Pain Management Flashcards
Which type of pain is most commonly associated with damage, tumours or trauma to bones, muscles, etc..?
1 - neuropathic
2 - somatic
3 - visceral
2 - somatic
Visceral relates to internal organs and blood vessels (liver, gallbladder, etc.)
Neuropathic relates to nerve damage
Between visceral and somatic pain, which is well localised and which is vague?
Somatic = well localised
Visceral = vague
SOCRATES is what is used for a pain history
Which 2 drugs make up co-codamol?
1 - codeine and aspirin
2 - codeine and ibuprofen
3 - codeine and paracetamol
4 - codeine and naproxen
3 - codeine and paracetamol
Codeine is metabolised by the liver into morphine and morphine-6-glucuronide.
What sensation is the use of tramadol associated with?
1 - dysuria
2 - burning sensation in feet
3 - walking on cotton wool
4 - all of the above
3 - walking on cotton wool
Associated with peripheral neuropathy
Codeine and tramadol are on the 2nd step of the analgesia ladder and are weak opioids. Morphine is a stronger opioid than codeine PO, but by what factor?
1 - 2 x stronger
2 - 5 x stronger
3 - 10 x stronger
4 - 20 x stronger
3 - 10 x stronger
240mg of codeine = 24mg morphine
Which 2 of the following can only be given via transdermal patches?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
4 - Oxycodone
1 - Fentanyl
Replaced every 72h
3 - Buprenorphine
Replaced every 7 days
Typically take 24h before they begin to work
Alfentanil = injectable only
Oxycodone = various forms
In palliative care, which of the following medications should NOT used in patients with renal impairment in case of renal accumulation and damage?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
4 - Morphine
4 - Morphine
In palliative care, in patients with renal impairment the following medications can be used, but in an acute setting, which would be most effective?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
2 - Alfentanil
The other 2 are patches and take longer to take an effect
In palliative care, which 2 of the following medications should be used in patients with hepatic impairment?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
4 - Morphine
1 - Fentanyl
4 - Morphine
Of the 4 medications below, which one is best to use in a palliative patient who has renal and hepatic impairment?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
4 - Morphine
1 - Fentanyl
SC or IV if available
2nd choice would be Alfentanil
Which of the following medications is NOT classes as an NSAID?
1 - Aspirin
2 - Diclofenac
3 - Ibuprofen
4 - Naproxen
5 - Celecoxib
6 - Amitriptyline
6 - Amitriptyline
Tricyclics antidepressant
Celecoxib = COX-2 inhibitor
All others are non-selective NSAIDs
In palliative patients, cancer is the most common type of pathophysiology. Which of the following medications is given as an adjuvant to help combat the fluid accumulation and inflammation tumours can cause?
1 - amitriptyline
2 - sumatriptan
3 - dexamethasone
4 - naloxone
3 - dexamethasone
Given to reduce ICP in metastatic brain cancer
In palliative patients, cancer is the most common type of pathophysiology. Which of the following medications is given as an adjuvant to help combat neuropathic pain and are classed as anti-epileptic medication?
1 - Gabapentin
2 - Ondansetron
3 - Pregabalin
4 - Amitriptyline
1 - Gabapentin
3 - Pregabalin
Both of these drugs can lead to delirium
In palliative patients, cancer is the most common type of pathophysiology. Which of the following medications is given as an adjuvant to help combat neuropathic pain and are classed as Tricyclics antidepressant antidepressant medication?
1 - Gabapentin
2 - Ondansetron
3 - Pregabalin
4 - Amitriptyline
4 - Amitriptyline
Fatal in overdoses
In drugs morphine and oxycodone, the SC route provides a stronger dose than the oral route. How much stronger is the SC dose when compared to the oral dose?
1 - 20 times stronger
2 - 10 times stronger
3 - 5 times stronger
4 - 2 times stronger
4 - 2 times stronger
100mg oral morphine or oxycodone =
50mg SC morphine or oxycodone
SC oxycodone is also 4 times stronger than oral morphine, for example:
20mg PO Morphine is = 10mg SC Morphine
10mg PO Oxycodone = 5mg SC Oxycodone
20/4 = 5mg
What is the half life of morphine?
1 - 1h
2 - 4h
3 - 8h
4 - 16h
2 - 4h
What is the most common side effect of morphines?
1 - nausea
2 - sweating
3 - pruritis
4 - constipation
4 - constipation
Nausea is next most common
Others do also occur
Morphine toxicity can occur at times. Which of the following is NOT a symptom of morphine toxicity?
1 - visual hallucinations
2 - myoclonas
3 - pinpoint pupils
4 - diarrhoea
5 - respiratory distress
4 - diarrhoea
Constipation is a side effect not this
What is the antidote to morphine, should morphine toxicity occur?
1 - Acetylcysteine
2 - Flumazenil
3 - Naloxone
4 - Glucagon
3 - Naloxone for opioid overdose
Acetylcysteine for acetaminophen poisoning
Flumazenil for benzodiazepine overdose
Glucagon for insulin
What is the equivalent of of Fentanyl patches at 25 micrograms (mcg) to morphine given orally?
1 - 25mg
2 - 50mg
3 - 60mg
4 - 100mg
3 - 60mg
What is the equivalent of of Buprenorphine patches at 10 micrograms (mcg) to morphine given orally?
1 - 20mg
2 - 50mg
3 - 60mg
4 - 100mg
1 - 20mg
Palliative patients are typically given analgesia for chronic pain over a 24h period. However, they may also be given analgesia pro re nata (PRN = as required) for break through pain. What %/ratio of the total daily dose is the break through pain calculated at?
1 - 1/2 (50%)
2 - 1/4 (25%)
3 - 1/6 (16.6%)
4 - 1/10 (10%)
3 - 1/6 (16.6%)
Palliative patients are typically given analgesia for chronic pain over a 24h period. However, they may also be given analgesia pro re nata (PRN = as required) for break through pain at 1/6 of the total daily dose. If a patient is taking 30mg BD Morphine Sulphate PO, what would the break through PRN PO dose for the 24h be?
1 - 30mg
2 - 15mg
3 - 10mg
4 - 1.6mg
3 - 10mg
Chronic = BD PO = 30mg x 2/24h =60mg PO/24h
PRN = 60/6 = 10mg
Palliative patients are typically given analgesia for chronic pain over a 24h period. However, they may also be given analgesia pro re nata (PRN = as required) for break through pain at 1/6 of the total daily dose. If a patient is on a syringe driver which gives continuous subcutaneous infusion (CSCI) of Oxycodone 15mg/24hrs, what would the break through SC PRN dose be?
1 - 8 (7.5)mg
2 - 4 (3.75) mg
3 - 3 (2.5) mg
4 - 2 (1.5) mg
3 - 3 (2.5) mg
15 / 6 = 2.5mg SC
If a patient needs to be prescribed steroids, such as dexamethasone, when should they be given?
1 - any time in the day
2 - morning only
3 - as required
4 - evenings
2 - morning only
Typically if BD then early morning and no later than lunch time
These drugs keep people awake
Which oof the following should be prescribed alongside dexamethasone?
1 - omeprazole
2 - aspirin
3 - metformin
4 - all of the above
1 - omeprazole
Risk of ulcers
Blood glucose should be monitored, as long duration can induce diabetes
Nerve blocks can be used in palliative care. Which of the following nerve blocks could be used for a brachial plexus block that spares the ulnar nerve (C8-L1)?
1 - INTERCOSTAL
2 - INTERSCALENE
3 - LUMBAR PLEXUS
4 - COELIAC PLEXUs
5 - GANGLION OF IMAPR
2 - INTERSCALENE
This is the space between the scalene muscles
Nerve blocks can be used in palliative care. Which of the following nerve blocks could be used for the liver, gallbladder, pancreas, spleen, stomach, kidneys, small bowel and first 2/3 of the large bowel pain?
1 - INTERCOSTAL
2 - INTERSCALENE
3 - LUMBAR PLEXUS
4 - COELIAC PLEXUs
5 - GANGLION OF IMAPR
4 - COELIAC PLEXUs
Nerve blocks can be used in palliative care. Which of the following nerve blocks could be used for sympathetically mediated region of the anus, distal parts of rectum, urethra and vagina?
1 - INTERCOSTAL
2 - INTERSCALENE
3 - LUMBAR PLEXUS
4 - COELIAC PLEXUs
5 - GANGLION OF IMAPR
5 - GANGLION OF IMAPR
Nerve blocks can be used in palliative care. Which of the following nerve blocks could be used for the psoas muscle, quadriceps femoris, lumbar transverse muscles?
1 - INTERCOSTAL
2 - INTERSCALENE
3 - LUMBAR PLEXUS
4 - COELIAC PLEXUs
5 - GANGLION OF IMAPR
3 - LUMBAR PLEXUS
An 78 year-old, retired naval officer, who has Mesothelioma, is on the following analgesia for pain in his chest wall.
Morphine MR 70mg bd PO
Gabapentin 600mg tds PO
Amitriptyline 50mg nocte PO
Paracetamol 1g qds
He has been taking Morphine IR PO PRN 5-10mg. He has noted that this was previously effective for at least 4 hours when used, but now the impact lasts just 2 hours. He does not require it as much as before but would like to talk to you about this. Is the PRN dose correct for this gentleman?
- No
70 x 2 = 140mg/24h PO
Breakthrough pain = 140/6 = 23.3 or 24mg PO PRN
This would be the reason the drug used for breakthrough pain was beginning to be less effective
Which of the following is NOT a common side effect of Amitriptyline?
1 - diarrhoea.
2 - dizziness.
3 - dry mouth.
4 - feeling sleepy, tired or weak.
5 - difficulty peeing.
6 - headaches.
1 - diarrhoea.
Typically causes constipation
All side effects are cholinergic and Amitriptyline has anti-cholinergic effects
If a patient presents with increased ICP, which of the following medications may be effective in reducing the risk of seizures and act as an anti-emetic?
1 - cyclizine
2 - ondersartan
3 - haloperidol
4 - metoclopramide
3 - haloperidol
Used as an anti-psychotic typically, but used as a D2 receptor antagonist to help treat nausea and reduce the risk of seizures
A 65 year-old lady has Metastatic Carcinoma of the colon, including liver and peritoneal involvement. She is admitted to the acute medical unit with uncontrolled vomiting and abdominal ‘’spasms’’. She is on Morphine Sulphate MR 50mg BD. On examination, her abdomen was soft and generally tender. No organomegaly was identified. Bowel sounds were high-pitched.
Further history revealed that she had neither passed flatus, nor stool, for 6 days.
BP 127/76, Pulse 94, RR 17. The patient was diagnosed with an obstruction due to the cancer in the colon. Which of the following medications should NOT be prescribed to alleviate the GIT spasms and vomiting?
1 - cyclizine
2 - ondansetron
3 - metoclopramide
4 - loperamide
3 - metoclopramide
This is an anti-emetic, but promotes gut motility by inhibition of presynaptic and postsynaptic D2 receptors, stimulation of presynaptic excitatory 5-HT4 receptors and antagonism of presynaptic inhibition of muscarinic receptors
A patient has been taking morphine as part of her palliative care package, which has been effective pain relief. However, the patients eGFR reduces during a hospital stay to 24. All of the following drugs should be considered, EXCEPT which drug as an alternative?
1 - Fentanyl
2 - Alfentanil
3 - Buprenorphine
4 - NSAIDs
4 - NSAIDs
Can make eGFR worse, and unlikely to be strong enough
If she remains on morphine, this could lead to morphine toxicity as it cannot be excreted.
A patient in palliative care develops the following symptoms:
- pinpoint pupils
- myoclonic jerks
- confusion
What is most likely to be occuring?
1 - Acute Hypoglycemia.
2 - Acute Subdural Hematoma Management in the ED.
3 - Alcohol Toxicity.
4 - Morphine Toxicity
4 - Morphine Toxicity
Can prescribe Naloxone as an antidote
A 67 year-old lady has Carcinoma of the Pancreas. She is on 300mg Pregabalin bd, Amitriptyline 50mg nocte and Oxycodone MR 20mg bd. The pain remains poorly controlled
Given this, the team have contacted the interventionalist pain team. Which of these nerve blocks is most appropriate?
1 - Intercostal
2 - Interscalene
3 - Brachial plexus
4 - Coeliac plexus
5 - Ganglion of Impar
4 - Coeliac plexus
Covers liver, gallbladder, pancreas, spleen, stomach, kidneys, small bowel and first 2/3 of the large bowel
A 71 year-old lady who has been receiving palliative chemotherapy develops a lancinating, vesicular rash in the T9 distribution. There are no vertebral metastases. Which of the following should you consider prescribing firstly?
1 - Amitriptyline
2 - Duloxetine
3 - Aciclovir
4 - Pregabalin
5 - Morphine IR
3 - Aciclovir
The patient is presenting with Herpes Zoster (shingles)
A 63 year-old lady is on Morphine MR 40mg bd PO. She has Metastatic Sarcoma of the Uterus with bilateral ureteric obstruction and liver metastases. Her last eGFR from 2 days before is 17. She is not jaundiced. Her Total Bilirubin is 6. She has developed confusion and some jerking of her limbs. Her Corrected Calcium is 2.45 (2.2-2.6).Previous abdominal pain is now well controlled. Which 2 of the following are likley to be occurring here?
1 - hypoglycaemia
2 - hypocalcaemia
3 - hypercalcaemia
4 - morphine toxicity
3 - hypercalcaemia
4 - morphine toxicity
This is hypercalcaemia of malignancy
Which of the following is the safest analgesic in renal impairment?
1 - Amitriptyline
2 - Morphine MR
3 - Oxycodone MR
4 - Nabumetone
5 - Gabapentin
1 - Amitriptyline
Morphine, Oxycodone and Gabapentin can all accumulate in the kidneys
Nabumetone = NSAIDs
