stimulation of large A fibers in the dorsal column of the spinal cord is called what?
Spinal cord stimulation or Dorsal column stimulation
What is most effective for neuropathic pain?
Spinal cord stimulation
Spinal cord stimulation placement is under what anesthesia?
MAC sedation, TIVA
in order to check with patient if placement is working
For Intracerebral stimulation the electrodes are implanted sterotactically into which areas?
Periaqueductal and periventricular gray areas
The most serious complications of Intracerebral stimulation are what?
Intracranial hemorrhage
Infection
This psychological intervention is based on the principle that patients can be taught to control involuntary physiological parameters?
Biofeedback
This psychological intervention teaches patients to alter pain perception by having them focus on other sensations?
Hypnosis
Heat or Cold pain relief?
Decreases joint stiffness and increased blood flow
Heat
Heat or Cold pain relief?
Vasoconstriction and reduces inflammation
Cold
Heat or Cold pain relief?
Ideal for chronic or arthritic pain, joint pain, osteoarthritis, pain that is not caused by immediate injury?
Heat therapy
Heat or Cold pain relief?
Ideal for acute injuries first (48-72hrs) with swelling, pain, and muscle spasms.
Cold therapy
Acupuncture stimulates ______ because its effects can be antagonized by naloxone?
Endogenous opioids
Which Block allows assessment of the benefits and risk of neurolytic and neurodestructive blocks?
Typically for patients with severe intractable pain such as cancer pain.
Prognostic blocks
Which Block is used to define the precise source of pain?
Diagnostic blocks
Cervicothoracic (Stellate) block is
used for patients with head, neck, arm, and upper chest pain.
T5 ganglia
Thoracic Sympathetic chain block is
lateral to the vertebral bodies and anterior to the spinal nerve roots, but this block is generally not used because of a significant risk of pneumothorax.
Celiac plexus block is
indicated for patients with pain arising from the abdominal viscera, particularly cancers.
L1
Spinal analgesia is primarily mediate by which opioid receptor?
Mu-2 receptors
Supraspinal analgesia is mediated by all opioid receptors except which one?
Mu-2 receptors
Which opioid receptor is associated with respiratory depression?
Mu-2 receptors
These neurons transmit sensory information from the periphery to the CNS?
First Order Neurons
These neurons communicate with reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus?
Second Order Neurons
These neurons relay information from the thalamus to the cerebral cortex?
Third Order Neurons
A sensory unit or ____ ___ ____ is where all somatosensory information from the limbs and trunk share common neurons?
Dorsal root ganglion
Which pathway crosses the base of the medulla and the anterolateral pathway and relays information to the brain for perceptions, arousal and motor control?
Discriminative pathway
Which pathway consists of bilateral multisynaptic slow conducting tract and provides sensory NOT of discrete localization or fine discrimination?
Anterolateral pathway
What is the central integrative mechanisms?
Post central gyrus and cerebral cortex
Emotional components of pain are experiences where?
Limbic system
Autonomic nervous system responses are recruited where?
Brain stem centers
Fast pain fibers?
Myelinated A-delta fibers
Acute
Slow pain fibers?
Unmyelinated C fibers
Chronic
Protopathic sensation?
Noxious
High threshold receptors
Smaller myelinated A-delta and un-myelinated C nerve fibers
Epicritic sensation?
Non-noxious
Low threshold receptors
Light touch
Pressure
proprioception
Temperature discrimination
Large myelinated nerve fibers
Pain can lead to leukopenia and leukocytosis along with ___ killer T cells and ___ immune function?
Decreased
What are free nerve endings that sense heat, mechanical and chemical tissue damage?
Nociceptors
Afferent ____ and Efferent _____
Afferent arrives
Efferent exits
What type:
Respond to mechanical stimulation such as pressure, vibration or movement?
Mechanociceptors
What type:
Respond to inflammation?
Silent nociceptors
What type:
Respond to excessive pressure and temperature?
Polymodal mechanoheat and Thermoreceptors
These nociceptors are
- most prevalent
- Respond to excessive pressure
- extreme heat
Respond to alogens
Polymodal mechanoheat nociceptors
Meissner corpuscles (touch) are located which layer of skin?
Epidermis
Merkel cell complexes (touch) and Ruffini endings (heat) are located which layer of skin?
Dermis
Pacinian corpuscles (pressure) are located in which layer of skin?
Subcutis (beneath the dermis)
Kinesthetic receptors do what?
Sense where the limbs are located in space and movement
Muscle spindles do what?
Sensory receptors located in muscles that sense tension “stretch receptors”
Muscle memory
In the Gate Theory, the spinal cord and brain stem contain gates, which fibers CLOSE the gates?
Large diameter A-beta fibers
Which fibers open the gates?
A delta and C fibers
Local anesthetics block Na channels, which form diffuses across the membrane and which form binds to the receptors?
Unionized- diffuses across
Ionized- binds to the receptor to inactivate
Which nerve fibers have autonomic function?
B fibers
These fibers are
5-12 microns
Large, myelinated
Transmit quick
Epicritic sensation
touch, pressure, proprioception
A-beta fibers
These fibers are
1-5 microns
Myelinated with lipid
Transmit fast
First pain, or acute pain
Sharp, well localized sensation
Protopathic
Releases Glutamate
A-delta fibers
These fibers are
0.4-1.2 microns
Unmyelinated
Transmit slow
Second pain or Chronic pain
Protopathic sensation of pain, temp, touch
Releases Substance P
C fibers
Eudynia ?
Acute pain
Maldynia?
Chronic pain
This type of pain is due to nociceptive stimuli from skin, subcutaneous, and mucous membranes.
- Well localized
- Sharp, pricking, throbbing, burning.
Hives/Rash
Acute Superficial Somatic
This type of pain arises from muscles, tendons, joints, or bones.
- Dull, aching quality
- Not well localized
Acute Deep Somatic
This type of pain is due to disease process or abnormal function of internal organ.
- Dull, aching, diffuse
- Poorly localized
Acute Visceral
This type of pain refers to a group of neuropathic pain disorders.
Nerve disorder occurs at the site of injury, most often the arms or legs.
- Chronic, severe burning pain.
- Changes in bone and skin, sweating, tissue swelling, and extreme sensitivity.
CRPS
Complex regional pain syndrome
This typically affects the extremities and follows relatively minor trauma.
- 3 phases
- Can resolve spontaneously
- No nerve injury
Reflex sympathetic dystrophy
CRPS type I
This typically follows a high velocity injury to large nerves.
- Immediate onset, allodynia, vasomotor and sudomotor dysfunction.
- Pain is exacerbated by fear, anxiety, noise or touch.
- Has nerve injury
Causalgia
CRPS type II
- Nociceptors are stimulated
- Noxious, painful or tissue damaging stimuli affects a peripheral nerve ending.
- Nerve is depolarized
- Generates electrical impulse
Which process?
Transduction
- Impulses is transmitted or carried throughout nervous system.
- Spinothalamic tract is most important pathway for transmission.
Which process?
Transmission
- Subjective interpretation of the pain
- “How it feels to the patient”
Which process?
Interpretation or perception
- Can either inhibit or facilitate pain.
- Neural response
- Many chemical messages are released.
Which process?
Modulation
Prostaglandins
Histamine
Bradykinin
Serotonin
Acetycholine
Lactic Acid
Hydrogen ions
Potassium ions
All are what?
Endogenous mediators of inflammation
What are the 3 major functions of the pain pathway?
- Conduit for motor information
- Conduit for sensory information
- Center for coordinating reflexes
Ventral?
Motor
Dorsal?
Sensory
First order neurons are located where?
Dorsal root ganglion
Second order neurons are located where?
Dorsal horn gray matter
Third order neurons are located where?
Inner chamber of the thalamus
Which lamina make up the dorsal horn?
Lamina 1-6
Where all afferent stimuli comes into the spinal cord
Lamina II is also called what?
Major site of action for what?
Substantia Gelatinosa
Site of action for opioids
Lamina III, IV and VI do what?
Non-nociceptive sensory input
Lamina VII does what?
Intermediolateral column, contains preganglionic symathetic neurons
Lamina VIII and IX do what?
Motor
Anterior horn
Lamina X does what?
Very small, involved in pain, temperature and visceral sensation.
Wide dynamic range neurons are located where?
Lamina V
Which neurons cause spinal wind up, increase firing rate without having an increase in intensity from stimulation?
Wide dynamic range neurons
Which spinothalamic tract?
- neospinothalamic tract
- Posterior portion of the thalamus
- Carries pain and temperature up to the brain
- Carries discriminative aspects of pain, such as location, intensity and duration.
- Slow transmission
Lateral Tract
Which spinothalamic tract?
- Paleospinothalamic tract
- Mediates the autonomic and unpleasant emotional perceptions of pain.
Medial tract
Which pathway is associated with sensory and transmitting information via the Cuneatus and Gracilis tracts?
Ascending Sensory pathway
What evaluate the integrity of the brain and spinal cord while monitoring the ascending sensory pathway?
Somatosensory Evoked Potentials (SSEPs)
Which descending tract modulates pain by activating enkephalin neurons of the substantia gelatinosa?
Dorsolateral funiculus
Somatic and visceral afferents are connected where?
Spinal cord
Vasoconstriction
Smooth muscle spasm
Release of Catecholamines
- All mechanisms of what?
Chronic pain
The most important excitatory peptides are what?
2
Substance P (pain) and
Calcitonin Gene related peptide (CGRP)
(arterial vasodilator)
What is the most important excitatory amino acid?
1
Glutamate
Transmits pain impulses by changing Na ion channels
Synthesized and released by First order neuron.
This facilitates ascending transmission in pain pathways.
- Causes a release of histamine from mast cells.
- Causes a release of serotonin from platelets.
Potent vasodilator
Substance P
This alogen is Released from mast cells and platelets
Histamine
This alogen is Released from tissues and causes increased vascular permeability, vasodilation and activates nociceptors?
Bradykinin
Mediated by the release of alogens which contribute to inflammation and sensitivity and pain at the site of damage. Includes Histamine and Bradykinin release?
Primary Hyperalgesia
Neurogenic inflammation
Triple response of redness, edema and sensitization to stimuli.
Occurs due to the release of prostaglandins and CGRP.
Secondary Hyperalgesia
Phospholipase A2 enzyme is stimulated by what?
Tissue damage
Activation of phospholipase A2 causes the release of what?
Arachidonic acid
This converts arachidonic acid to prostaglandins and prostacyclins which potentiates edema from bradykinin?
Cycloxygenase
This converts arachidonic acid to leukotrienes which cause increased vascular permeability and release of leukocytes?
Lipoxygenase
Central modulation DOES NOT respond to which opioid receptor?
Kappa
____ analgesia occurs when transmission stops at the spinal cord in the substantia gelatinosa?
Spinal
____ analgesia occurs when transmission stops in the brain (limbic, thalamus, hypothalamus)?
Supraspinal
____ released from the lamina II interneurons attach to the receptors of the C-fibers nerve terminals and inhibit the release of Substance P?
Enkephalins
Which nerve innervates above the vocal cords?
Internal branch of superior laryngeal nerve
Which nerve innervates below the vocal cords?
Recurrent laryngeal nerve
Which nerve provides sensory to the vallecula and base of tongue?
Glossopharyngeal nerve IX
Which nerve innervates the pharynx?
Glossopharyngeal nerve
Which nerve innervates the oropharynx?
Vagus, trigeminal and glossopharyngeal
Which nerve innervates the larynx?
Vagus nerve.
Internal branch above vocal cords and
Recurrent laryngeal nerve below vocal cords
Airway blocks are used most often to aid with what?
Awake intubation, awake fiberoptics, awake laryngoscopy
Which nerve block will abolish the gag reflex or hemodynamic response to laryngoscopy?
Superior laryngeal nerve block
Glossopharyngeal block
What is defined as an aspiration of 25mL of gastric contents with a pH of less than 2.5.
- Can produce aspiration pneumonia
- Potentially fatal
Mendelson’s Syndrome
With Local anesthestics, Esters are metabolized by what?
Plasma cholinesterase
With Local anesthestics, Amides are metabolized by what?
Primarily in the liver by CYP enzymes
Which locals are most likely to cause an allergic reaction?
Esters secondary to Para-aminobenzoic acid (PABA) which is a metabolic end product of esters.
Dibucaine number is used to check if patient is incapable of hydrolyzing ester locals?
Results in decreased enzyme function
Dibucaine =80
Normal response
Homozygous typical
Dibucaine = 50-60
Lengthened by 100%
Heterozygous atypical
Dibucaine = 20-30
Prolonged 4-8 hours
Homozygous atypical
What are mirror images that can not be superimposed on eachother called?
Optical isomers (enantiomers)
What contains two isomers in equal concentrations?
50:50 ratio?
Which local does this apply to?
Racemic Mixture
Bupivacaine is a racemic mixture
What determines the potency of local anesthetics?
Lipid solubility
As lipid solubility increases so does the ability of the molecule to penetrate the cell membrane.
What determines the duration of action of local anesthetics?
Protein Binding
Local anesthetics exist as a ?
Weak base
Which form of local anesthetic is lipid soluble and penetrates the cell membrane easily?
Un-ionized form
Which form of local anesthetic is water soluble and binds to the receptor?
Ionized form
If pKa is close to the physiological pH then there will be a ____ concentration of non-ionized base and a ____ onset?
Higher concentration
Faster onset
Adding Sodium Bicarbonate to a Local ane does what?
Increases the amount of free base form (Unionized) of the local.
speeds the onset
Prolongs the duration of block
Decreased pain
T/F
Local anesthetics alter the resting membrane potential?
False
They block propagation of a nerve impulse.
Local anesthetics bind more rapidly when the conformational state is in ___ state?
Open or inactivated state
What is the order of nerve fiber blockage by local anesthetics?
- SNS response
- Temperature perception
- Motor response
- Proprioception
Which local anesthetic toxicity is associated with CV collapse?
Bupivacaine
Epinephrine is added to local anesthetics for what?
To extend the duration of action and limit the drugs absorption.
What is the epinephrine dose for locals?
5mcg/mL
1g:200,000ml
Which system is responsible for the extraction of local anesthetics?
Pulmonary system
Largest reservoir of local anesthetics is?
Skeletal muscles
Amide local anesthetics rate of metabolism?
mepivacaine
lidocaine
bupivacaine
ropivacaine
prilocaine
- prilocaine
- lidocaine
- mepivacaine
- ropivacaine
- bupivacaine
Amide local anesthetics effects on vasculature?
Which drugs vasodilate and which drugs vasoconstrict
Vasodilate- Lidocaine then Bupivacaine
Vasoconstrict- Ropivacaine then Mepivacaine
Which LA location has the slowest onset and longest duration?
Brachial plexus blockade
Which LA location has the quickest onset and shortest duration?
Subarachnoid blockade
The spread of local anesthetics and depth of epidural/spinal is greatest affected in pregnancy by what?
If the patient is a parturient and previously had children.
Lipid emulsion therapy to treat LAST dosage?
>70kg and. <70kg
> 70kg dose is 100mL bolus over 2 mins then infuse 200-250mL over 15 mins
<70kg dose is 1.5mL/kg bolus over 2 mins then infuse 0.25mL/kg/min ideal body weight
Do not give more than 12mL/kg
