Unit 3 - Musculoskeletal/Neuro Flashcards
The WHO ladder for assessing pain:
First Step – Mild pain: Non-opioid analgesics such as (NSAIDs) or acetaminophen are administered with/without adjuvants
Second Step – Moderate pain: Weak opioids (hydrocodone, codeine, tramadol) with/ without non-opioid analgesics and with/without adjuvants
Third Step – Severe and/or persistent pain: Potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, hydromorphone, oxymorphone) are administered with/without non-opioid analgesics, and with/without adjuvants
Adjuvants
Drugs that have a different primary purpose than pain, but can help with pain secondarily, like gabapentin
Acetaminophen
MOA: inhibit prostaglandins
Considerations: 1. Safe for all ages.
2. Caution with alcohol use and with pregnant/breast-feeding patients.
3. Can increase the risk of bleeding with anticoagulants.
4. Should be taken with food & water or milk.
Side effects/rare adverse effects: hypertension, allergic reactions, hepatotoxicity (yellowing of the eyes or skin indicates it), bleeding disorders if taken with anticoagulants
Aspirin
MOA: inhibits prostaglandins and is anti-inflammatory; additionally decreases platelet aggregation.
Considerations:
1. Not safe for children / limited use for anyone under 18 years old, because of Reye’s syndrome.
2. Okay for pregnant/breastfeeding women.
3. Should not be given to anyone with a bleeding disorder.
4. Should be taken with food & water.
Side effects: GI upset.
Adverse effects: renal/hepatic impairment, bleeding disorders, salicylate poisoning (can be an emergency situation - tinnitus, fevers, respiratory & metabolic acidosis).
NSAIDs
MOA: inhibits prostaglandins and COX (COX 1 & COX 2) enzymes, and has analgesic effects.
Considerations: 1. safe for anyone 6 months and older.
2. We don’t like pregnant or breastfeeding women to use them.
3. Take with food and a full glass of water.
Side effects: GI upset and/or bleeding, rashes (Steven Johnson’s Syndrome);
Adverse effects: all NSAIDs increase the risk of cardiovascular events like heart attack and stroke, mostly if you take more than indicated.
2nd-Gen NSAIDs
only COX2 inhibitors, so they cause less stomach upsets. Examples: Celebrex.
Side effects: These can cause renal impairment and cardiovascular events (just like 1st gen NSAIDs).
Corticosteroids
(like prednisone) - MOA: adjuvants. Suppress the immune system to decrease inflammation.
Considerations:
1. Important to never discontinue use abruptly.
2. Monitor electrolyte and blood sugar levels.
3. Don’t take with alcohol or other NSAIDs.
Side effects: skin changes (poor wound healing, bruising), hyperglycemia, hypokalemia, cardiovascular events, weight gain, mood swings, Cushing’s or Addison’s, osteoporosis and fractures, immunosuppression.
Sumatriptan (rep of Triptan class)
MOA: Help with migraine pain by binding to 5HT receptors on CNS blood vessels, causing them to narrow. This reduces the inflammation and pain associated with migraines.
Considerations:
1. May be contraindicated in patients with cardiac issues (they can get angina).
Side effects: Dizziness, vertigo, GI upset.
Morphine & Fentanyl
MOA: binds to opioid receptors in the CNS and alters the perception of/response to painful stimuli; additionally it depresses CNS.
Considerations:
1. safe for all ages.
2. use cautiously in clients with hepatic/renal impairment
3. do NOT use in anyone with a GI obstruction.
4. Do not use in people with COPD or breathing issues.
5. Don’t take with alcohol or other NSAIDs (other CNS depressants) (very dangerous!) 6. Black Box Warning: is for the risk of respiratory depression and for the risk of addiction being high.
Side/adverse effects: respiratory depression, hypOtension, dizziness, sedation, constipation/GI upset, sweating.
Naloxone
The overdose med we all know and love. Can be given IM, subcut, or via nasal spray.
MOA - This blocks the same receptors that the opioids use to stop the opioid from binding.
Side effects: The return of the symptoms of the opioid was used for - tachycardia, tremors, etc. are all normal to see because of the rapid reversal.
Midazolam (Versed)
Class: benzodiazepine
MOA: Depresses CNS for conscious sedation by promoting the binding of GABA (GABA agonist).
Considerations:
1. Pretty safe for all ages.
2. Very important not to take with any other CNS depressants (alcohol included).
3. It can cause muscle rigidity so you push it slowly through IV.
Side/adverse effects: respiratory depression or disruption, confusion, cardiac dysrhythmias or hypertension.
Antigout (allopurinol)
MOA: anti-inflammatory effects by blocking the production of uric acid thus inhibiting the action of xanthine oxidase.
Considerations: 1. It’s safe for all ages. 2. Watch for anyone with renal impairment. 3. No alcohol when on it. 4. Should increase water intake by a lot to prevent the formation of kidney stones.
Side/adverse effects: GI upset, hypOtension. Rashes. Blood in urine.
Baclofen
Class: muscle relaxant
MOA: Inhibits reflexes at the spinal level. Used for things like spasms or spinal cord injuries. Another GABA agonist (promotes binding of GABA).
Considerations:
1. Safe for anyone over age 12.
2. Can be given intrathecally in the spine through a pump!
3. Abrupt drug withdrawal CANNOT happen - you have to taper them (can cause hallucinations and seizures if stopped abruptly).
Side effects: Weakness, nausea, vomiting, headaches, drowsiness. Hypertension and constipation.
Cyclobenzaprine
Class: muscle relaxant.
MOA: Reduces somatic muscle activity at the level of the brainstem. This reduces pain and acute muscle spasms.
Considerations:
1. Cautious use in an elderly patient (on the BEERS list) or someone with hepatic impairment.
2. Don’t use it on anyone with urinary retention or glaucoma.
3. Don’t use in patients with hepatic impairment.
4. It can be problematic to take with any other CNS depressants (alcohol, MAOIs, benadryl, etc.).
Side effects: Dizziness, drowsiness, dry mouth, urinary intention.
Adverse effects: orthostatic hypertension, hepatic toxicity (pale stools, yellowing eyes), serotonin syndrome (confusion, agitation, diaphoresis, tachycardia).
Gabapentin
MOA: anticonvulsant, but also adjuvant (for any nerve pain).
Considerations:
1. Start at a low dose and go higher.
2. CANNOT be stopped abruptly.
3. There is no treatment for overdose on this one.
Side effects: dizziness, drowsiness, lethargy, GI upset.
Lidocaine
MOA: blocks sodium channels which prevents transmission of nerve signals -> numbing the skin as a result.
Routes: patches, creams, injection.
Considerations:
1. Wear gloves and wash hands when administering so your hands don’t go numb. 2. Use as minimal as possible to minimize the risk of systemic effects.
Side effects: bruising, pain, or itching/flushing (allergic reaction) at the site. Adverse effects if you’re using a LOT and it gets systemic: changes in heart rate and blood pressure, fainting.
Lidocaine w/ epinephrine
The same as regular lidocaine, except the epi will vasoconstrict blood vessels in that area, so do not use it in areas of poor circulation (ear, nose, fingers, toes). It can be used on the cheeks, or the top of feet or hands.
General anesthetics
Cause reversible unconsciousness. Important to watch for airways and breathing while patients are “under”.
How do you treat an acetaminophen overdose?
Acetylcysteine.
What side effect do we look out for specifically in ibuprofen?
ibuprofen has been known to cause severe allergic reactions.
Would it be a good idea to give morphine or midazolam to a COPD patient?
No, because of the risk for respiratory depression.
What other uses does lidocaine have besides numbing?
It can be used as a cardiovascular medication.
