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High weighted topic ~ NS > Pain ~ Neuropathic, chronic, headaches, > Flashcards

Pain ~ Neuropathic, chronic, headaches, Flashcards

1
Q

Types of pain

A
  1. Nociceptive
  2. Neuropathic
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2
Q

Nociceptive pain

A

~ Musculoskeletal; non-opioidsm NSAIDs
~ Dental: route cause? NSAIDs
~ Moderate-severe visceral: opioids
~ period: contraceptives, antispasmodics, non-opioids
~ palliative care

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3
Q

Neuropathic pain

A

~ TCA; Amitriptyline, Nortriptyline
~ Anti-epileptics: gabapentin, pregablin
~ nerve compression by tumours = dexamethasone

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4
Q

WHOs pain ladder

A
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5
Q

Non-opioid analgesia

A

~ paracetamol
~ NSAIDs
~ Aspirin
~ Nefopam

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6
Q

Paracetamol uses

A

Mild-moderate pain/fever (NO inflammatory action)
~ preferred in elderly (As does not cause gastric irritation like aspirin, NSAIDs)

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7
Q

Paracetamol adult dose

A

0.5-1g every 4-6hours as required. MAX 4g per day

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8
Q

paracetamol overdose

A

= liver damage (higher risk of hepatotoxicity if <50kg)
~ tx = acetylcysteine

symptoms =
N, V, right subcostal pain/tenderness

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9
Q

aspirin uses & dose

A

~ antiplatelet
– medical emergencies: ACS, TIA/Stroke
300mg stat
– secondary prevention of thrombotic event
75mg OD for life

~ NSIADs
–fever / pain e.g. headache, musculoskeletal, dysmenorrhoea
300-900mg every 4-6hours as required . MAX 4g per day

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10
Q

aspirin cautionary / advisory label warning

A

“Take with food or just after food or a meal”

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11
Q

Aspirin SEs

A
  1. Gastric irritation : use enteric coated (but avoid this in medical emergencies)
  2. Tinnitus (high doses)
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12
Q

Aspirin contra-indications

A

~ <16 years old, Reyes syndrome (exception in Kawasaki disease / antiplatelet)
~ Salicylates or NSAID hypersensitivity
e.g. bronchospasms, asthma attacks, rhinitis, urticaria, angioedema

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13
Q

Aspirin interactions

A

~ increased risk of bleeding
.. antiplatelets or anti-coagulants e.g. warfarin

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14
Q

weak opioids e.g.

A

~ codeine (CD5, injection = CD2)
~ Dihydrocodeine (CD5)

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15
Q

Opioid analgesic MOA

A

act on opioid receptors in brain, spinal cord, other nervous tissues to relive pain

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16
Q

Mdderate opioid e.g.

A

Tramadol (CD3, exempt from safe custody)

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17
Q

Strong opioids e.g.

A

~ Morphine (CD2, but oral 10/5mg = CD5)
~ Oxycodone (CD2)
~ Diamorphine (CD2, IV, aka Heroin)
~ Buprenorphine (CD3 = S/L or 3/4/7 patch)
~ Fentanyl (CD2, 72h transdermal patch, injection in intra-operative analgesia)
~ Methadone (CD2)

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18
Q

Other opioids e.g.

A

~ Alfentanil (CD2)
~ Remifentanil (CD2)
~ Pethidine (CD2, overaccumulation = convulsions)
~ Dipipanone (CD2, comes with anti-emetic only)
~ Papaveretum (CD2, partial agonist )
~ Pentazocine (CD3)

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19
Q

Breakthrough pain
~ recuse doses
~ rescue preparation

A

~ recuse doses (1/10th or 1/6th of total daily dose of strong opioid, every2-4 hours as required)
~ rescue preparation (immediate release e.g. oral morphine solution, oxycodone solution)

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20
Q

Opioid overdose

A

symptoms = coma, pinpoint pupils, respiratory depression
Naloxone = antidote, opioid receptor antagonist
~~~ reverses respiratory depression
~~~ can be supplied w/o prescription

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21
Q

Opioid SEs

A

~ dry mouth
~ N, V (morphine)
~ Constipation (opioid induced, give senna + lactulose)
~ Sedation (warn in driving/alcohol)
~ reduced concentration / confusion
~ euphoria (morphine) & hallucinations
~ dependence & tolerance
~ respiratory depression

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22
Q

tolerance

A

higher doses needed to achieve same level analgesia

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23
Q

physical dependence

A

apparent on withdrawal reactions, avoid abrupt withdrawal after long-term tx

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24
Q

long term opioid uses leads to

A

~ hypogonadism (reduced fertility, amenorrhoea, erectile dysfunction)
~ adrenal insufficiency
~ hyperalgesia

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25
Opioid SE mnemonics
MORPHINE M = miosis (pinpoint pupils, muscle rigidity) O = out of it (sedation) R = respiratory depression P = postural hypotension H = Hyperalgesia, hallucination I = Infrequency (urinary retention, constipation) N = Nausea/Vomiting E = Euphoria
26
Opioid contra-indcations
~ Comatose patient (as opioids cause neurological depression and sedation) ~ risk of paralytic ileus (opioids reduce GI motility, caution in IBD) ~ respiratory depression (opioids reduce respiratory drive, avoid in asthma/COPD) ~ head injury or raised intra-cranial pressure (opioids interfere with pupillary responses)
27
Opioid interactions
~ increased sedation -- antidepressants, antihistamines, alcohol, Z-drugs, antipsychotics, anti-epileptics, benzodiazepines (also cause respiratory depression) ~ possible CNS excitation or depression --- hypertension or hypotension, MAOIs
28
Oral route opioids
~ MORPHINE (also use in coughs in palliative care) ~ choice for severe pain in palliative care ~ causes most euphoria, N, V ~ dose = every 4h (immediate release), or 12hourly / 24hourly MR preparations) ~ max dose increments = 1/3 or 1/2 of total daily dose per 24h ~ equivalent parenteral dose (SC, IV, IM) = 1/2 oral dose
29
parenteral route opioid
DIAMORPHINE (heroin) ~ preferred over morphine as IV ~ is more soluble & smaller volumes can be injected in palliative care ~ equivalent dose of diamorphine = 1/3 of oral morphine dose ~ less N. hypotension SEs
30
Table of equivalent doses of opioid analgesia
31
Transdermal route BUPRENORPHINE
long-acting ~ 72h, 96h, or 7 day patch ~ partial agonost = precipitates withdrawal symptoms ~ effects only partially reversed by naloxone ~ available as S/L e.g. subutex
32
Transdermal route FENTANYL
~ long acting ~ 72h patch ~ risk of respiratory depression in opioid-naiive pt, only use IF opioid-tolerant counsel = remove patch immediately if breathing difficulties, drowsiness, confusion, impaired speech ~ switching due to hyperalgesia = reduce dose of new opioid by 1/4 or 1/2
33
oral morphine to transdermal patch (fentanyl) equivalence table
34
oral morphine to transdermal patch (buprenorphine) equivalence table
35
Codeine uses
~ mild-moderate pain; 30-60mg every 4h ~ codeine linctus in dry or painful cough (POM now) ~ acute diarrhoea
36
Codeine MHRA warning
~ for acute moderate pain in children >12 only if other painkillers not working (paracetamol/ibuprofen) ~ children 12-18 = 240mg MAX daily for 3 days,
37
codeine contra-indications
~ ultra-rapid metabolisers (as codeine is metabolised to morphine) ~ children <18 undergoing tx for OSA or tonsil removal ~ children <12
38
codeine and breast-feeding
~ NO , as it passes in milk
39
codeine counselling
~ know signs and symptoms of morphine toxicity ~ stop and seek medical attention, reduced consciousness, lack of appetite, constipation, pinpoint pupils, N, V, respiratory depression
40
Codeine route of admin.
NEVER give IV as severe reaction similar to anaphylaxis
41
Tramadol drug action
moderate opioid ~ affects NA, 5-HT reuptake inhibitor
42
tramadol side effects
~ increased risk of bleeding ~ lowers seizure threshold ~ psychiatric reactions
43
tramadol interactions
~ lowers seizure threshold --- SSRI, TCA, Anti-epileptics ~ increased serotonergic effects; serotonin syndrome risk --- SSRI, TCA, 5-HT agonists, MAOIs ~ increased bleed risk --- warfarin
44
Migraine
moderate / severe headache felt as throbbing pain 1 side of head
45
MIGRAINE SYMPTOMS
~ intense throbbing headache on 1 side of head ~ N, V ~ sensitivity to light or sound AURA (temporary warning symptoms before migraine) ~ visual disturbances ~ numbness / pins/ needles ~ dizzy ~ difficulty speaking
46
Migraine tx
~ 5HT agonists "triptans" ~ ergot alkaloids (rare use) ~ NSAIDs
47
5HT agonists in migraine tx
"triptan" ~ sumatriptan, Zolmitriptan
48
ergot alkaloids in migraine tx
ergotamine ~ no repeat less than 4 days, limited use to x2 a month to avoid habituation
49
NSAIDs in migraine tx
Tolfenamic acid (licensed for acute migraine attack)
50
Prophylaxis of migraine
~ Beta-blockers (propranolol, atenolol, metoprolol, timolol) ~ anti-epileptics (topiramate, sodium valproate, gabapentin) ~ TCAs ~ Pizotifen (antihistamine 5HT antagonist, weight gain SE)
51
Acute migraine attacks management
1st line = simple analgesia 2nd line - 5HT agonists "triptans" 3rd line = ergot alkaloids 4th line = antiemetics (meto or domperidone) - prokinetic
52
when do you need prophylaxis of migraine
~ suffer at least 2 attacks a month ~ frequent headaches ~ significant disability despite tx ~ not able to take suitable tx for migraine attack
53
5HT agonists MOA
act on 5HT-1D, 5HT-1B on cranial arteries & veins = vasoconstriction
54
5HT agonists use / dose
use = tx acute migraine dose ~ take 1 ASAP after onset, then 2nd dose at least 2h later (4h if naratriptan) NOT TAKE 2ND DOSE FOR SAME ATTACK
55
5HT agonists SEs
coronary vasoconstriction or anaphylaxis
56
5HT agonists contra-indications~
~ IHD ~ MI hx ~ Vasospams ~ Angina ~ HTN ~ Vascular disease ~ STROKE/TIA ~ Hemiplegic, basilar or ophthalmoplegic migraines
57
5HT agonists counsel
stop if intense tingling, heat, heaviness, pressure or tightness in any part of body
58
Neuropathic pain management classess
1. TCAs (amitriptyline/nortriptyline) 2. Anti-epileptics (gabapentin, pregabalin) 3. Opioids (morphine/oxycodone/tramadol)
59
tx for compression neuropathy
corticosteroid
60
Trigeminal neuralgia
~ sudden & severe facial pain like electric shocks in jaw, teeth or gums ~ short unpredictable attacks ~ tx = carbamazepine or Phenytoin
61
localised pain tx
~ topical local anaesthetic ~ capsaicin cream

High weighted topic ~ NS (28 decks)

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