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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
What occurs to LA when entering the circulation
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
26
how does pregnancy impact LA
--
27
Lidocaine across the BBB contributes to what?
CNS Depression Tonic-Clonic convulsions
28
Septocaine
4 % * aka articaine * shortest duration
29
lidocaine
2% * aka xylocaine * safest in children
30
mepivacaine
3% * aka Carbocaine * causes least vasodilation * no epi
31
standard mepivacaine/carbocaine epi
0
32
bupivacaine
0.5% aka Marcaine Longest duration * not safe in children
33
Standard bupivacaine epi
1:200,000 0.009 mg per cartridge
34
what is the maximum cartridges used for health pts vs cardiac pts
---
35
what is the limiting factor for LA in pediatric pts, LA or epi?
LA
36
what is the LA maximum in pediatric patients?
4 mg/Kg Kg=lbs/2.2
37
what are the signs & symptoms of LA toxicity?
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
What are the signs & Symptoms of LA overdose
Signs: * Slurred speech * Excitability * Elevated BP, HR, Respiratory Rate * Sweating * Vomiting Symptoms: * Metalic Taste * Visual Disturbances (inability to focus) * Loss of consciousness
39
What are local complications when delivering LA
Needle breaks Prolonged anesthesia or paresthesia-resolves 8 wks Facial nerve Paralysis Trismus (restricted jaw movement) Soft Tissue Injury Hematoma Burning on injection
40
How can LA get to facial nerve?
to far posterior of IAN block can contribute to facial nerve paralysis
41
what is the most likely adverse run to LA administration?
Fainting
42
What is the solubility of N2O in the blood?
0.47
43
When administering N2O, what should O2 saturation be above?
94%
44
What date do you want to collect for patients before a procedure with N2O?
PMH, PSH, MED-DRUG hx Drug Abuse Vital Signs Respiratory System Assessment
45
After administering N2O, what do you want to monitor?
Level of consciousness-Mental Status Ventilatory Function Oxygen Desaturation-Hypoxemia Pulse Oximetry End Tidal CO2 Pt response to gas response or hypo-response
46
What is the appropriate response to nitrous?
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
what is the maximum N2O Flow
50%
48
What is the technique for nitrous administration
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
What does 5 mins of post-op O2 prevent
diffusion hypoxia
50
What information should you obtain from a patient post N2O
Vital Signs Lethargy Headache, Dizziness, Confusion, Nausea
51
What are potential changes w/N2O administration
Myocardial Depression: Mild Cardiac Output: Unchanged BP: Unchanged Arrthymia potential: None Respiratory Depression: Mild Respiratory Rate: Slightly increased Tidal Volum: Decreased
52
Can we administer N2O to pregnant patients? If so, when?
Can be used in pregnant patient Use after 1st trimester * Consult pt's OBGYN
53
What are relative contraindications for N2O
1st trimester pregnancy Pneumothorax Cystic Fibrosis URI COPD Psychologic impairment
54
What is the universal color for N2O & O2?
N2O=Blue O2: Green
55
What are the advantages of N2O
Smaller volume of gases used less cost Decreased in exhaled N2O Contamination
56
What are the disadvantages of N2O Administration
Fixed Percent increments of N2O=easier to oversedate pt
57
What is the normal variation in vital signs before and after administering N2O
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
Ibuprofen MOA
NSAID * inhibits prostaglandin synthesis * vasodilation-acts on heat regulating center of hypothalamus Produces analgesic and anti-inflammatory effects * decreases fever 30 min onset
59
Ibuprofen: Max dose
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
Where is ibuprofen metabolized?
Liver
61
Ibuprofen: Pregnancy
Category B 3rd trimeter=D
62
Acetaminophen: MOA
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
Where is Acetaminophen metabolized?
Liver
64
Acetaminophen: Pregnancy
Category B
65
Acetaminophen: Max Dose
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
Hydrocodone: MOA
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
Hydrocodone: Pregnant
Category C
68
Hydrocodone: Max Dose
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
What is Norco
Hydrocodone + Acetaminophen 7.5 or 10 mg hydrocodone + 325 mg Tylenol
70
Side effects of opioids
N & V Constipation Sedation Respiratory Depression Addiction
71
Oxycodone: MOA
Opioid Analgesic * Binds opioid receptors in CNS Alters the perception & emotional response to pain
72
Oxycodone: Max Dose
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
What is Percocet
oxycodone 2.5-10 mg Acetaminophen: 325 mg
74
What is the appropriate pain control for dental procedures

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