pain management Flashcards
pain def 1
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
pain def 2
A revised definition identifies pain as “a somatic perception containing: (1) a bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, and (3) a feeling of unpleasantness or other negative emotion based on this experienced threat”
hyperalgesia
Increased response to a stimulus that normally is painful
hypoalgesia
Diminished response to a normally painful stimulus
hyperesthesia
Increased sensitivity to stimulation, excluding the special senses
hypesthesia
Diminished sensitivity to stimulation, excluding the special senses
dysesthesia
An unpleasant abnormal sensation, whether spontaneous or evoked
paresthesia
An abnormal sensation, whether spontaneous or evoked
allodynia
Pain resulting from a stimulus (such as light touch) that does not normally elicit pain
addiction
misuse of a substance for purposes other than one for which it was prescribed and despite negative consequences in health, employment, or legal/social spheres, demand for specific medications and doses, anger and irritability, poor cooperation, disturbed interpersonal reactions
pseudo-addiction
exhibiting behaviors associated with addiction but only because their pain is inadequately treated *undercontrolled* figuring out difference is tough!* -assess validity of pain -multidisc. approach -get a good hx -tx pain
avoid profiling in drug addiction
“white women” are the face of modern pill addiction
Neuropathic pain
abnormal neural activity secondary to disease, injury, or dysfunction of the nervous system
Sympathetically mediated pain (SMP) arises from ???
assoc. w/ ???
known as…
most common cause ??
a peripheral nerve lesion
associated with autonomic changes (complex regional pain syndrome I and II, formerly known as reflex sympathetic dystrophy and causalgia)
Diabetic neuropathy most common!
Peripheral neuropathic pain
damage to a peripheral nerve without autonomic change (postherpetic neuralgia, neuroma formation)
Central pain arises from ???
examples:
abnormal central nervous system (CNS) activity
phantom limb pain, pain from spinal cord injuries, and post-stroke pain
-hard to tx, tx CNS issue
pain toxonomy axes (IASP)
Axis I: Anatomic regions
Axis II: Organ systems
Axis III: Temporal characteristics, pattern of occurrence
Axis IV: Intensity, time since onset of pain
Axis V: Etiology
chronic pain dx
Chronic complaints of pain Symptoms frequently exceed signs Minimal relief with standard treatment History of having seen many clinicians Frequent use of several nonspecific medications
visceral pain is very hard to ?
localize
fibromyalgia dx
Usually women aged 20-50
- Chronic widespread musculoskeletal pain syndrome with multiple tender points
- Fatigue, headaches, numbness
- Inflammation absent*, lab studies normal
- easily written off!
- look like have MDD
afferent pain tract
STT: spinothalamic tract
benzos for chronic pain
diazepam (valium)
lorazepam (ativan)
midazolam (versed)
clonazepam (klonopin)
opioid withdrawal stage I
opioid withdrawal stage II
8-24 hrs
insomnia, restlessness, anxiety, yawning, stomach cramps, lacrimation, rhinorrhea, diaphoresis, mydriasis
opioid withdrawal stage III
up to 3 days
vomiting, diarrhea, fever, chills, musc. spasms, tremor, tachycardia, piloerection, HTN, seizures (neonates)
muscle relaxants for chronic pain
cyclobenzaprine carisoprodol (soma) baclofen (lioresal) methocarbamol (robaxin) *loopiness-take before bed, used with ice packs
barriers
Physicians have poor training
Fears of legality:
FDA, DEA, controlled substance
document!
Fears of abuse:
-Tolerance vs Dependence vs Addiction vs Pseudo-addiction
-IPMP website, can see pts prescribed opioids to
pain1 slide 17: KNOW!!***
WHO analgesic ladder
mild pain
non-opioid: acetaminophen (paracetomol)(liv. tox, not v. strong), ASA, NSAID (GI, CV, renal SE)
+/-adjuvant
mild-mod pain
opioid (codeine-not so much, tramadol*partial agonist)
+/- non-opioid
+/- adjuvant
mod-sev pain
opioid (morphine, fentanyl, dilaudid etc)
+/-non-opioid
+/-adjuvant
nociceptive pain: joints
patches, topical lidocaine
non-imflamm pain
tylenol
for chronic pain
adjuvants
neuropathic pain tx: 1st line agents
gabapentin
SNRIS
TCAs
neuropathic pain tx: 2nd line
opioids (tramadol)
antiepileptics
neuropathic pain tx: 3rd line
NMDA antagonists
combo
tizanidine
baclofen
neuropathic pain tx: 4th line
consider botulinum toxin injection or
intrathecal ziconotide
spinal stimulator
for chronic lower lumbar pain, block pain
not first line tx, meds first
opioid manangement
document everything
- avoid refills
- printed out, NOT electronic prescription
benzos good for..
but…
central, spasm, neuropathic pain, also tx anxiety rel. to pain
tough to manage, can make pt “high”
-Brown does not give often
tapering protocal
DEA have sp. protocol for opioids, give less and less with added behavioral therapy
palliative care focus
Focus on symptoms, quality of life, and goals of care
palliative care management
Pain
Dyspnea
Nausea,vomiting
Constipation
Agitation
Emotional distress (depression, anxiety, relationships)
Existential distress (spiritual distress)
opioid SEs
constipation- may need meds (docusate, colace, etc)
methalnaltrexone reverses constipation
OMM
medium effect on chronic low back pain
case 1: motorbike accident, 100 mph, road rash, stabilized
Need pain scale
Probably in v. severe pain, potentially in shock (mental)
Opioids are a good choice: don’t want to give so much stop breathing, or affect neural reflexes and cannot monitor
-give morphine, “start low and go slow”(better for when you want to give a lot and worried about neuro) could use dilaudid, longer dosage schedule, not ideal
-do everything when get to ER: head CT, CXR (ptx, broken clavicle etc.)
-paramedics may call ahead to drs and give meds/prep for others/procedures
-needle thoracotomy (fastest- relieves pressure, chest tube)
case 2: sharp stomach pain around lunch time, right of bb-radiates to right side
no rebound tenderness
no pmhx
- abdominal CT: appendicitis (take out), diverticulitis
- visceral pain, not well localized
- morphine, potentially stronger- dilaudid, fentanyl patch
- control pain, prep for surgery
case 3: unresponsive old man, low RR, HTN, dying, end-stage lung ca
- family wanted comfort measures only (not IV)
- palliative care, end of life care (not just, however-diff than hospice)
- fentanyl patch: long-acting
