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BOARDs > PAIN OSCE > Flashcards

PAIN OSCE Flashcards

1
Q

MOA of local anesthetics

A

Blocks Na+ channels
* bind receptors in phospholipid membrane
* Stops transmission of action potential

There are at least 9 Na+ channel binding sites
* heterogeneous structure

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2
Q

How are LA classified

A

Classified by their ability to react w/specific receptor sites in Na+ channel
* 4 sites w/in sodium channel

  1. w/in Na+ channel (tertiary amine local anesthetics)
  2. outer surface of Na+ channel (tetrodotoxin, saxitoxin)
    3-4. Activation or inactivation gates (Scorpion venom)
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3
Q

Characterize Sodium Channels in Neurons

A

Na+ migrates inward bc:
1. concentration (Greater outside)
2. electrostatic gradient positive ion attracted by neg. intracellular potential)

Resting nerve membrane=impermeable to Na+
* prevents massive influx

Na+ travels external to internal=Depolarizing event

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4
Q

What is highly conc around nodes of ranvier?

A

Na+ Channels

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5
Q

Where does LA act?

A

Nodal areas (Nodes of Ranvier)
* blocks depolarization

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6
Q

Can you block one node of ranvier w/local anesthetic to implement action

A

No, must block multiple nodes of ranvier

LA must bathe 8-10 mm of neuron to block

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7
Q

Characterize the resting state of neurons

A

Slightly permeable to Na+
Freely Permeable to K+ & Cl-

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8
Q

What stimuli excite pain receptors? How sensitive are receptors to these stimuli?

A

Mechanical, Thermal, Chemical

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9
Q

Does local anesthetic block more than pain

A

Does not block proprioception
* Pressure, vibration, temperature

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10
Q

What is important regarding local anesthetic application

A

volume
concentration
pH

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11
Q

what can remove LA at the site of LA administration

A

Most is lost at the perineurium
* absorbed by Nutrient blood vessels & lymphatics
* greatest barrier to diffusion

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12
Q

What form of LA penetrates the lipid bilayer of the nerve axon membrane?

A

Base form

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13
Q

Drugs w/what pka have a slower onset

A

High pka=slower onset
pka 7.5-9.0

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14
Q

What is the pH of LA w/o vasoconstrictors

A

pH 5.5-7

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15
Q

Characterize LA pH w/vasoconstrictors

A

LA w/vasoconstrictor are acidified to retard oxidation & prolong shelf life

Sodium Bisulfite
* antioxidant
* increase shelf lie

2% Lidocaine HCL
* pH: 6.8
* acidified to pH 4.2 w/sodium bisulfite
* at pH 4.2 it will take longer for anesthetic to function at full effect

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16
Q

What are the properties of LA

A

Reversibly block nerve conduction
* Must be lipophilic & hydrophilic for effective parenteral injection

Drugs that are not hydrophilic=Topical Drugs

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17
Q

LA w/o hydrophilic component is used for what?

A

Topical

Benzocaine gel

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18
Q

What influences drug removal & how do we modulate it?

A

Factors that remove:
* Increased protein binding
* Vascularity of injection site
* presence or absence of vasoactive substance

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19
Q

What is the max dose of each type of LA

A
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20
Q

What is the typical amount of episodes in a cartridge of LA

A

18 micrograms=.018 mg

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21
Q

What is the typical amount of LA in a cartridge (1%)

A

18 mg

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22
Q

What is the significance of epi in LA

A

20 ug of epi: Doubles pre-op plasma conc.

200 ug of epi surpases
* heavy exercise
* surgery
* pheochromocytoma

Increases cardiac work
* MI & arrhythmias are more likely to occur

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23
Q

do LA have significant systemic effects?

A

Aside from their influence on cardiovascular & CNS fxn
* LA exert few systemic effects

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24
Q

What determines LA toxic Potential

A

The uptake of LA into systemic circulation & removal by redistribution, metabolism & excretion

Drug w/potent vasodilating properties may enhance their own uptake=esters

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25
Q

What occurs to LA when entering the circulation

A

Proteins made in liver (Albumin)
* if liver is not working properly, less will be bound to plasma proteins

entering circulation, LA is partially (5-95%) bound to plasma proteins
* a1-acidglycoprotein
* albumin
* RBCs

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26
Q

how does pregnancy impact LA

A

–

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27
Q

Lidocaine across the BBB contributes to what?

A

CNS Depression
Tonic-Clonic convulsions

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28
Q

Septocaine

A

4 %
* aka articaine
* shortest duration

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29
Q

lidocaine

A

2%
* aka xylocaine
* safest in children

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30
Q

mepivacaine

A

3%
* aka Carbocaine
* causes least vasodilation
* no epi

31
Q

standard mepivacaine/carbocaine epi

A

0

32
Q

bupivacaine

A

0.5%
aka Marcaine

Longest duration
* not safe in children

33
Q

Standard bupivacaine epi

A

1:200,000

0.009 mg per cartridge

34
Q

what is the maximum cartridges used for health pts vs cardiac pts

A
35
Q

what is the limiting factor for LA in pediatric pts, LA or epi?

A

LA

36
Q

what is the LA maximum in pediatric patients?

A

4 mg/Kg

Kg=lbs/2.2

37
Q

what are the signs & symptoms of LA toxicity?

A

Signs:
* Slurred speech
* Shivering
* Muscle Twitching
* Dizziness
* Disorientation

Symptoms:
* Warm, flushed feeling of skin
* Pleasant dream-like state
* Numbness of tongue and entire mouth

38
Q

What are the signs & Symptoms of LA overdose

A

Signs:
* Slurred speech
* Excitability
* Elevated BP, HR, Respiratory Rate
* Sweating
* Vomiting

Symptoms:
* Metalic Taste
* Visual Disturbances (inability to focus)
* Loss of consciousness

39
Q

What are local complications when delivering LA

A

Needle breaks
Prolonged anesthesia or paresthesia-resolves 8 wks
Facial nerve Paralysis
Trismus (restricted jaw movement)
Soft Tissue Injury
Hematoma
Burning on injection

40
Q

How can LA get to facial nerve?

A

to far posterior of IAN block can contribute to facial nerve paralysis

41
Q

what is the most likely adverse run to LA administration?

A

Fainting

42
Q

What is the solubility of N2O in the blood?

A

0.47

43
Q

When administering N2O, what should O2 saturation be above?

A

94%

44
Q

What date do you want to collect for patients before a procedure with N2O?

A

PMH, PSH, MED-DRUG hx
Drug Abuse
Vital Signs
Respiratory System Assessment

45
Q

After administering N2O, what do you want to monitor?

A

Level of consciousness-Mental Status

Ventilatory Function

Oxygen Desaturation-Hypoxemia

Pulse Oximetry

End Tidal CO2

Pt response to gas response or hypo-response

46
Q

What is the appropriate response to nitrous?

A

comfortable/relaxed
reduced fear/anxiety
aware of surroundings
responds to commands

Might experience tingling of extremities &/or mouth, heavy legs/arms, body warms, light feeling,

47
Q

what is the maximum N2O Flow

A

50%

48
Q

What is the technique for nitrous administration

A

Assemble and assess N2O cart, tanks etc
* Check scavenger device fxn

Oxygen Flow: reservoir bag 2/3 full
Secure Nasal Hood & Establish baseline
Titrate Nitrous
Terminate Nitrous-5 min Post op O2 100%
Assess recovery
Discharge pt

49
Q

What does 5 mins of post-op O2 prevent

A

diffusion hypoxia

50
Q

What information should you obtain from a patient post N2O

A

Vital Signs
Lethargy
Headache, Dizziness, Confusion, Nausea

51
Q

What are potential changes w/N2O administration

A

Myocardial Depression: Mild
Cardiac Output: Unchanged
BP: Unchanged
Arrthymia potential: None
Respiratory Depression: Mild
Respiratory Rate: Slightly increased
Tidal Volum: Decreased

52
Q

Can we administer N2O to pregnant patients? If so, when?

A

Can be used in pregnant patient

Use after 1st trimester
* Consult pt’s OBGYN

53
Q

What are relative contraindications for N2O

A

1st trimester pregnancy
Pneumothorax
Cystic Fibrosis
URI
COPD
Psychologic impairment

54
Q

What is the universal color for N2O & O2?

A

N2O=Blue
O2: Green

55
Q

What are the advantages of N2O

A

Smaller volume of gases used

less cost

Decreased in exhaled N2O Contamination

56
Q

What are the disadvantages of N2O Administration

A

Fixed Percent increments of N2O=easier to oversedate pt

57
Q

What is the normal variation in vital signs before and after administering N2O

A

Blood Pressure
* +/- 20 mmHg/10 mmHg from baseline

Heart rate:
* +/- 15 beats/in from baseline
* Same rhythm as baseline

Respirations:
* +/- 3 breaths/min from baseline

58
Q

Ibuprofen MOA

A

NSAID
* inhibits prostaglandin synthesis
* vasodilation-acts on heat regulating center of hypothalamus

Produces analgesic and anti-inflammatory effects
* decreases fever

30 min onset

59
Q

Ibuprofen: Max dose

A

Adults:
* 400-800 mg 3-4 times/day
* Maximum: 3.2 g/day

Children:
* 5-10 mg/kg/dose q6-8h
* Max: 40 mg/kg/day

60
Q

Where is ibuprofen metabolized?

A

Liver

61
Q

Ibuprofen: Pregnancy

A

Category B
3rd trimeter=D

62
Q

Acetaminophen: MOA

A

Central Analgesic

Unknown MOA
* inhibit prostaglandin synthesis in CNS
* Block pain impulses through peripheral action (less)
* Peripheral vasodilation by acting on hypothalamic heat-regulating center

antipyresis (Fever reducer)
Analgesic

15-30 min onset

63
Q

Where is Acetaminophen metabolized?

A

Liver

64
Q

Acetaminophen: Pregnancy

A

Category B

65
Q

Acetaminophen: Max Dose

A

Adults/Elderly:
* 365-650 mg q4-6H or 1 g 3-4x daily
* Maximum: 4g/day

Children:
10-15 mg/kg/dose q4-6h as needed
Max: 5 doses/24 hr

66
Q

Hydrocodone: MOA

A

Blocks pain perception in cerebral cortex
* bind to u &. K opiate receptors at synapse
* results in decreased synaptic chemical transmission throughout CNS

Alters pain perception
Analgesic

67
Q

Hydrocodone: Pregnant

A

Category C

68
Q

Hydrocodone: Max Dose

A

Adults & Children older than 13 or 50Kg +: 60 mg/daily

Elderly: 2.5-5 mg q4-6h

Children: 0.135 mg/kg/dose q4-6h

69
Q

What is Norco

A

Hydrocodone + Acetaminophen

7.5 or 10 mg hydrocodone + 325 mg Tylenol

70
Q

Side effects of opioids

A

N & V
Constipation
Sedation
Respiratory Depression
Addiction

71
Q

Oxycodone: MOA

A

Opioid Analgesic
* Binds opioid receptors in CNS

Alters the perception & emotional response to pain

72
Q

Oxycodone: Max Dose

A

Adults, Elderly:
* initially 5 mg q6h as neeeded
* may increase up to 30 mg q4h
* usual: 10-30 mg q4h as needed

Children:
0.05-0.15 mg/kg/dose 14-6h

73
Q

What is Percocet

A

oxycodone 2.5-10 mg
Acetaminophen: 325 mg

74
Q

What is the appropriate pain control for dental procedures

A

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