Pain Exam 1-S4 Flashcards by Brad Koester

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

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Narcotic analgesic derived from an opium poppy?
Morphine
Codeine

Opiate

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A narcotic analgesic that is at least part synthetic, not found in nature?
Heroin
Fentanyl

Opioid

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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

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Which Schedule has the highest potential for abuse and is no current accepted medical use?

Schedule I

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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

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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

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Which schedule of drugs can have 7 day prescriptions with up to 90 day supply?

Schedule II

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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

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This schedule has
- Low potential for abuse
- Accepted medical use
- May lead to limited physical dependence.
- Benzos
- Tramadol
- Chloral hydrate

Schedule IV

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This schedule has
- Low potential for abuse
- Accepted medical use
- May lead to limited physical dependence
- Pregabalin
- Cough suppressants
- Atropine (lomotil)

Schedule V

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APRN (Except psych NP) can prescribe Schedule II controlled substances for how many days?

7 days

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APRN must complete how many hours of CE every 2 years for prescription authority and is required?

3 hours

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In 2001 who issued pain management standards that instructed hospitals to measure pain and prioritize its treatment?
5th Vital sign

Join Commission

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> 60% of drug overdose deaths are caused by what?
78 Americans die every day
Record in 2014

Now more than 28k Americans yearly

Fentanyl

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T/F
More people die annually of opiod ovderdose than MVA?

True

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SRNA and CRNA substance abuse rate?

Now more than 15%

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One of the strongest NSAD pain reliever combinations available is what?
Stronger than oxycodone and percocet

200mg ibuprofen and
500mg acetaminophen

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Max dose of tylenol daily?

3000mg daily or
3 grams

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Advil is a combination of ibuprofen 125mg and acetaminophen 250mg.
What is the max dose of Advil Qd?

3200mg daily

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Uncontrolled chronic pain can lead to what?

Disability and despair

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Loss of awareness is called ___?

Hypnosis

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Loss of memory is called ___?

Amnesia

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Loss of pain is called ___?

Analgesia

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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.

1. Nonopioids for mild pain 2. Weak oral opioids for moderate pain 3. 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?

Nipple dermatome?

Xiphoid dermatome?

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?

1. Conduit for motor information 2. Conduit for sensory information 3. 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?

1. SNS response 2. Temperature perception 3. Motor response 4. 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

1. prilocaine 2. lidocaine 3. mepivacaine 4. ropivacaine 5. 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