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MD2 Foundation > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Why should we treat pain?

A

Avoid physiological effects of untreated pain
- Sympathetic response
- Reduced function
- Poor mobility
- Ineffective cough
Avoid psychological effects of untreated pain
Humane thing to do

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2
Q

What is acute pain?

A

Pain of recent onset and probable limited duration

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3
Q

What is chronic pain?

A

Pain persisting beyond healing of injury
Often no identifiable cause
Lasting for >3 months

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4
Q

What is nociceptive pain?

A

Obvious tissue injury/illness
Physiological
Protective function

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5
Q

What are the different types of nociceptive pain?

A

Superficial somatic
Deep somatic
Visceral

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6
Q

What is neuropathic pain?

A 
Nervous system damage/abnormality
Pathological
Doesn't have protective function
Tissue injury not obvious
Not well localised
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7
Q

What are the positive features of neuropathic pain?

A

Allodynia

Hyperalgesia

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8
Q

What are the negative features of neuropathic pain?

A

Hypoesthesia

Numbness

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9
Q

What happens in the periphery to first cause pain?

A

Tissue injury > release of chemicals > stimulation of nociceptors > signal travels in A-delta/C fibres to spinal cord

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10
Q

What happens to pain information in the spinal cord?

A

Dorsal horn 1st synapse - site of decussation

2nd nerve travels up spinal cord

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11
Q

What happens to pain information in the brain?

A 
Thalamus = 2nd synapse
Connections to many parts of brain
- Cortex
- Limbic system
- Brainstem
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12
Q

Where does pain perception occur?

A

Cortex

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13
Q

What does pain modulation involve?

A

Descending pathway from brain to dorsal horn

Usually decreases pain signal

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14
Q

What is the mechanism of action of paracetamol?

A

Unclear but acts in CNS
Inhibits peripheral prostaglandin synthesis
Analgesic and antipyretic

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15
Q

What are the indications for paracetamol?

A

Analgesia alone/in combination

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16
Q

What are the adverse effects of paracetamol?

A

Hepatic necrosis in overdose

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17
Q

What are the interactions of paracetamol with other analgesics?

A

Additive with NSAIDs

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18
Q

What is the mechanism of action of NSAIDs?

A

Non-specific inhibition of COX-1 and -2 > inhibits prostaglandin synthesis
Analgesic, antipyretic, and anti-inflammatory

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19
Q

What are the indications for NSAIDs?

A

Analgesia alone/in combination

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20
Q

What are the adverse effects of NSAIDs?

A 
Peptic ulceration
Renal impairment
Anti-platelet action
Bronchospasm in asthma
Exacerbation of CCF
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21
Q

What are the interactions of NSAIDs with other analgesics?

A

Reduce opioid requirements by 20-40%

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22
Q

What is the mechanism of action of opioids?

A 
Mu opioid receptors to produce analgesia
Sites of action
- Peripheral nociceptors
- Dorsal horn
- Cerebral cortex
- Descending tracts
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23
Q

What are the indications for opioids?

A

Severe acute pain

Cancer pain

24
Q

What are the adverse effects of opioids?

A 
Sedation
Respiratory depression
Nausea
Euphoria
Miosis
Bradycardia
Postural hypotension
Urinary retention
25
Q

What are the interactions of opioids with other analgesics?

A

Caution with other sedative agents

26
Q

What is the mechanism of action of tramadol?

A

Weak opioid effect

Inhibition of serotonin and noradrenaline reuptake

27
Q

What are the indications for tramadol?

A

Moderate pain

28
Q

What are the adverse effects of tramadol?

A

Hypertension
Nausea and vomiting
Ceiling effect for analgesia
Lowers seizure threshold

29
Q

What are the interactions of tramadol with other analgesics?

A

Risk of serotonin syndrome with other serotonergic agents

30
Q

What are two examples of tricyclic antidepressants?

A

Amitriptyline

Nortriptyline

31
Q

What is the mechanism of action of tricyclic antidepressants?

A

Inhibit reuptake of NA and serotonin into pre-synpatic terminals
Inhibit cholinergic, histaminergic, alpha1-adrenergic, and serotonergic receptors
Increases descending inhibitory signals

32
Q

What are the indications for tricyclic antidepressants?

A

Neuropathic pain
Depression
Poor sleep

33
Q

What are the adverse effects of tricyclic antidepressants?

A

Anti-cholinergic side effects
Postural hypotension
Liver dysfunction
QTc prolongation and arrythmia

34
Q

What other drugs do tricyclic antidepressants interact with?

A

Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Tramadol

35
Q

What should you monitor when a patient is using tricyclic antidepressants?

A

Liver function
ECG
Nortryptiline levels

36
Q

What is the mechanism of action of gabapentin/pregabalin?

A

Exact mechanism unknown
Binds to alpha-2 delta protein subunit of high threshold voltage-dependent Ca channels > reduces Ca influx > reduces neurotransmitter release

37
Q

What are the indications for gabapentin/pregabalin?

A

Focal seizures

Neuropathic pain

38
Q

What are the adverse effects of gabapentin/pregabalin?

A

Sedation

39
Q

What are the drug interactions of gabapentin/pregabalin?

A

Other sedative drugs

40
Q

What should you monitor when a patient is using gabapentin/pregabalin?

A

Reduce dose in renal impairment

Can cause raised bilirubin

41
Q

What is the mechanism of action of ketamine?

A

Antagonises NMDA receptors
Descending monoaminergic pain pathways
Voltage-sensitive Ca channels and opioid receptors in brain and spinal cord

42
Q

What are the indications for ketamine?

A

Anaesthesia

Pain

43
Q

What are the adverse effects of ketamine?

A 
Sedation
Hyper-salivation
Tachycardia
Dysphoria
- Relatively contraindicated in psychiatric patients
44
Q

What are the drug interactions of ketamine?

A

Other sedative drugs

45
Q

What should you monitor when a patient is using ketamine?

A

Dysphoria

46
Q

What is the mechanism of action of clonidine?

A

Alpha-2 adrenoceptor agonist

47
Q

What are the indications for clonidine?

A

Sedation
Analgesia
Antihypertensive
Addiction medicine for opioid withdrawal management

48
Q

What are the adverse effects of clonidine?

A

Sedation
Hypotension
Bradycardia

49
Q

What are the drug interactions with clonidine?

A

Other sedative agents

50
Q

What should you monitor when a patient is using clonidine?

A

Rebound hypertension

Reduce dose in renal impairment

51
Q

What is the gold standard in the measurement of pain?

A

Self reporting

52
Q

What are the non-drug treatments for pain?

A 
RICE
- Rest
- Ice
- Compression
- Elevation of injuries
Nursing care
Physiotherapy
Surgery
Acupuncture
Massage
Psychological
- Explanation and reassurance
- Input from social worker/pastor
- Relaxation
- Coping strategies
53
Q

What are the drug treatments for mild nociceptive pain?

A

Paracetamol +/- NSAID

54
Q

What are the drug treatments for moderate nociceptive pain?

A

Paracetamol +/- NSAID +/- opioids; eg:

  • Codeine
  • Oxycodone
  • Tramadol
55
Q

What are the drug treatments for severe nociceptive pain?

A

Strong opioids/regional anaesthesia + paracetamol +/- NSAID
Adjuvants
- Alpha-2 agonists
- NMDA antagonists

56
Q

What are the drug treatments for neuropathic pain?

A 
Traditional drugs may not be useful, especially NSAIDs and chronic opioids
Use other drugs early
- Amitriptyline
- Carbamazepine
- Gabapentinoids

MD2 Foundation (42 decks)

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