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Ortho > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Inpt pain management?

A
  • controlled enviro: need for pain control over at least 12 hrs
  • PCA: usually written on pre-printed order sets - usually have loading dose, PCA dose, lockout interval, 4 hr limit
  • choice of morphine, fentanyl, deluded, demerol
  • need coherent pt, attentive staff, Narcan taped to pump and bowel program
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2
Q

Pain management - inpt for sporadic pain control?

A 
- need to be able to adjust:
Toradol IM/IV
morphine IM/IV
Dilaudid IM/IV
Demerol/Phenergan IM: most pts however can usually be controlled w/ oral meds
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3
Q

Management for acute pain?

A
  • usually in ambulatory setting following injury or post op recovery
  • mix of narcotic and non-narcotic meds
  • don’t forget importance of splinting/bracing/immobilization in ortho pain management
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4
Q

How is chronic pain managed?

A
  • ground rules need to be est early
  • most cases are better dealt w/ through chronic pain providers
  • pain contracts:
    pain med - amt - time period
    drug testing
    providers
    ancillary services: behavior health, biofeedback, PT, OT, hypnosis, osteopathic medicine
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5
Q

Most common narcotics used in ortho pain?

A
  • most in combo w/ APAP
  • codeine
  • hydrocodone
  • oxycodone
  • tramadol
  • hydromorphone
  • meperidine
  • fentanyl
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6
Q

Schedule I drugs?

A
  • use: illegal/restricted to research. No accepted medical use
  • drug or other substance has high potential for abuse
  • lack of accepted safety for use
  • ex:
    hallucinogens, heroin, peyote, coca, psilocybin mushrooms
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7
Q

Schedule II drugs?

A
  • reqr Rx
  • high abuse potential: psych of physical dependence (No refills or verbal orders)
  • ex:
    codeine
    hydrocodone
    hydromorphone
    morphine
    cocaine
    fentanyl
    methadone
    meperidine
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8
Q

Schedule III drugs?

A
  • reqr a Rx
  • moderate abuse potential
  • max 5 refills/6 mos
  • verbal orders allowed
  • ex: some opioid combos
  • stimulants:
    benzphetamine
    clortemine
  • depressants:
    ketamine
    pentobarbital
    secobarbital
    sulfomethane
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9
Q

Schedule IV drugs?

A
  • reqr Rx
  • low abuse potential
  • max 5 refills/6 mos
  • verbal orders allowed
  • benzos, sedatives/hypnotics and now tramadol
  • ex:
    alprazolam
    barbital
    clonazepam
    lorazepam
    midazolam
    phenobarbital
    diazepam
    tramadol
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10
Q

Schedule V drugs?

A
  • reqr Rx or may be OTC w/ restrictions in some states
  • low abuse potential
  • currently accepted medical use in tx
    -ex:
    Robitussin AC
    lyrica
    lomotil
    potiga (anticonvulsant)
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11
Q

Combo of codeine/APAP?

A
  • opioid agonist (binds to opioid receptors)
  • used as antitussive as well
  • schedule III
  • good choice for peds
  • cost approx $15 for 30 tabs
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12
Q

What is hydrocodone? Combos?

A
  • opioid agonist
  • many combo formulations w/ APAP
    lorcet
    Vicodin
    norco
    lortab
    price: 30 tabs for $55
  • schedule II
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13
Q

Oxycodone use? Combo?

A
  • can be combo or not
  • percocet = oxycodone + APAP
  • oxycontin = no APAP: MS-contin, oral morphine sulfat - for chonic pain
  • Opioid agonist: bind APAP to opioid receptors
  • Schedule II
  • Percodan has aspirin instead of APAP
  • cose $100 for 30 tabs
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14
Q

Tramadol (ultram) MOI? combo?

A
  • APAP combo called Ultracet
  • MOA unknown, binds to opioid receptors and inhibits NE/serotonin reuptake: caution w/ seizure hx and cause cause serotonin syndrome
  • schedule IV
  • cost: 30 tabs for $60
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15
Q

Hydromorphone MOA, Schedule?

A
  • Dilaudid
  • MOA - opioid agonist
  • high abuse potential and highly sedative
  • taper dose to D/C
  • schedule II
  • cost 20 tabs/$30
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16
Q

Meperidine MOA, caution, schedule?

A
  • Demerol
  • opioid agonist
  • very sedative
  • seizure risk over time and dose
  • oral route least effective
  • avoid abrupt cessation
  • Schedule II
  • 20 tabs for $30
  • often causes N/V so give Phenergan
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17
Q

Use of Fentanyl? Schedule?

A
  • Duragesic
  • for chronic pain
  • for opioid tolerant pts only
  • major abuse potential
  • need responsible pts and/or caregiver to administer
  • schedule II
  • cost $100 for 5 patches, 1 patch= 3 days dose
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18
Q

Use of NSAIDs in ortho

A
  • anti-inflammatory
  • caution w/ concomitant anticoagulation
  • some studies have suggested NSAIDs may slow down fracture healing
  • all have warnings pertaining to CV risk, GI bleeding, kidney risk
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19
Q

Acetic acid group of NSAIDs?

A
  • Diclofenac, Etodolac, Indomethacin, Ketorolac
  • thought to inhibit cox, reducing prostaglandin and thromboxane synthesis
  • usually fairly cheap and this class is effective for management of arthritis assoc pain (rheum., osteo, ankylosing spondylitis)
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20
Q

Propionic acid groups of NSAIDs?

A
  • Naproxen, Ibuprofen
  • MC OTC grouping
  • still has BBWs
  • Cox 1 and Cox 2 inhibitor, mess w/ prostaglandins
  • can cause GI issues, kidney issues
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21
Q

Cox 2 inhibitor group of NSAIDs?

A
  • Celebrex
  • many ortho surgeons use in adjunct w/ narcotics following total jt
  • may not interfere w/ anticoag as bad as others, or delay fx repair
  • CI in person w/ sulfa alelrgy
  • less of GI profile
22
Q

Diff steroid formulations?

A
  • oral: medrol dose pack
    rheum: longer duration, mostly use prednisone, need to taper
  • injectable:
    Triamcinalone-kenalog
    celestone-betamethasone
    depo-medrol-methylprednisolone
23
Q

Why are oral muscle relaxants used?

A
  • aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone and involuntary movement w/o loss of voluntary motor fxn or consciousness
  • alters the balance of synaptic excitation and inhibition the motor neuron receives
  • primarily to elicit varying degrees of skeletal muscle relaxation
24
Q

Indications for muscle relaxants?

A
  • for relief of acute painful MSK conditions of local origin
  • as an adjunct to rest and PT
  • for the relief of acute painful MSK conditions which include muscle spasm secondary to trauma, radiculopathy, MSK strain or sprain, herniated intervertebral disc and muscle spasm of OA
25
Q

Muscle relaxants are all ____ depressants?

A
  • CNS depressants
    so caution w/ elderly
  • all are well absorbed orally w/ quick effects
26
Q

Caution use of muscle relaxants w/?

A
  • renal and hepatic insufficiency
  • leukopenia, thrombocytopenia, hemolytic anemia, bleeding agranulocytosis w/ long term use primarily so no initial or F/u labs unless sxs occur
  • freq. used w/ EToH or opioids for abusive purposes
  • can have withdrawl from muscle relaxants
  • taper off to avoid withdrawls
27
Q

When should muscle relaxants not be used?

A
  • in pregnancy
  • in kids
  • shouldn’t be mixed w/ EToH or other CNS depressants, this will potentiate effects
  • should only be taken 10-14 days optimally, must revaluate need
28
Q

Guidelines for muscle relaxants use?

A
  • combo muscle relaxant and analgesic agent appear to be preferred
  • most effective therapy should consider drugs in conjunction w/ various modes of PT
  • all agents have potential to cause drowsiness, HA, dizziness, and blurred vision, dry mouth
  • pts shouldn’t be tx for protracted periods:
    initial: 10-14 days
    eval after to determine need for further therapy
  • NSAIDs may be useful where pain predominates
  • for pts w/ anxiety in whom sedation is desireable - Diazepam (valium) should be considered
  • combo muscle relaxant and analgesics are available, equally effective and less costly: norgesic (asa/caffeine/orphenadrine)
29
Q

What is Carisoprodol (Soma)?

MOA?

A
  • centrally acting skeletal muscle relaxant that doesn’t directly relax tense skeletal muscles
  • MOA: relieving acute muscle spasm of local origin has not been clearly ID, but may be related to its sedative properties
  • in animals: been shown to produce muscle relaxation by blocking interneuronal activity and depressing transmission of polysynaptic neurons in spinal cord and in descending reticular formation of the brain
  • one of products of metabolism, meprobamate, is active as an anxiolytic. Its contributing efficacy is unknown
30
Q

Adverse effects of Carisoprodol (soma)?

A
  • shouldn’t be used for periods longer than 10-14 days, eval need for further tx
  • Adverse effects:
    drowsiness, dizziness
    vertigo, ataxia
    N/V
    hiccups
    epigastric distress
    tremor, agitation
    HA, insomnia
    tachycardia
    postural hypotension
    facial flushing
31
Q

CIs to Soma? Precautions?

A

CI:
- porphyria: inherited porphobilinogen deaminase mutation -
abdominal and urinary sxs, periph. neuropathy, systemic and CNS involvement

precautions:
seizures

32
Q

MOA of cyclobebenzaprine (flexeril)?

A
  • structurally similar to TCAS
  • relieves skeletal muscle spasm of local origin w/o interfering w/ muscle fxn:
    onset of action: 1 hr, effects last up to 12 hours, has an anticholinergic effect
  • shouldn’t be used for periods longer than 10-14 days, eval needed for further tx
33
Q

CIs, adverse effects of Flexeril?

A

CI:

  • w/ concurrent use of MAOIs
  • acute phase of MI
  • arrhythmias
  • heart block

MC adverse effects:

  • drowsiness**
  • dry mouth
  • fatigue
  • HA

less common adverse effects:

  • constipation
  • abdominal pain
  • acid regurg
  • dizziness
  • nausea
34
Q

Use of diazepam (valium) as muscle relaxant?

A
  • used as centrally acting skeletal muscle relaxant
  • diazepam depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition med by GABA
  • among benzos, diazepam is only agent in this class to be approved for tx of muscle spasm or MSK disorders
35
Q

Use of methocarbamol (robaxin)?

A
  • MOA hasn’t been established, may be due to CNS depression
  • has no direct action on contractile mechanism of striated muscle, the motor end plate or nerve fiber
  • less sedating than some other muscle relaxants
  • rx to pts w/ dizziness, risk of falling - can dial down dose as well
  • start w/ 6 gms/day for first 48-72 hrs and then can reduce down to 4 grams/day
  • should not be used longer than 10-14 days: eval need for further tx
36
Q

Other muscle relaxants used?

A
  • Metaxalone (skelaxin)
  • Tizanidine (Zanaflex): indicated for more chronic pain in conjuction w/ other meds
  • baclofen (Lioresal): for spinal cord injuries
37
Q

How can ortho pain be managed?

A
  • NSAIDs
  • muscle relaxants
  • narcotics
  • steroids
  • TCAs
  • GABA analog: gabapentin, valproic acid
  • OTC: glucosamine, Omega 3s
  • ice/heat
  • stretches/exercises
  • PT/OT
  • plain films then MRI
  • osteopathic manipulation/chiropractor
  • behavioral health for chronic pain
  • biofeedback/hypnosis/anti-inflam diet
  • splinting/bracing/immobilization
38
Q

Tx of Grade I ankle sprain?

A
  • most likely inversion injury w/ immediate pain and then some swelling
  • no sig past hx
  • consider:
    NSAIDs - ibuprofen 800 mg 1 po tid-qid
    or
    Naproxen 250mg 1-2po bid
39
Q

Tx of Grade 2-3 ankle sprain?

A
  • NSAIDs - ibuprofen, naproxen, indocin 25mg 1 po tid
  • at noc: vicodin #10 1-2 po q noc prn pain
  • Percocet probably little too strong but can be considered
40
Q

SEs of vicodin?

A 
- 5mg/325mg
SEs:
- constipation
- shallow breathing, slow heartbeat
- feeling light headed, fainting
- confusion, fear, unusual thoughts or behavior
- seizure 
- problems w/ urination
- nausea, upper stomach pain, itching, loss of appetite, dark urine, clay colored stools, jaundice
- diversion is a real problem!
41
Q

Pt was lifting heavy object when he had sudden sharp, non radiating LBP. No bowel, bladder fever or saddle parasthesia

  • DTRs 2+ BL, neg SLR, no CVA tenderness
  • what would you do for this pt?
A
  • Start NSAID: ibuprofen for 3-5 days then prn
    or
    naproxen
  • start a muscle relaxer: Robaxin 500 mg 1-2 po qid x 3 days then prn (Can combine w/ NSAID)
42
Q

What is fibromyalgia? Rfs?

A
  • widespread msk pain accompanied by fatigue, sleep, memory and mood issues
  • researchers believe fibromyalgia amplifies painful sensations
  • cause is unknown
  • RFs:
    genetics, rheum diseases, physical or emotional trauma
43
Q

Meds for fibromyalgia?

A
  • pain relievers
  • antidepressants
  • anti-seizure drugs
44
Q

Pain relievers used for fibromyalgia?

A
  • OTC meds
  • tylenol
  • ibuprofen
  • naproxen
  • tramadol
  • narcotics not advised
45
Q

Antidepressants used to tx fibromyalgia?

A
  • Amitriptyline: initial dose 10mg qhs (can icnrease to 150mg)
  • duloxetine (cymbalta): 30 mg qdx 1 wk then increase to 60 mg qd as tolerated
  • upon d/c of antidepressant therapy, gradually taper the dose
  • an alt to amitriptyline is Flexeril - immediate release initial dose is 5 mg, may increase up to 10 mg tid prn - doesn’t tx depression
46
Q

Anticonvulsants used to tx fibromyalgia?

A
  • Gabapentin: 300 mg starting dose

- pregabalin: 75 mg starting dose

47
Q

Combo tx for fibromyalgia?

A
  • use if unresponsive to monotherapy
  • get psych, PT involved
  • directed at reducing major sxs:
    chronic widespread pain, fatigue, insomnia, cognitive dysfxn
48
Q

What is reflex sympathetic dystrophy?

A
  • disorder of body region: usually extremites
  • characterized by severe pain, swelling, limited ROM, and skin changes
  • inciting event:
    soft tissue injury in 40%
    fxs in 25%
    MI 12%
    Cerebrovascular accidents 3%
49
Q

Meds for reflex sympathetic dystrophy?

A
  • topical tx: capsaicin cream
  • glucocorticoids: prednisone 30-80mg/day may be effective
  • NSAIDs: motrin or naproxen
  • sympathetic blockers: propranolol
  • alpha 1 adrenoceptor antagonist: Terazosin, prazosin
  • opioids: for severe pain
50
Q

How do you ID drug seeking behavior?

A
  • distinguish medical use from abuse, monitor response to tx
  • know medical and nonmedical use
  • characteristics:
    request for early refills
    multisourcing
    intoxicated behaviors
    pressuring behaviors

Ortho (24 decks)

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