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Flashcards in Chapter 10. Interdisciplinary Pain Management Deck (70):
1

763. The second most common cause of pain in the
elderly is
(A) musculoskeletal
(B) cancer
(C) temporal arteritis
(D) postherpetic neuralgia
(E) diabetic neuropathy

763. (B) Many other studies have verified that the
predominant cause of pain in the elderly is, by
far, musculoskeletal. The second most common
source of pain is caused by cancer. Rheumatologic
diseases are, therefore, important to the pain
practitioner because these diseases are usually
amenable to various treatment modalities. Other
types of pain found commonly in the elderly
include herpes zoster, postherpetic neuralgia,
temporal arteritis, polymyalgia rheumatica,
atherosclerotic and diabetic peripheral vascular
disease, cervical spondylosis, trigeminal neuralgia,
sympathetic dystrophies, and neuropathies
from diabetes mellitus, alcohol abuse, and
malnutrition.

2

764. Pain assessment in the elderly is usually more
difficult than in the young because it is often
complicated by
(A) good health status which may confuse
the physician
(B) poor memory
(C) depression, which is only seen in cancer
pain patients
(D) most complains are psychiatric as
opposed to organic
(E) none of the above

764. (B) Pain assessment in the elderly is usually
more difficult than in the young because it is
often complicated by poor health, poor
memory, psychosocial concerns, depression,
denial, and distress. Caution in not attributing
new pain complaints to preexisting disease
processes is mandatory. Most pain complaints
in the elderly are of organic, not psychiatric,
origin. Nonetheless, concomitant depression is
also usually present among the elderly with
chronic, nonmalignant pain.

3

765. Which of the following includes recommendations
by the American Geriatric Society for pain
patients?
(A) Pain and its response to treatment do
not necessarily need to be measured
(B) Nonsteroidal anti-inflammatory drugs
(NSAIDs) are contraindicated in older
patients
(C) Acetaminophen is the drug of choice for
relieving mild to moderate pain
(D) Nonopioid analgesic medications may
be appropriate for some patients with
neuropathic pain and other chronic pain
syndromes
(E) Nonpharmacologic approaches (eg,
patient and caregiver education,
cognitive-behavioral therapy, exercise)
have no role in the management of geriatric
pain

765. (C) Recommendations from the American Geriatric
Society for the management of patients with
pain are
1. Pain should be an important part of each
assessment of older patients; along with
efforts to alleviate the underlying cause,
pain itself should be aggressively treated.
2. Pain and its response to treatment should be
objectively measured, preferably by a validated
pain scale.
3. NSAIDs should be used with caution. In
older patients, NSAIDs have significant side
effects and are the most common cause of
adverse drug reactions.
4. Acetaminophen is the drug of choice for
relieving mild to moderate musculoskeletal
pain.
5. Opioid analgesic drugs are effective for
relieving moderate to severe pain.
6. Nonopioid analgesic medications may be
appropriate for some patients with neuropathic
pain and other chronic pain syndromes.
7. Nonpharmacologic approaches (eg, patient
and caregiver education, cognitive-behavioral
therapy, exercise), used alone or in combination
with appropriate pharmacologic strategies,
should be an integral part of care plans
in most cases.
8. Referral to a multidisciplinary painmanagement
center should be considered
when pain-management efforts do not meet
the patients’ needs. Regulatory agencies
should review existing policies to enhance
access to effective opioid analgesic drugs for
older patients in pain.
9. Pain-management education should be
improved at all levels for all health care
professionals.

4

766. The functional pain scale has been standardized
for the older population. Which of the following
includes levels of assessment in this
scale?
(A) Rating pain as tolerable or intolerable
(B) A functional component that adjusts the
score depending on whether a person
can respond verbally
(C) A 0 to 5 scale that allows rapid comparison
with previous pain levels
(D) Only A and C are correct
(E) A, B, and C are correct

766. (E) The functional pain scale, which has been
standardized in an older population for reliability,
validity, and responsiveness, has three
levels of assessment: first, the patient rates the
pain as tolerable or intolerable. Second, a functional
component adjusts the score depending
on whether a person can respond verbally.
Finally, the 0 to 5 scale allows rapid comparison with prior pain levels. Ideally all patients should reach a 0 to 2 level.

5

767. Which of the following is a major concern
regarding antiepileptic agents when used to
treat neuropathic pain in the elderly patient?
(A) Propensity to interfere with vitamin D
metabolism
(B) Need to use higher doses than those
used in the young adult
(C) May disrupt balance
(D) Only A and C are correct
(E) A, B, and C are correct

767. (D) Antiepileptic medications are used to
manage certain painful conditions, including
trigeminal neuralgia. Gabapentin is indicated
for postherpetic neuralgia and may be effective
when administered initially at 100 mg
orally one to three times per day and increased
by 300 mg/d as needed. Clonazepam, phenytoin,
and carbamazepine are other alternatives.
The greatest concern with antiepileptic agents
is their propensity to disrupt balance and to
interfere with vitamin D metabolism.

6

768. Which of the following is true regarding opioid
use in the geriatric patient?
(A) Use of long-acting opioids may facilitate
tolerance and lead to higher opioid
dosage requirements for adequate pain
control
(B) μ-Receptor antagonists are less desirable
in the elderly
(C) Meperidine is an excellent choice alone
or in combination with adjuvant medications
for intractable pain
(D) Moderate to severe pain responds well
to agonists-antagonists agents
(E) The transdermal route of fentanyl
should be used as the first choice in the
elderly, in order to increase compliance
with the treatment

768. (B)
A. Use of short-acting opioids (not long-acting
opioids) may facilitate tolerance and lead
to higher opioid dosage requirements for
adequate pain control.
B. Opioids that are antagonistic to the μ-
receptor are less desirable, given the high
prevalence of unrecognized and untreated
depression in seniors who can benefit from
the euphoric component that occurs with
binding to the μ-receptor.
C. Meperidine has been associated with a host
of adverse events in seniors and should be
avoided either alone or in combination with
a product such as hydroxyzine, which is
anticholinergic and can be associated with
orthostatic hypotension and confusion.
D. There is no role for the geriatric patient for
agonist-antagonists.
E. Transdermal fentanyl patch may be useful
when oral medications cannot be administered
and subcutaneous and intrathecal
routes are too cumbersome. In the older
patient, these patches should be carefully
considered before using as a first-line
agent because age-related changes in body
temperature and subcutaneous fat may
cause fluctuations in absorption.

7

769. Which of the following is true about the elderly
and pain?
(A) Incidence of chronic pain in the
community-dwelling elderly is the same
as in nursing home residents
(B) The prevalence of pain in patients older
than 60 years of age is twice the incidence
of those younger than 60 years of age
(C) The geriatric population in the United
States consumes more than 50% of all
prescription drugs
(D) The elderly often report pain differently
from other patients because of
decreased pain threshold
(E) None of the above

769. (B)
A. Of the community-dwelling elderly, 25% to
50% suffer from chronic pain. Of nursing
home residents, 45% to 80% have chronic
pain.
B. The prevalence of pain is twofold higher in
those older than 60 years (250 per 1000)
compared with those younger than 60 years
(125 per 1000).
C. Older Americans make up approximately
13% of the US population, yet consume
30% of all prescription drugs (including
pain medications) and about 50% of all
over-the-counter medications purchased.
D. The elderly often report pain very differently
from the younger people suffering
from pain and are more stoic, consequently
underreporting their pain.

8

770. When referring to pharmacokinetics in the elderly,
which of the following variables is altered
in the elderly?
(A) Volume of distribution (Vd)
(B) Clearance of drugs (Cl)
(C) Elimination half-life (t1/2 β)
(D) Receptor binding affinity
(E) All of the above

770. (E)
A. Vd is a function of drug protein binding
and its lipid solubility. Vd is altered significantly
in the elderly, in that the lipid content
increases from 14% to 30%, with a
decrease in the lean body mass between
ages 25 and 75 years. As a result of the
increased lipid content in older people,
lipid-soluble drugs (opioids, benzodiazepines,
barbiturates) can therefore have
dramatically altered elimination t1/2 in this
patient population.
B. The clearance of drugs from the body (Cl) is
the rate at which drugs are removed from
the blood (ie, mL/min/m2). This elimination
of drugs usually occurs in the liver and
kidneys, but lungs and other organs may
also contribute. In general, most drugs
undergo somewhat slower biotransformation
and demonstrate prolonged clinical
effects if they require hepatic or renal
degradation.
C. Aging adversely affects the elimination t1/2
of drugs.
D. Receptor-binding affinity is a pharmacodynamic
variable.

9

771. Which of the following is true regarding pharmacodynamics
in the elderly?
(A) Pharmacodynamic changes in the elderly
are closely associated with agerelated
decline in central nervous
system (CNS) function
(B) Decreased sensitivity to benzodiazepines
(C) Increased sensitivity to β-blockers
(D) Decreased sensitivity to opioids
(E) When compared to the young adult,
there are no changes in pharmacodynamics
in the elderly

771. (A) Pharmacodynamic principles describe the
responsiveness of cell receptors at the effector
site. In general, the elderly usually have
increased sensitivity to centrally acting drugs
(ie, benzodiazepines and opioids), whereas the
adrenergic and cholinergic autonomic nervous
systems generally have decreased sensitivity
to receptor-specific drugs (ie, β-blockers). Pharmacodynamic changes in the elderly are
closely associated with age-related decline in
CNS function.

10

772. Which of the following includes factors with
clear associations contributing to poor compliance
in the elderly?
(A) Race
(B) Religious beliefs
(C) Physician-patient communication
(D) Only A and C are correct
(E) A, B, and C are correct

772. (D) The rate of compliance with long-term
medication regimens is approximately 50%
across most age groups. Many reasons have
been cited for this low rate, but the major factor
predicting compliance is because of simply the
total number of different medications taken;
the more the medications, the worse the compliance.
Other factors with clear associations
contributing to poor compliance in the elderly
include race, drug and dosage form, cost, insurance
coverage, and physician-patient communication.
Alternatively, inconsistent findings
regarding compliance and the following factors
have also been noted: age, sex, comorbidity,
socioeconomic status, living arrangement,
number of physician visits, and knowledge,
attitudes, and beliefs about one’s health.

11

773. An 82-year-old male suffers from low back pain
caused by facet arthropathy. His pain has been
well under control with weak opioids for several
years. Over the last year pain has increased in
severity and current pain medications, although
still make him slightly drowsy, do not provide
adequate pain relief. The next step in the management
of this patient’s pain should be
(A) switching to strong opioids
(B) diagnostic lumbar facet blocks
(C) radiofrequency lesions to the lumbar
medial branches
(D) using a combination of two different
weak opioids
(E) intrathecal opioids

773. (B) In the elderly, if weak opioids are not efficacious
in attenuating pain intensity, an
analysis of the risk to benefit ratio would recommend
that therapeutic nerve blocks or lowrisk
neuroablative pain procedures should be
employed prior to strong opioids. For example,
a geriatric patient with severe lower back pain
resulting from facet arthropathy might significantly
benefit from a facet rhizotomy after a
diagnostic nerve block with local anesthetic
proves efficacious. In this case, the risk to benefit
ratio is tilted toward minimally invasive
pain procedures, as opposed to opioid therapy,
since opioid therapy has the potential to impair
both cognitive and functional status in addition
to its many other known side effects.

12

774. Chronic use of NSAIDs in the geriatric patient
should be accompanied by
(A) monitoring liver function test when
appropriate
(B) monitoring renal function
(C) concomitant use of medications such as
misoprostol or histamine-2 (H2)-blockers
(D) occasional testing for occult blood in stool
(E) all of the above

774. (E) Chronic use of NSAIDs in the elderly must
be accompanied by vigilance in monitoring for
the various side effects. This vigilance includes
determining (when appropriate) liver function
tests, hematocrit, renal function, and occult
blood in stool. Long-term use should probably
also include use of misoprostol, which can
reduce the incidence of NSAID-induced
ulcers; empirical data suggest that other drugs
(H2-blockers, sucralfate, antacids, H+ pump
blockers) may have similar effects.

13

775. When opioid therapy is first begun in the geriatric
patient which of the following should be
considered?
(A) It is desirable to use drugs with short
half-life (t1/2)
(B) Close monitoring of side effects should
occur for the first three t1/2 while a therapeutic
blood level is obtained
(C) Meperidine would be a better choice as
an initial opioid than hydromorphone
(D) Methadone is an excellent choice owing
to its t1/2
(E) If pain control with minimal side effects
has been established with a short-acting
opioid, it is never recommended to
switch to a controlled-release formulation
of the opioid

775. (A) When opioid therapy is first begun, it is
desirable to use drugs with short t1/2 so that a
therapeutic blood level of drug can be reached
relatively quickly. It is during this initial trial of
opioids that close monitoring for side effects
must occur, especially during the first six t1/2
while a therapeutic blood level of drug is being
obtained. Consequently, drugs such as hydromorphone
and oxycodone, which have minimal
active metabolites and relatively short t1/2
(ie, 2-3 hours), are more desirable than drugs
with variable t1/2, such as methadone (ie, 12-
190 hours) or meperidine with its accumulation
of metabolites toxic to both the kidneys and
the CNS.

14

776. Which of the following is an important goal
for the elderly patient undergoing physical
therapy for pain management?
(A) Obtaining a gainful employment
(B) Live a more independent life with
enhanced dignity
(C) Improve sleeping pattern
(D) Gain back the physical skills they had as
a young adult
(E) None of the above

776. (B) Rehabilitation is an important treatment
modality for the older patient in pain. By
decreasing pain and improving function, rehabilitation
allows the patient to live a more independent
life with enhanced dignity. This is in
contrast to the rehabilitation goals of persons
younger than 65 years of age in whom the primary
emphasis is on obtaining gainful employment.
Rehabilitation among chronic geriatric
pain patients involves adapting, in an optimal
way, to the loss of physical, psychologic, or
social skills they once possessed prior to complaints
of chronic pain.

15

777. Prior to a chemical neurolysis to be performed
in an 80-year-old male for trigeminal neuralgia,
potential risks must be explained to the patient.
Which of the following is a potential hazard?
(A) Motor weakness
(B) Neuritis
(C) Deafferentation pain
(D) Persistent pain at the site of injection
(E) All of the above

777. (E) Prior to a chemical neurolysis, patients must
have had successful pain relief after a diagnostic
local anesthetic block and no intolerable
side effects. They must also be fully informed
of the risks, benefits, and options available to
them prior to consenting for the procedure.
Many medicolegal issues have resulted from
this technique because of its complications.
Most of these complications result from the
spread of the neurolytic solution to the surrounding
anatomic structures. Frequent side
effects (depending on location) can include persistent
pain at the site of injection, paresthesias,
hyperesthesia, systemic hypotension,
bowel and bladder dysfunction, motor weakness,
deafferentation pain, and neuritis.

16

778. Which of the following best describes the definition
of recurrent abdominal pain in childhood
and adolescence?
(A) Abdominal pain resulting from gastrointestinal
disease occurring on at
least three occasions over a 3-month
period
(B) Abdominal pain resulting from gastrointestinal
disease, gynecologic conditions,
or congenital anomalies, occurring
on at least three occasions over a
3-month period
(C) Abdominal pain with no organic cause
occurring on at least three occasions over
a 3-month period that is severe enough
to alter the child’s normal activity
(D) Abdominal pain with an organic cause,
such as metabolic disease, neurologic
disorders, hematologic disease, gastrointestinal
disease, gynecologic condition,
or other, that occurs at least in three
occasions over a 3-month period
(E) Acute abdominal pain from intestinal,
renal, and gynecologic disorders, which
can be treated surgically

778. (C)
A. and B. The definition of recurrent abdominal
pain in childhood excludes abdominal pain resulting from known medical conditions
such as pain from neurologic disorders,
metabolic disease (diabetes, porphyria,
hyperparathyroidism), hematologic disease
(sickle cell anemia), gastrointestinal disease,
gynecologic conditions, chronic infection,
and pain related to congenital anomalies
C. The definition of recurrent abdominal pain
in childhood and adolescence is pain with
no organic cause occurring on at least three
occasions over a 3-month period that is
severe enough to alter the child’s normal
activity.
D. and E. The definition of recurrent abdominal
pain in childhood excludes abdominal
pain resulting from known medical conditions
such as pain from neurologic disorders,
metabolic disease (diabetes, porphyria,
hyperparathyroidism), hematologic disease
(sickle cell anemia), gastrointestinal disease,
gynecologic conditions, chronic infection,
and pain related to congenital anomalies. It
also excludes acute pain from acute renal,
intestinal, and gynecologic disorders, which
can be treated surgically.

17

779. Which of the following is true regarding
migraine headaches in the pediatric population?
(A) Incidence of migraine is higher in prepubertal
children when compared to
those who have reached puberty
(B) In children with common migraine,
there is unilateral localization of pain
which is mostly preceded by an aura
(C) Classic migraine usually present in children
with an aura, followed by a
bifrontal or bitemporal pain
(D) Most children with common migraine
present with abdominal pain
(E) Ophthalmoplegic migraine is fairly
common in children younger than
4 years of age, and is usually accompanied
by miosis

779. (D)
A. The incidence of migraine is about 3% to
5% of prepubertal children. After puberty,
the incidence of migraine increases notably,
reaching 10% to 20% of children by age
20 years.
B. Common migraine is the type seen in children
before puberty. Most recurrent childhood
migraine is of this type. There is no
aura before the headache and no unilateral
focal localization of the pain. The pain is
usually bifrontal or bitemporal.
C. Classic migraine is different from common
migraine; the former starts with a visual
aura in 30% of children affected and a
sensory, sensorimotor aura, or speech
impairment in 10%. These auras are followed
by severe, throbbing, hemicranial,
well-localized headache.
D. Migraine in children can be defined as
recurrent headache accompanied by three
of the following symptoms:
• Recurrent abdominal pain with or without
nausea or vomiting
• Throbbing pain on one side of the cranium
• Relief of the pain by rest
• A visual, sensory, or motor aura
• A family history of migraine
About 70% of children with common
migraine have abdominal pain.
E. Ophthalmoplegic migraine is rare in children
before 4 to 5 years of age, usually
affects only one eye, and is often accompanied
by mydriasis.

18

780. Which of the following best describes chest
pain during childhood?
(A) Cardiac involvement is extremely rare;
an electrocardiogram (ECG) is indicated
but mainly for reassurance of the parents,
since it will be normal in most cases
(B) It is seen more often in children younger
than 10 years of age
(C) It is more common than abdominal pain
or headaches
(D) Costochondritis ranks second to cardiac
involvement in being the most common
cause of chest pain in this population
(E) Muscle strain is the most common cause
of chest pain in children

780. (A)
A. Identification of the origin of the pain and
reassurance of the patient and family are
often the most important elements of treatment
provided that specific organic causes
have been investigated. Since cardiac
involvement is what worries the child and
family most, it should be stressed that this
cause is extremely rare. An ECG will be
normal and is indicated only to reassure
the parents.
B. and C. Chest pain is relatively common in
children. It ranks third in frequency after
headache and abdominal pain and may be
as common as limb pain. It is seen most
often between 10 and 21 years of age.
D. Costochondritis is the most common cause
of chest pain in children. It often occurs
after an upper respiratory infection, can
radiate to the back, and can last from a few
days to several months. The pain can be
reproduced by palpating the painful area
or by mobilizing the arm or shoulder.
E. Costochondritis is the most common cause
of chest pain in children. Trauma, muscle
strain, chest wall syndrome, rib anomalies,
and hyperventilation have been cited as
other causes of the pain.

19

781. Which of the following is false regarding sickle
cell anemia in children?
(A) Pain occurs when and where there is
occlusion of small blood vessels by sickled
erythrocytes, usually small bones of
the extremities in smaller children and
abdomen, chest, long bones, and lower
back in older children
(B) Tricyclic antidepressants are recommended
for analgesia during the acute
phase of a vasoocclusive crisis
(C) Use of opioids is indicated in patients
with severe pain
(D) Painful crisis can be triggered by hypoxemia,
cold, infection, and hypovolemia
(E) In children with excruciating pain that
does not respond to nonnarcotic analgesics,
and inadequate treatment of the
painful crisis can lead to drug-seeking
behavior and profound psychosocial
problems

781. (B)
A. Sickle cell anemia is the most common
hemoglobinopathy in the United States. It
occurs in 0.3% to 1.3% of the African
American population. Pain occurs during
vasoocclusive crisis, the frequency of which is unpredictable and ranges from less than
one crisis a year to a crisis several times a
year or several times a month. Pain occurs
when and where there is occlusion of small
blood vessels by sickled erythrocytes, usually
small bones of the extremities in smaller
children and abdomen, chest, long bones,
and lower back in older children.
B. Tricyclic antidepressants are not recommended
for analgesia during the acute
phase of a vasoocclusive crisis because they
do not act quickly enough. They can, however,
be useful for long-term use in patients
who have frequent crises.
C. and E. Although the use of narcotics can
lead to complications such as respiratory
depression as well as complications from
atelectasis and focal pulmonary hypoxia,
this issue alone should not preclude the use
of potent analgesics for patients in severe
pain. On the contrary, these children can
have excruciating pain that does not
respond to nonnarcotic analgesics, and inadequate
treatment of the painful crisis can
lead to drug-seeking behavior and profound
psychosocial problems.
D. The painful crisis can be triggered by
hypoxemia, cold, infection, and hypovolemia
and evolves in three phases:
1. The prodromal phase occurs up to 2 days
before the actual sickle crisis with paresthesias,
numbness, and an increase in
circulating sickle cells.
2. The following phase or initial phase lasts
1 to 2 days and includes pain, anorexia,
and fear and anxiety.
3. During the established phase, pain that
lasts 3 to 7 days, inflammation, swelling,
and leukocytosis are present.

20

782. Which of the following is the best choice for
management of the painful hemarthroses in
children suffering from hemophilia?
(A) Aspirin
(B) Pentazocine
(C) Cortisone
(D) Ibuprofen
(E) Acetaminophen

782. (E)
A. Analgesic therapy is an important part of
the management of hemophilia, although
it is secondary to replacement therapy.
Aspirin and drugs that inhibit platelet
function should be avoided, but acetaminophen,
codeine, hydromorphone, and
methadone can be given orally.
B. Pentazocine is never indicated in patients
with painful hemarthroses secondary to
hemophilia because it causes dysphoria.
C. and D. Steroids and NSAIDs can be used to
relieve pain from arthritis, but caution
should be exercised when these drugs are
used because they inhibit platelet activity.
E. Acetaminophen, codeine, hydromorphone,
and methadone can be given orally for the
treatment of painful hemarthroses in these
patients.

21

783. Which of the following is false regarding complex
regional pain syndrome type I (CRPS I) in
children?
(A) The affected area is usually the upper
limb as opposed to the lower limb in
adults
(B) Physical therapy is withheld for cases
that do not respond to oral medication
and/or sympathetic blocks in the first
place
(C) Multidisciplinary treatment combining
transcutaneous electrical nerve stimulation
(TENS), physical therapy, psychotherapy
using behavior modification
techniques, and oral medications is
effective in most children
(D) Typical children with CRPS I or CRPS II
show a profile of being intelligent,
driven overachievers who are involved
in very competitive activities and who
often react to the loss of this activity
with depression
(E) Sympathetic blocks are indicated to permit
more vigorous physical therapy if
pain prevents the start of these therapies

783. (B)
A. CRPS I has been reported in children as
young as 3 years. It is characterized by
severe pain, often burning in quality, persisting
much longer than would be
expected after the initial injury. The
affected area, more often an upper limb
than a lower limb in children (most common
areas are hand or wrist, elbow, shoulder,
or hip), is intermittently swollen, mottled,
and alternately red or cyanotic.
B. Physical therapy is probably the most
important intervention and combines cautious
manipulation of the affected limb,
hot and cold therapy, whirlpool massages,
and a program of intense active exercise.
C. Multidisciplinary treatment combining
TENS, physical therapy, psychotherapy
using behavior modification techniques,
and oral medications is effective in most
children. The TENS unit is worn for a few
hours every day or for 1 to 2 hours before
going out for some activity or to school.
TENS brings some degree of pain relief to
many patients and produces spectacular
results in a few. Behavior modification is
an important part of the treatment and
should be instituted from the beginning of
the therapeutic plan. Patients are taught
relaxation techniques and are given relaxation
tapes to use at home. An NSAID and an antidepressant at a low analgesic dose
are often given, as is an anticonvulsant.
D. Sometimes a particular psychologic profile
can be seen in children with CRPS I or
CRPS II. The children are intelligent, driven
overachievers who are involved (usually with success) in very competitive activities
and who often react to the loss of this activity
with depression. Other psychologic
issues such as family discord or divorce and
enmeshment with one parent are found.
School attendance is often an issue.
E. In patients with CRPS, if pain or dysfunction
prevents the start of physiotherapy or
persists despite these treatments, sympathetic
blocks such as lumbar, stellate ganglion,
or epidural with dilute solutions of
local anesthetics are indicated. The goals of
the sympathetic blockade are to
1. Ascertain the sympathetic origin of the
disorder.
2. Break the vicious circle of sympathetically
maintained pain.
3. Permit more vigorous physical therapy.

22

784. Which of the following is true regarding sport
injuries in the pediatric patient?
(A) The injuries encountered are overuse
injuries similar to those found in the
adult recreational athlete who does not
train correctly, usually doing too much
in too short a time
(B) Growth is not an important factor in
these injuries
(C) Growth spurts in children cause tendon
and muscle tightness, both of which
minimize the chances of a sport injury
(D) Treatment options such as oral acetaminophen,
NSAIDs and aspirin do not
provide adequate pain relief and should
not be used in these cases
(E) Sport injuries are responsible for less
than 10% of the cases of low back pain
in children

784. (A)
A. The sports injuries encountered in children
are overuse injuries similar to those found
in the adult recreational athlete who does
not train correctly, usually doing too much
in too short a time. The causes of these
injuries also include muscle-tendon imbalance,
anatomical malalignment, inadequate
footwear, and growth.
B. and C. Growth is an important factor in
sports injuries for two reasons:
1. Growth cartilage is less resistant to
injury than the adult-type cartilage.
2. Growth spurts in children cause tendon
and muscle tightness, leading to pain
and sometimes stress fracture. These
fractures are most often seen in the tibia
or the fibula.
D. Treatment consists of immobilization of
fractures, straight leg strengthening exercises
with use of leg braces in cases of knee
injuries, rest, and use of orthotic footwear.
NSAIDs and minor pain medicine, such as
aspirin and acetaminophen, are useful
when pain is present. These injuries usually
respond well to these conservative measures
but are best avoided through primary
prevention, because it is recognized that
they are bound to happen in young children
involved in sports.
E. Low back pain is rare in children and shares
neither the etiology nor the poor prognosis
with the adult form. Most cases of low back
pain in children and adolescents are sportsrelated
and occur during the growth spurt
phase. A tendency for lordosis of the spine
to develop appears at that time. With overuse,
low back pain may develop.

23

785. Which of the following statements is false
regarding pediatric cancer pain?
(A) Phantom sensations and phantom limb
pain are common among children following
amputation for cancer in an
extremity
(B) Phantom pain in children tends to
increase with time
(C) Some patients have chronic lower
extremity pain caused by avascular
necrosis of multiple joints
(D) An example of a neuropathic pain syndrome
in pediatric cancer patients is
postherpetic neuralgia
(E) Children with cancer pain often present
with longstanding myofascial pain

785. (B)
A. and B. Phantom sensations and phantom
limb pain are common among children following
amputation for cancer in an extremity.
Phantom pain in children tends to
decrease with time. Preamputation pain in
the diseased extremity may be a predictor
for subsequent phantom pain.
C., D., and E. Long-term survivors of childhood
cancer occasionally experience chronic pain.
Neuropathic pains include peripheral neuralgias
of the lower extremity, phantom limb
pain, postherpetic neuralgia, and central
pain after spinal cord tumor resection. Some
patients have chronic lower extremity pain
caused by a mechanical problem with an
internal prosthesis or a failure of bony union
or avascular necrosis of multiple joints.
Others have long-standing myofascial pains
and chronic abdominal pain of uncertain etiology.
Some patients treated with shunts for
brain tumors have recurrent headaches that
appear unrelated to intracranial pressure or
changes in shunt functioning.

24

786. Which of the following statements is false
regarding interventional approaches for pediatric
cancer pain management?
(A) In the pediatric cancer population, many
children and parents are reluctant to
consider procedures with the potential
for irreversible loss of somatic function
(B) Dose requirements vary dramatically for
spinal infusions in children, and they
require individualized attention
(C) For pediatric spinal infusions, the
process of converting from systemic to
spinal drug is often quite unpredictable,
with the potential for either oversedation
or withdrawal symptoms
(D) As opposed to the adult population,
celiac plexus blockade barely produces
pain relief for children with severe pain
caused by massively enlarged upper
abdominal viscera owing to tumor
(E) In pediatric patients, it is recommended
to place catheters while patients are
under general anesthesia or deep sedation,
not awake

786. (D)
A. and D. As with adults, celiac plexus blockade
can provide excellent pain relief for
children with severe pain caused by massively
enlarged upper abdominal viscera
owing to a tumor. Many children and
parents are reluctant to consider procedures
with the potential for irreversible loss
of somatic function. Decompressive operations
on the spine can in occasional cases
produce dramatic relief of pain.
B., C., and E. Spinal infusions can provide excellent
analgesia in refractory cases, but they
require individualized attention and should
not be undertaken by inexperienced practitioners
without guidance. Dose requirements
vary dramatically, and the process of
converting from systemic to spinal drug is
often quite unpredictable, with the potential
for either oversedation or withdrawal symptoms.
If children with spinal infusions are to
be treated at home, it is essential to have
resources available to manage new symptoms,
such as terminal dyspnea and air
hunger. In pediatric patients, it is recommended
to place catheters while patients are
under general anesthesia or deep sedation,
not awake.

25

787. In the immediate postoperative period, why
are parenteral pain medications best given by
continuous infusion rather than intermittent
intravenous (IV)/intramuscular (IM) boluses?
(A) Opioid infusions do not cause nausea or
vomiting
(B) Continuous infusions are associated with
higher serum concentrations of the drug
(C) Opioid infusions are not associated with
somnolence or respiratory depression, as
opposed to intermittent opioid dosing
(D) No need of monitoring pediatric
patients with continuous opioid infusions
as opposed to constant monitoring
in patients with intermittent boluses
(E) Boluses are associated with frequent
periods of inadequate pain relief

787. (E)
A., B., C., and D. The most common side
effects found with narcotic administration
are nausea or vomiting and pruritus. The
former usually respond to perphenazine or
prochlorperazine and the latter to diphenhydramine
or promethazine. Because somnolence
and respiratory depression can
also occur, patients receiving infusions of
narcotics require close attention, especially
when the pain is so well-controlled that the
pain stimulus of respiration is no longer
present.
E. Drugs can be given as boluses or continuous
infusions. Boluses are easy to administer
and provide rapid pain relief; however,
they have the disadvantage of providing
short periods of analgesia sometimes associated
with side effects when serum drug
concentration peaks, followed by inadequate
pain relief while the level decreases
until the next injection. Continuous infusions,
conversely, avoid this roller coaster
of pain relief followed by pain and provide
continuous analgesia with low plasma levels
of drugs even in newborns and infants.

26

788. Which of the following is an acceptable alternative
for postoperative pain management in
children when able to tolerate the oral route?
(A) Codeine
(B) Acetaminophen
(C) Methadone
(D) Immediate-release morphine
(E) All of the above

788. (E) Postoperatively, when the oral route can
again be used, methadone can be prescribed at
a dose one- to twofold that of the IV route. Oral
morphine sulfate can also provide adequate pain relief for moderate to severe pain. Codeine
can be given orally alone or in combination with
acetaminophen or aspirin for moderate pain;
mild pain is relieved by acetaminophen alone in
most cases. In any case, the most important
aspect of postoperative pain control is to assess
pain repeatedly with simple pain and behavior
scales and to adapt pain medication to the pain
scores provided by these scales and physiological
findings.

27

789. Which of the following is true regarding pediatric
regional anesthesia?
(A) Epidural catheters placed in the thoracic
or lumbar spine should not be left in
place for more than 2 days because of
concerns about infection, displacement,
or discomfort
(B) Caudal epidural catheters are contraindicated
for postoperative pain management
in small children because of
the high incidence of infection
(C) Spinal anesthesia has had limited indications
in children and adolescents
because of the incidence of postspinal
headache in this age group
(D) In newborns and infants, spinal anesthesia
provides anesthesia with a profound
motor block for a prolonged period of
time, making it a useful alternative for
postoperative pain relief
(E) All of the above

789. (C)
A. and B. These catheters can be left in place
for as long as a week or more without concerns
about infection, displacement, or discomfort.
An alternate approach to the
epidural space is catheter placement via the
caudal route, but its proximity to the anus
raises concern about puncture site infection
in the postoperative period, especially in
small children.
C. and D. Spinal anesthesia has had limited
indications in children and adolescents
because of the incidence of postspinal
headache in this age group. In newborns
and infants, it provides anesthesia with a
profound motor block for a short time (45-
100 minutes) and thus cannot be used for
postoperative pain relief. It is indicated in
infants born prematurely and are less than
45 to 60 weeks’ postconceptual age in whom
general anesthesia and sedation have been
shown to induce postoperative apnea.

28

790. In pediatric patients taking high doses of opioids,
it is advised that an opioid contract should
be signed by all parties involved. Which of the
following should be included in this contract?
(A) Use of multiple prescriptions for all
pain-related medications
(B) Use of as many pharmacies as possible
(C) A statement specifying that there is no
need for monitoring compliance of treatment
since this does not apply to pediatric
patients
(D) Need for random urine or serum medication
levels screening, regardless that
the patient is a child
(E) None of the above

790. (D) Opioid contracts are used in many adult
practices, but their use is not common in pediatrics.
The opioid contract clearly defines the
expectations and responsibilities of the patient,
parent, and medical caregiver. Guidelines from
the Medical Society of Virginia’s special
Pain Management Subcommittee have been
employed by many pain physicians throughout
the United States.
Written documentation of both physician
and patient responsibilities must include
1. Risks and complications associated with
treatment using opioids
2. Use of a single prescriber for all painrelated
medications
3. Use of a single pharmacy, if possible
4. Monitoring compliance of treatment
a. Urine or serum medication levels
screening (including checks for nonprescribed
medications and substances)
when requested
b Number and frequency of all prescription
refills
c. Reasons for which opioid therapy
may be discontinued

29

791. Which of the following includes common misconceptions
regarding pediatric pain?
(A) It appears that adults are more likely to
be believed than children when they
complain of pain or discomfort
(B) Neonates and young children do not
display learned pain behavior and
therefore do not express pain in an adult
fashion
(C) Silence is interpreted as a sign of being
comfortable
(D) Immobility without facial grimace or
focus on the pain source is interpreted
as absence of pain
(E) All of the above

791. (E) There are several distinctions between pediatric
pain concerns and adult pain concerns.
Misconceptions about a child’s inability to feel
pain persists. The belief that children “tolerate
pain well” still prevails. Children continue to
receive fewer analgesics than adults do in comparable
settings.
Adults indirectly require that children
prove their pain to merit the administration of
pain interventions. If a child does not act as if
he or she is experiencing severe pain, the child
is less likely to receive analgesic care. It appears
that adults are more likely than children to be
believed when they complain of pain or discomfort.
Studies show that for similar surgeries
in adult and pediatric patients, the adults
receive more doses of analgesic medications.
Neonates and young children do not display
learned pain behavior and therefore do not
express pain in an adult fashion. Adult caregivers
often miss pain cues that are developmentally
appropriate. Silence is interpreted as a
sign of being comfortable. Similarly, immobility
without facial grimace or focus on the pain
source is interpreted as absence of pain. Yet, on
direct questioning about the existence of pain,
many children do affirm that they are experiencing
pain. Children may lie quietly and enjoy
television; however, they do not want to move
because of fear of increased pain.

30

792. Differences between opioid abuse and opioid
physical dependence include
(A) physical dependence involves loss of
control and compulsive use regardless
of the adverse consequences
(B) opioid abuse is characterized by presence
of withdrawal symptoms during
abstinence
(C) physical dependence is a physiologic
state characterized by the presence of
withdrawal symptoms during abstinence
(D) physical dependence and addiction are
synonymous
(E) patients presenting opioid abuse are not
likely to develop addiction in the future

792. (C) The term “addiction” is familiar to medical
and private sectors, but both factions often
misuse the term as describing both physical and
psychologic dependence. Addiction is a disease
process involving the use of opioids wherein
there is a loss of control, compulsive use, and
continued use despite adverse social, physical,
psychologic, occupational, or economic consequences.
Physical dependence is a physiological
state of adaptation to a specific opioid characterized
by the emergence of a withdrawal syndrome
during abstinence, which may be
relieved totally or in part by readministration of
the substance. Physical dependence is predictable
sequelae of regular, legitimate opioid
or benzodiazepine use and is not identical to
addiction. The incidence of addiction in children
receiving prescribed opioids is low.
The present climate of drug-abuse prevention
has, in part, emphasized the predatory
nature of drug addiction and heightens fear in
children and adults. More education is
needed by lay people and health care professionals
in distinguishing addiction from physical
dependence. Patients who receive analgesics
for a recognized pain complaint are not
more likely to become addicted than the general
population. The incidence of addiction in
children receiving prescribed opioids is low.

31

793. The term “whiplash injury” that results in
chronic neck pain describes the resultant injury
caused by an abrupt
(A) hyperflexion of the neck from a direct
force
(B) hyperextension of the neck from an
indirect force
(C) hyperflexion of the neck from an indirect
force
(D) hyperextension of the neck from a direct
force
(E) rotation of the neck from a direct force

793. (B) Neck injuries often are a result of motor
vehicle accidents. Some studies have shown
that up to 60% of patients injured in car accidents
present to the hospital with neck pain.
The term “whiplash” describes the resultant
injury caused by an abrupt hyperextension of
the neck from an indirect force.

32

794. After sustaining a rear-end collision in a car
accident, a 25-year-old male patient complains
of neck pain. Which of the following are the
cervical structures involved in this whiplash
injury?
(A) Sternocleidomastoid muscle
(B) Longus colli muscle
(C) Scalene muscles
(D) Only A and C are correct
(E) A, B, and C are correct

794. (E) After a whiplash injury, symptoms may
occur 12 to 24 hours later. This is because of the
fact that muscular hemorrhage and edema may
need to evolve prior to inciting a nociceptive
response. The cervical flexors, specifically the
sternocleidomastoid, scalene, and the longus
colli undergo acute stretch reflex. Some fibers
are torn.

33

795. Which of the following is a prognostic indicator
of chronic symptoms after sustaining a
whiplash injury?
(A) Use if a cervical collar for more than
12 weeks
(B) Physical therapy restarted more than
once
(C) Numbness and pain in the upper
extremity
(D) Requirement of home traction
(E) All of the above

795. (E) A substantial number of patients with
whiplash have chronic symptoms. Prognostic
indicators for chronic symptoms include
numbness and pain in the upper extremity, use
of a cervical collar for more than 12 weeks,
requirement of home traction, physical therapy
restarted more than once.

34

796. A32-year-old male sustained a blunt trauma to
the left supraorbital area of his face. The patient
manifests burning pain, occasional tingling,
and intermittent stabbing. Which of the following
is true about this patient’s pain?
(A) This is a self-limiting condition that generally
resolves spontaneously within
several years
(B) With trophic changes, edema, and redness,
CRPS I should be suspected
(C) Sympathetic blockade of the stellate
ganglion may be effective
(D) Amitriptyline may reduce pain
(E) All of the above

796. (E) Facial pain may occur after trauma.
Examples include bullet wounds, maxillofacial surgery, and dental procedures. Some patients
manifest constant burning pain, occasionally
with tingling and intermittent stabbing. With
trophic changes, edema, and redness, CRPS I
should be suspected. In patients with burning
pain, sympathetic blockade of the stellate ganglion
may be effective. Amitriptyline may
reduce pain.

35

797. Which of the following variables may improve
significantly in a patient with multiple rib fractures
and an epidural infusion of epidural
bupivacaine?
(A) Vital capacity (VC)
(B) Hematocrit
(C) Expiratory reserve volume (ERV)
(D) Platelet aggregation
(E) Hemoglobin oxygen saturation

797. (A) Rib fracture pain may cause a decrease in
ventilatory function and increase in incidence of
pulmonary morbidity. It has been found that
epidural analgesia is an independent predictor
of decreased mortality and incidence of pulmonary
complications. Significant improvements
in VC and FEV1 (forced expiratory
volume) occur in patients with rib fractures who
receive thoracic epidural bupivacaine compared
with those that receive lumbar epidural morphine.
There are no changes in hematocrit,
oxygen saturation, platelet aggregation, or expiratory
reserve volume.

36

798. Flail chest because of multiple rib fractures may
result in
(A) changes in oxygenation, but not in ventilation
status
(B) mild pain that usually does not results
in splinting or atelectasis
(C) increase in shunt fraction
(D) increase in ventilation and hypocarbia
(E) shunt, but no ventilation and perfusion
mismatch

798. (C) Trauma to the chest is a significant cause of
morbidity and mortality. The pathophysiologic
sequelae of multiple rib fractures, especially
with flail chest, are pain and hypoxia. Hypoxia
results from the ventilation and perfusion mismatch
in the underlying contused lung.
Uncontrolled pain can result in splinting and
muscle spasms, which lead to decreased ventilation
and atelectasis. The compromise in pulmonary
function causes hypoxemia, an
increase in shunt fraction, or infection.

37

799. When sustaining trauma to the spine, which of
the following statements regarding elements
injured is correct?
(A) Disc injuries are common in the thoracic
spine
(B) Vertebral end-plate fractures are common
in the cervical spine
(C) Injury to the thoracic facets is more
common than to the cervical facets
(D) Disc injuries are predominant in the cervical
spine
(E) The posterior elements of the vertebral
fractures are never involved

799. (D) When comparing injuries in the thoracic
and cervical spine areas after sustained trauma,
it is observed that there are similar incidences
of facet injuries in the upper thoracic spine and
the cervical spine. By contrast, in the anterior
elements, vertebral end-plate fracture and bone
bruising are more common in the thoracic
spine, whereas disc injuries predominate in the
cervical spine. This raises the question whether
interscapular pain is referred from the neck or
arises locally. Investigations of pathology, to be
correlated with the effect of local anesthetic
blocks, should enable the clinician to distinguish
the true pain source.

38

800. Which of the following is true regarding the
management of pain in the traumatic injury
pain patients?
(A) Obtaining hemodynamic stability is one
of the main goals
(B) It is important to sustain sympathetic
hyperactivity
(C) Uncontrolled pain may contribute to
the development of posttraumatic stress
disorder
(D) When pain is adequately treated, these
patients will always present with
impairment of consciousness
(E) None of the above

800. (C) Hemodynamic stability, minimal impairment
of the patient’s level of consciousness and
responsiveness, and adequate analgesia to
reduce sympathetic hyperactivity and to allow
patient rehabilitation efforts are the primary
goals in the management of the patient with
pain after traumatic injury. Uncontrolled pain
following traumatic injury compounds the anxiety
and posttraumatic sympathetic nervous
system hyperactivity. Uncontrolled pain following
traumatic injury has been associated
with the development of posttraumatic stress
disorder.

39

801. Techniques in the management of pain in
patients with spinal cord injury (SCI) include
(A) opioid analgesics via IV patientcontrolled
analgesia (PCA)
(B) bedside placement of epidural catheters
for continuous infusion
(C) bedside placement of intrathecal
catheters for continuous infusion
(D) no need for oral adjuvant medications
besides opioids
(E) all of the above

801. (A) Patients with spine injury are usually managed
with systemic analgesic techniques
because of the risk of SCI or obscuring ongoing
neurologic assessment with epidural analgesic
techniques. Systemic opioid analgesic techniques,
such as intravenous PCA, allow patient
titration of analgesia and ongoing neurologic
evaluation. Adjuvant analgesics, such as acetaminophen,
may improve pain relief while
reducing opioid requirements and opioidrelated
side effects. Intraoperative administration
of epidural or intrathecal opioid analgesics
with epidural catheter placement and maintenance
of continuous postoperative epidural
opioid analgesia is an excellent technique for
postsurgical analgesia. The percutaneous exit
site for the epidural catheter can be made some
distance lateral to the surgical incision, minimizing
the effects on wound healing or infection.

40

802. Which of the following is a good alternative
for pain control in the patient with post–burn
injury pain?
(A) Scheduled around-the-clock opioid
boluses
(B) Continuous IV infusion of hydromorphone
(C) Transdermal fentanyl
(D) Intramuscular morphine given only as
needed
(E) None of the above

802. (B) Post–burn injury pain has two primary
components: a relatively constant background
pain and an intermittent procedure-related
pain. Continuous IV infusion of opioid analgesics
is an effective method of managing the
background pain component. Morphine and
fentanyl have been extensively used in this setting
although rapid escalation of opioid dose
requirement and hemodynamic instability are
not uncommonly seen. Hydromorphone is
another alternative. A continuous IV titration
paradigm for methadone has been described
which produces effective and stable analgesia
with minimal hemodynamic effects. Patients
receive an IV loading dose by IV infusion of methadone over an initial period of 2 hours at
0.1 mg/kg/h. The infusion is terminated prior
to the end of the initial 2-hour period if the
patient develops signs of excessive somnolence
or respiratory depression. This initial loading
dose infusion is followed by a maintenance
infusion of 0.01 mg/kg/h of methadone.
Transdermal preparations are not appropriate.

41

803. In the patient with trauma injuries involving an
extremity it is important to monitor for compartment
syndrome. When using a regional technique
for pain control, methods that may help
monitoring compartment syndrome include
(A) use of epidural infusion containing local
anesthetics at doses where motor block
is present
(B) continuous plexus catheter using high
concentration of local anesthetics to
avoid incidental pain with movement
(C) continuous peripheral nerve catheter
using low-dose local anesthetic
(D) continuous IV local anesthetic infusion
(E) all of the above

803. (C) Trauma patients with extremity injuries can
be managed with a variety of techniques, including
peripheral neural blockade, epidural analgesia,
and systemic opioid analgesia. Adjuvant
analgesics, such as acetaminophen and NSAIDs,
are particularly effective in providing supplemental
analgesia for orthopedic injuries, reducing
opioid requirements and opioid-related side
effects. Brachial plexus or peripheral neural
blockade is effective for upper extremity injuries,
whereas lumbar plexus or sciatic or femoral
neural blockade techniques are effective for
many lower extremity injuries. Continuous analgesia
can be maintained with continuous plexus
or peripheral nerve catheter techniques or continuous
epidural analgesia. Monitoring for compartment
syndrome may be necessary in some
patients with extremity trauma, although low
concentrations of local anesthetics (bupivacaine
0.125% or ropivacaine 0.2%) and opioids allow
continued monitoring of compartment pressures
and subjective changes in pain report in most
patients. Intermittent interruption in continuous
local anesthetic infusions may provide a greater
margin of safety in patients at high risk for development
of compartment syndrome.

42

804. In the trauma patient with chest injury, epidural
analgesia has been proven to provide excellent
pain control and to
(A) avoid endotracheal intubation is some
cases
(B) shorten the stay at the intensive care
unit (ICU)
(C) decrease ventilator dependence
(D) shorten hospital stay
(E) all of the above

804. (E) Effective analgesia is especially important in
the postinjury rehabilitation of the patient with
a chest injury such as rib fractures, flail chest,
sternal fractures, or thoracostomy drainage
tubes because of the risk of chest wall splinting
and inadequate lung expansion and clearance
of pulmonary secretions secondary to pain.
Several studies have demonstrated a significant
benefit in avoidance of endotracheal intubation,
earlier postinjury extubation, decreased
ventilator dependence, shorter stay in the ICU,
shorter hospital stay, and improved postinjury
rehabilitation with the use of continuous
epidural analgesia with local anesthetic and opioid or intercostal neural blockade for pain
management following chest injury.

43

805. Types of pain commonly treated after major
abdominal surgery for patients with a wellknown
history SCI are
(A) musculoskeletal pain
(B) visceral pain
(C) at-level neuropathic pain
(D) below-level neuropathic pain
(E) all of the above

805. (E)
A. Most patients who sustain an injury to the
spinal cord have also received massive
trauma to the vertebral column and its supporting
structures, and will have acute
nociceptive pain arising from damage to
structures such as bones, ligaments, muscles,
intervertebral discs, and facet joints.
Some acute musculoskeletal pain is also
related to structural spinal damage and
instability without necessarily having
spinal cord damage.
B. Pathology in visceral structures, such as urinary
tract infections, bowel impaction, and
renal calculi, will generally give rise to nociceptive
pain, although the level of the injury
will affect the quality of the pain. Therefore
paraplegic patients may experience visceral
pain that is identical to that in patients who
have no spinal cord damage. However,
tetraplegic patients may experience more
vague generalized symptoms of unpleasantness
that are difficult to interpret.
C. The diagnosis of neuropathic pain is largely
based on descriptors (sharp, shooting, electric,
burning, and stabbing), and the pain is
located in a region of sensory disturbance.
Neuropathic at-level pain refers to pain
with these features, and present in a segmental
or dermatomal pattern within two
segments above or below the level of injury.
This type of pain is also referred to as segmental,
transitional zone, border zone, end
zone, and girdle zone pain, names that
reflect its characteristic location in the dermatomes
close to the level of injury. It is
often associated with allodynia or hyperesthesia
of the affected dermatomes.
D. This type of pain, which is also referred to
as central dysesthesia syndrome, central
pain, phantom pain, or deafferentation
pain, presents with spontaneous and/or
evoked pain that is present often diffusely
caudal to the level of SCI. It is characterized
by sensations of burning, aching, stabbing,
or electric shocks, often with hyperalgesia and it often develops sometime after the
initial injury. It is constant but may fluctuate
with mood, activity, infections, or other
factors, and is not related to position or
activity. Sudden noises or jarring movements
may trigger this type of pain. Differences
in the nature of below-level neuropathic
pain may be apparent between those with
complete and incomplete lesions. Both
complete and partial injuries may be associated
with the diffuse, burning pain that
appears to be associated with spinothalamic
tract damage. However, incomplete
injuries are more likely to have an allodynia
component because of sparing of tracts conveying
touch sensations.

44

806. Characteristics of below-level neuropathic pain
in patients with SCI include
(A) spontaneous pain cephalad to the level
of SCI
(B) not related to position or activity
(C) only present in patients with partial
injuries to the spinal cord
(D) associated to sensation of dull ache
(E) intermittent, but never constant

806. (B)

45

807. Which of the following medications have
proven to be useful in the treatment of neuropathic
pain of patients with SCI?
(A) IV propofol infusion
(B) IV ketamine infusion
(C) Intrathecal clonidine
(D) Only A and C are correct
(E) A, B, and C are correct

807. (E)
A. IV administration of propofol, a GABAA
receptor agonist, has been reported to be
more effective than placebo in relieving
neuropathic SCI pain.
B. The efficacy of IV ketamine infusion in the
management of neuropathic SCI pain has
been evaluated. IV infusion of ketamine
(bolus 60 μg followed by 6 μg/kg/min)
results in a significant reduction in the
evoked and spontaneous neuropathic pains
associated with SCI.
C. Clonidine administered spinally either
alone or in combination with morphine may
also be effective for the control of neuropathic
SCI pain. Clonidine has been found
to be more effective than morphine for pain
relief in patients with SCI. Combinations of
clonidine with other agents may also be
effective.

46

808. Drug exposure prior to organogenesis (before
the fourth menstrual week) usually results in
(A) an all-or-none effect; either the embryo
does not survive, or it develops without
abnormalities
(B) single-organ abnormalities
(C) multiple-organ abnormalities
(D) developmental syndromes
(E) intrauterine growth retardation

808. (A) Drug exposure before organogenesis
(before the fourth menstrual week) usually
causes an all-or-none effect; either the embryo
does not survive, or it develops without abnormalities.
Drug effects later in pregnancy typically
lead to single- or multiple-organ involvement,
developmental syndromes, or intrauterine
growth retardation

47

809. The US Food and Drug Administration (FDA)
have developed a five-category labeling system
for all approved drugs in the United States.
Which if the following is not a category in the
mentioned system?
(A) Category A: controlled human studies
indicate no apparent risk to fetus. The
possibility of harm to the fetus seems
remote (eg, multivitamins)
(B) Category B: Animal studies do not indicate
a fetal risk or animal studies do
indicate a teratogenic risk, but well-controlled
human studies have failed to
demonstrate a risk (eg, acetaminophen,
caffeine, fentanyl, hydrocodone)
(C) Category C: studies indicate teratogenic
or embryocidal risk in animals, but no
controlled studies have been done in
women or there are no controlled studies
in animals or humans (eg, aspirin,
ketorolac, codeine, gabapentin)
(D) Category D: there is positive evidence of
human fetal risk, but in certain circumstances,
the benefits of the drug may
outweigh the risks involved (eg,
amitriptyline, imipramine, diazepam,
phenobarbital, phenytoin)
(E) Category E: there is positive evidence of
significant fetal risk, and the risk clearly
outweighs any possible benefit (eg,
ergotamine)

809. (E)
A. The FDA has developed a five-category
labeling system for all approved drugs in
the United States. This labeling system rates
the potential risk for teratogenic or embryotoxic
effects, according to available scientific
and clinical evidence. Category A: controlled
human studies indicate no apparent risk to
fetus. The possibility of harm to the fetus
seems remote (eg, multivitamins).
B. Category B: animal studies do not indicate a
fetal risk or animal studies do indicate a teratogenic
risk, but well-controlled human
studies have failed to demonstrate a risk (eg,
acetaminophen, butorphanol, nalbuphine,
caffeine, fentanyl, hydrocodone, methadone,
meperidine, morphine, oxycodone, oxymorphone,
ibuprofen, naproxen, indomethacin,
metoprolol, paroxetine, fluoxetine, and
prednisolone).
C. Category C: studies indicate teratogenic or
embryocidal risk in animals, but no controlled
studies have been done in women
or there are no controlled studies in animals
or humans. (eg, aspirin, ketorolac,
codeine, propoxyphene, gabapentin, lidocaine,
mexiletine, nifedipine, propranolol,
sumatriptan).
D. Category D: there is positive evidence of
human fetal risk, but in certain circumstances,
the benefits of the drug may outweigh
the risks involved (eg, amitriptyline,
imipramine, diazepam, phenobarbital,
phenytoin, valproic acid).
E. Category E is not part of the FDA labeling
system. Category X is part of the FDA
labeling system and includes drugs were
there is positive evidence of significant
fetal risk, and the risk clearly outweighs
any possible benefit (eg, ergotamine).

48

810. Acetaminophen falls in which of the following
FDA labeling categories regarding risk of teratogenic
or embryotoxic effects?
(A) Category A
(B) Category B
(C) Category C
(D) Category D
(E) Category X

810. (B)
A. The FDA has developed a five-category
labeling system for all approved drugs in
the United States. This labeling system
rates the potential risk for teratogenic or
embryotoxic effects, according to available
scientific and clinical evidence. Category A: Controlled human studies indicate no
apparent risk to fetus. The possibility of
harm to the fetus seems remote (eg, multivitamins).
B. Category B Animal studies do not indicate a
fetal risk or animal studies do indicate a teratogenic
risk, but well-controlled human
studies have failed to demonstrate a risk. (eg,
acetaminophen, butorphanol, nalbuphine,
caffeine, fentanyl, hydrocodone, methadone,
meperidine, morphine, oxycodone, oxymorphone,
ibuprofen, naproxen, indomethacin,
metoprolol, paroxetine, fluoxetine, prednisolone).
C. Category C: studies indicate teratogenic or
embryocidal risk in animals, but no controlled
studies have been done in women
or there are no controlled studies in animals
or humans. (eg, aspirin, ketorolac,
codeine, propoxyphene, gabapentin, lidocaine,
mexiletine, nifedipine, propranolol,
sumatriptan).
D. Category D: there is positive evidence of
human fetal risk, but in certain circumstances,
the benefits of the drug may outweigh
the risks involved. (eg, amitriptyline,
imipramine, diazepam, phenobarbital,
phenytoin, valproic acid).
E. Category X is part of the FDA labeling system
and includes drugs were there is positive
evidence of significant fetal risk, and
the risk clearly outweighs any possible
benefit. (eg, ergotamine).

49

811. During pregnancy, NSAIDs may
(A) accelerate the onset of labor
(B) increase amniotic fluid volume
(C) decrease the newborn’s risk for pulmonary
hypertension
(D) increase the risk of renal injury
(E) all of the above

811. (D)
A. Aspirin remains the prototypical NSAID
and is the most thoroughly studied of this
class of medications. Prostaglandins appear
to trigger labor, and the aspirin-induced
inhibition of prostaglandin synthesis may
result in prolonged gestation and protracted
labor.
B. and D. The use of ibuprofen during pregnancy
may result in reversible oligohydramnios
(reflecting diminished fetal urine output) and
mild constriction of the fetal ductus arteriosus.
Similarly, no data exist to support any
association between naproxen administration
and congenital defects. Because it shares the renal and vascular effects of ibuprofen,
naproxen should be considered to have the
potential to diminish ductus arteriosus diameter
and to cause oligohydramnios.
C. Circulating prostaglandins modulate the
patency of the fetal ductus arteriosus.
NSAIDs have been used therapeutically in
neonates with persistent fetal circulation to
induce closure of the ductus arteriosus via
inhibition of prostaglandin synthesis.
Patency of the ductus arteriosus in utero is
essential for normal fetal circulation.
Indomethacin has shown promise for the
treatment of premature labor, but its use
has been linked to antenatal narrowing
and closure of the fetal ductus arteriosus.

50

812. Which of the following is true regarding use of
opioids during pregnancy?
(A) Mixed agonist-antagonist opioid analgesic
agents are superior to pure opioid
agonists in providing analgesia
(B) Opioids are excreted into breast milk in
negligible amounts
(C) Methadone is not compatible with
breast-feeding
(D) Significant accumulation of normeperidine
is unlikely in the parturient who
receives single or infrequent doses
(E) All of the above

812. (D)
A. Although mixed agonist-antagonist opioid
analgesic agents are widely used to provide
analgesia during labor, they do not appear
to offer any advantage when compared to
pure opioid agonists. When compared,
meperidine and nalbuphine provide comparable
labor analgesia as well as similar
neonatal Apgar and neurobehavioral
scores. Use of either nalbuphine or pentazocine
during pregnancy can lead to neonatal
abstinence syndrome.
B. Opioids are excreted into breast milk.
Pharmacokinetic analysis has demonstrated
that breast milk concentrations of codeine
and morphine are equal to or somewhat
greater than maternal plasma concentrations.
Meperidine use in breast-feeding
mothers via PCA resulted in significantly
greater neurobehavioral depression of the
breast-feeding newborn than equianalgesic
doses of morphine
C. Methadone levels in breast milk appear sufficient
to prevent opioid withdrawal symptoms
in the breast-fed infant. The American
Academy of Pediatrics considers methadone
doses of up to 20 mg/d to be compatible
with breast-feeding. Recognition of infants
at risk for neonatal abstinence syndrome
and institution of appropriate supportive and
medical therapy typically results in little
short-term consequence to the infant. The long-term effects of in utero opioid exposure
are unknown.
D. Meperidine undergoes extensive hepatic
metabolism to normeperidine, which has a
long elimination t1/2 (18 hours). Repeated
dosing can lead to accumulation, especially
in patients with renal insufficiency.
Normeperidine causes excitation of the
CNS, manifested as tremors, myoclonus,
and generalized seizures. Significant accumulation
of normeperidine is unlikely in the
parturient who receives single or infrequent
doses; however, meperidine offers no advantages
over other parenteral opioids.

51

813. A25-year-old primigravida just gave birth to a
healthy baby boy. She had an epidural infusion
containing lidocaine for labor analgesia.
She asks you how long does she has to wait after the infusion is turned off in order to be
able to breast-feed her son. Your answer is
(A) she should wait at least 24 hours since
concentration of lidocaine in breast milk
may be toxic at this time
(B) it is safe to breast-feed her son since
concentration of lidocaine is minimal in
breast milk after an epidural infusion
(C) it would be safer to breast-feed if the
infusion had bupivacaine, but since
lidocaine was used, she will need to
wait 36 hours
(D) mothers who had an epidural infusion
for labor should not be allowed to
breast-feed until 1 week postpartum
(E) none of the above

813. (B) Few studies have focused on the potential
teratogenicity of local anesthetic agents.
Lidocaine and bupivacaine do not appear to
pose significant developmental risk to the fetus.
Only mepivacaine had a suggestion of teratogenicity
in one study. However, the number of
patient exposures was inadequate to draw conclusions.
Animal studies have found that continuous
exposure to lidocaine throughout
pregnancy does not cause congenital anomalies
but may decrease neonatal birth weight.
Neither lidocaine nor bupivacaine appears in
measurable quantities in the breast milk after
epidural local anesthetic administration during
labor. IV infusion of high doses (2-4 mg/min)
of lidocaine for suppression of cardiac arrhythmias
led to minimal levels in breast milk. Based
on these observations, continuous epidural
infusion of dilute local anesthetic solutions for
postoperative analgesia should result in only
small quantities of drug actually reaching the
fetus. The American Academy of Pediatrics
considers local anesthetics to be safe for use in
the nursing mother.

52

814. A 23-year-old female patient with chronic low
back pain as a result of a motor vehicle accident
becomes pregnant. For the past 4 years she has
been taking diazepam for muscle spasms and to
help her sleep at night. She asks for your advice
in terms of continuing or quitting diazepam
during her pregnancy. Your answer should be
(A) second-trimester exposure to benzodiazepines
may be associated with an
increased risk of congenital
malformations
(B) diazepam’s association with cleft lip,
cleft palate, and congenital inguinal hernia
has been disregarded recently
(C) neonates who are exposed to benzodiazepines
in utero usually do not experience
withdrawal symptoms after birth
since the amount that crosses the placenta
is negligible
(D) it appears most prudent to avoid any
use of benzodiazepines during organogenesis,
near the time of delivery, and
during lactation
(E) all of the above

814. (D)
A. and B. Benzodiazepines are among the
most frequently prescribed of all drugs and
are often used as anxiolytic agents, as an
aid to sleep in patients with insomnia, and
as skeletal muscle relaxants in patients with
chronic pain. First-trimester exposure to
benzodiazepines may be associated with an
increased risk of congenital malformations.
Diazepam may be associated with cleft lip
and cleft palate as well as congenital
inguinal hernia. However, epidemiologic
evidence has not confirmed the association
of diazepam with cleft abnormalities; the
incidence of cleft lip and palate remained
stable after the introduction and widespread
use of diazepam. Epidemiologic
studies have confirmed the association of
diazepam use during pregnancy with congenital
inguinal hernia.
C. and D. Aside from the risks of teratogenesis,
neonates who are exposed to benzodiazepines
in utero may experience withdrawal
symptoms immediately after birth. In the
breast-feeding mother, diazepam and its
metabolite desmethyldiazepam can be
detected in infant serum for up to 10 days
after a single maternal dose. This is caused by
the slower metabolism in neonates than in
adults. Clinically, infants who are nursing
from mothers receiving diazepam may show
sedation and poor feeding. It appears most
prudent to avoid any use of benzodiazepines
during organogenesis, near the time of delivery,
and during lactation.

53

815. A 28-year-old female with myofascial pain is
taking tricyclic antidepressants for pain control
with good results. She is planning to
become pregnant in the next few months.
Which of the following is true regarding use of
tricyclic antidepressants during pregnancy?
(A) Amitriptyline, nortriptyline, and
imipramine are all safe to use since they
are rated risk Category D by the FDA
(B) Amitriptyline, nortriptyline, and
desipramine are found in high quantities
in breast milk, and are not safe to
use while breast-feeding
(C) The selective serotonin reuptake
inhibitors (SSRIs) fluoxetine and paroxetine
are rated FDA risk Category B.
These are safe to administer while
breast-feeding
(D) Withdrawal syndromes have not been
reported in neonates born to mothers
using nortriptyline, imipramine, and
desipramine
(E) All of the above

815. (C)
A. and C. Antidepressants are often employed
in the management of migraine headaches as
well as for analgesic and antidepressant purposes
in chronic pain states. Amitriptyline,
nortriptyline, and imipramine are all rated
risk Category D by the FDA. The SSRIs, fluoxetine
and paroxetine, are rated FDA risk
Category B. Desipramine and all other conventional
antidepressant medications are
Category C.
B. Amitriptyline, nortriptyline, and desipramine
are all excreted into human milk.
Pharmacokinetic modeling suggests that
infants are exposed to about 1% of the
maternal dose. Amitriptyline, nortriptyline,
desipramine, clomipramine, and
sertraline were not found in quantifiable
amounts in nurslings and that no adverse
effects were reported.
D. Withdrawal syndromes have been reported
in neonates born to mothers using nortriptyline,
imipramine, and desipramine with symptoms that include irritability,
colic, tachypnea, and urinary retention.

54

816. Which of the following is true regarding the
use of anticonvulsants for neuropathic pain
during pregnancy?
(A) In general, the use of anticonvulsants
during lactation does not seem to be
harmful to infants
(B) Frequent monitoring of serum anticonvulsant
levels and folate supplementation
should be initiated, and maternal α-
fetoprotein screening may be considered
to detect fetal neural tube defects
(C) Pregnant women taking anticonvulsants
for chronic pain have a lower risk of
fetal malformations than patients taking
the same medications for seizure control
(D) Women who are taking anticonvulsants
for neuropathic pain should strongly
consider discontinuation during pregnancy,
particularly during the first
trimester
(E) All of the above

816. (A)
A. The use of anticonvulsants during lactation
does not seem to be harmful to
infants. Phenytoin, carbamazepine, and
valproic acid appear in small amounts in
breast milk, but no adverse effects have
been noted.
B. and D. For patients contemplating childbearing
who are receiving anticonvulsants,
their pharmacologic therapy should be critically
evaluated. Women who are taking
anticonvulsants for neuropathic pain
should strongly consider discontinuation
during pregnancy, particularly during the
first trimester. Consultation with a perinatologist
is recommended if continued use of
anticonvulsants during pregnancy is being
considered. Frequent monitoring of serum
anticonvulsant levels and folate supplementation
should be initiated, and maternal
α-fetoprotein screening may be considered
to detect fetal neural tube defects.
C. While anticonvulsants have teratogenic
risk, epilepsy itself may be partially responsible
for fetal malformations. Perhaps pregnant
women taking anticonvulsants for
chronic pain have a lower risk of fetal malformations
than patients taking the same
medications for seizure control.

55

817. Caffeine is found in many over-the-counter
pain medications. Pregnant women should be
careful because
(A) caffeine ingestion of more than 300 mg/d
is associated with decreased birth weight
(B) caffeine ingestion combined with
tobacco use increases the risk for delivery
of a low-birth-weight infant
(C) caffeine ingestion is associated with an
increased incidence of tachyarrhythmias
in the newborn
(D) moderate caffeine ingestion during lactation
does not appear to affect the
infant
(E) all of the above

817. (E)
A. and B. Early studies of caffeine ingestion
during pregnancy suggested an increased
risk of intrauterine growth retardation, fetal
demise, and premature labor. However,
these early studies did not control for concomitant
alcohol and tobacco use.
Subsequent work that controlled for these
confounding factors found no added risks
with moderate caffeine ingestion, although
ingestion of more than 300 mg/d was associated
with decreased birth weight. Caffeine
ingestion combined with tobacco use
increases the risk for delivery of a low-birthweight
infant.
C. Ingestion of modest doses of caffeine
(100 mg/d) in caffeine-naïve subjects produces
modest cardiovascular changes in
both mother and fetus, including increased
maternal heart rate and mean arterial pressure,
increased peak aortic flow velocities,
and decreased fetal heart rate. The modest
decrease in fetal heart rate and increased frequency
of fetal heart rate accelerations may
confound the interpretation of fetal heart
tracings. Caffeine ingestion is also associated
with an increased incidence of tachyarrhythmias
in the newborn, including
supraventricular tachyarrhythmias, atrial
flutter, and premature atrial contractions.
D. Many over-the-counter analgesic formulations
contain caffeine (typically in amounts
between 30 and 65 mg per dose), and one
must consider the use of these preparations
when determining total caffeine exposure.
Moderate ingestion of caffeine during lactation
does not appear to affect the infant.
Breast milk usually contains less than 1% of
the maternal dose of caffeine, with peak
breast milk levels appearing 1 hour after
maternal ingestion. Excessive caffeine use
may cause increased wakefulness and irritability
in the infant.

56

818. A 23-year-old female at 24 weeks of gestation
shows to the clinic with low back pain of sudden
onset. She describes her pain as originating lateral
to the left lumbosacral junction. The pain
radiates to the posterior part of the left thigh
and does not extend below the knee. Which of
the following is the most likely diagnosis?
(A) Transient osteoporosis of the hip
(B) Sacroiliac joint pain
(C) Osteonecrosis of the hip
(D) Sciatica
(E) None of the above

818. (B)
A. and C. Two relatively rare conditions—
osteonecrosis and transient osteoporosis of
the hip—both occur with somewhat greater
frequency during pregnancy. Whereas the
exact etiology is not known, high levels of
estrogen and progesterone in the maternal
circulation and increased interosseous pressure
may contribute to the development of
osteonecrosis. Transient osteoporosis of the
hip is a rare disorder characterized by pain
and limitation of motion of the hip and
osteopenia of the femoral head. Both conditions
present during the third trimester
with hip pain that may be either sudden or
gradual in onset.
Osteoporosis is easily identified by plain
radiography, which demonstrates osteopenia
of the femoral head with preservation
of the joint space. Osteonecrosis is best evaluated with magnetic resonance imaging
(MRI), which shows changes before
they appear on plain radiographs.
B. and D. The hormonal changes that occur
during pregnancy lead to widening and
increased mobility of the sacroiliac synchondroses
and the symphysis pubis as
early as the 10th to 12th weeks of pregnancy.
This type of pain is often described
by pregnant women and is located in the
posterior part of the pelvis distal and lateral
to the lumbosacral junction. Many terms
have been used in the literature to describe
this type of pain, including “sacroiliac dysfunction,”
“pelvic girdle relaxation,” and
even “sacroiliac joint pain.” The pain radiates
to the posterior part of the thigh and
may extend below the knee, often resulting
in misinterpretation as sciatica. The pain is
less specific than sciatica in distribution
and does not extend to the ankle or foot.

57

819. Which of the following is not a main cause of
low back pain during pregnancy?
(A) Increased incidence of herniated nucleus
pulposus during pregnancy
(B) The lumbar lordosis becomes markedly
accentuated during pregnancy
(C) Endocrine changes during pregnancy
soften the ligaments around the pelvic
joints and cervix
(D) Direct pressure of the fetus on the lumbosacral
nerves may cause radicular
symptoms
(E) Sacroiliac joint dysfunction is common
during pregnancy

819. (A)
A. and D. Although radicular symptoms often
accompany low back pain during pregnancy,
the incidence of herniated nucleus
pulposus is only 1:10,000. The prevalence
of lumbar intervertebral disk abnormalities
is not increased in pregnant women. Direct
pressure of the fetus on the lumbosacral
nerves has been postulated as the cause of
radicular symptoms.
B. Back pain occurs at some time in about
50% of pregnant women and is so common
that it is often looked on as a normal part
of pregnancy. The lumbar lordosis becomes
markedly accentuated during pregnancy
and may contribute to the development of
low back pain.
C. Endocrine changes during pregnancy may
also play a role in the development of back
pain. Relaxin, a polypeptide secreted by
the corpus luteum, softens the ligaments
around the pelvic joints and cervix, allowing
accommodation of the developing
fetus and facilitating vaginal delivery. This
laxity may cause pain by producing an
exaggerated range of motion.
E. The hormonal changes that occur during
pregnancy lead to widening and increased
mobility of the sacroiliac synchondroses
and the symphysis pubis as early as the
10th to 12th weeks of pregnancy.

58

820. Which of the following is a true statement
regarding headaches during pregnancy?
(A) In pregnant women with a history of
migraines prior to pregnancy, more than
50% will report worsening of migraine
headaches during this period
(B) In women of childbearing age, their first
migraine headache will usually occur
during pregnancy
(C) Pregnant patients presenting with “the
worst headache of my live” should have
an immediate rule out of subarachnoid
hemorrhage
(D) Preeclampsia usually does not presents
with headaches
(E) Initial presentation of headaches during
pregnancy should not precipitate thorough
search for potential pathology
unless the headaches continue after
labor and delivery

820. (C)
A. Migraines occur more often during menstruation,
because of decreased estrogen levels.
During pregnancy, 70% of women report
improvement or remission of migraines.
B. and E. Migraine headaches rarely begin
during pregnancy. Headaches that initially
present during pregnancy should initiate a
thorough search for potentially serious
causes. Examples may include strokes,
pseudotumor cerebri, tumors, aneurysms,
atrioventricular malformations, and others.
C. Patients presenting with their first severe
headache should receive a complete neurologic
examination, toxicology screen, serum
coagulation profiles, and an MRI should be
encouraged. In the patient who presents
with “worst headache of my life,” subarachnoid
hemorrhage should be ruled out.
D. Progressively worsening of headaches in
the setting of weight gain may be secondary
to preeclampsia or pseudotumor cerebri.
Preeclampsia has the triad of elevated
blood pressure, proteinuria, and peripheral
edema.

59

821. A 22-year-old female patient presents to the
office with sudden onset of abdominal pain.
She has a 10-week pregnancy history and no
other symptoms upon questioning. Pain is
localized to the lower portion of the abdomen.
The differential diagnosis should not include
(A) miscarriage
(B) ovarian torsion
(C) ectopic pregnancy
(D) myofascial pain
(E) sacroiliac joint pain

821. (E)
A., B., C., and D. One of the most common
causes of abdominal pain early in pregnancy
is miscarriage, presenting with
abdominal pain and vaginal bleeding.
Ectopic pregnancy and ovarian torsion may
present with hypogastric pain and suprapubic
tenderness. Once these conditions
have been ruled out, myofascial causes of
abdominal pain should be considered.
E. Sacroiliac joint pain or sacroiliac dysfunction
usually does not presents with
abdominal pain, but with low back pain
that may radiate to the hip and thigh area.

60

822. Which of the following opioids is considered to
be compatible with breast-feeding by the
American Academy of Pediatrics?
(A) Codeine
(B) Methadone
(C) Fentanyl
(D) Propoxyphene
(E) All of the

822. (E) Opioids are excreted into breast milk. It has been shown that concentrations of morphine and codeine are equal to or greater than maternal
plasma concentrations. The American
Academy of Pediatrics considers use of many
opioid analgesics including codeine, fentanyl,
methadone, morphine, and propoxyphene to
be compatible with breast-feeding.

61

823. In the critically ill patient, true statements
regarding pain assessment include all of the
following, EXCEPT
(A) pain assessment tools such as the visual
analogue scale or numeric rating scale
(NRS) are most useful
(B) in noncommunicative patients, assessment
of behavioral and physiologic
indicators is necessary
(C) the NRS may be preferable because it is
applicable to many age groups and does
not require verbal responses
(D) patient self-reporting is not useful for
the assessment of pain and the adequacy
of analgesia
(E) the patient and family should be
advised of the potential for pain and
strategies to communicate pain

823. (D) Perception of pain is influenced by prior
experiences, expectations, and the cognitive
capacity of the patient. The patient and family
should be advised of the potential for pain and
strategies to communicate pain. Patient selfreporting
is the gold standard for the assessment
of pain and the adequacy of analgesia.
Pain assessment tools such as the visual analogue
scale or numeric rating scale are most
useful. The numeric rating scale may be preferable
because it is applicable to many age groups
and does not require verbal responses. In noncommunicative
patients, assessment of behavioral
(movements, facial expressions, posturing)
and physiologic (heart rate, blood pressure, respiratory
rate) indicators is necessary.

62

824. A 27-year-old male patient is at the ICU after
sustaining multiple body traumas in a motor
vehicle accident. The patient is on a mechanical
ventilator with mild sedation. He has acute
renal insufficiency and vital signs show mild to
moderate hypotension. Upon evaluation it is
determined that he has moderate to severe pain
in both upper extremities and in the chest area
as a result of multiple fractures. Which of the
following would be the best medication to provide
by an IV infusion for pain control?
(A) Fentanyl
(B) Morphine sulfate
(C) Ketorolac
(D) Demerol
(E) Hydromorphone

824. (A)
A. Opioids are the mainstay of pain management
in the ICU. Desired properties of an
opiate include rapid onset of action, ease
of titration, lack of accumulation of parent
drug or active metabolites, and low cost.
The most commonly prescribed opioids
are fentanyl, morphine, and hydromorphone.
Fentanyl has a rapid onset of action
and short t1/2 and generates no active
metabolites. It is ideal for use in hemodynamically
unstable patients or in combination
with benzodiazepines for short
procedures. Continuous infusion may result
in prolonged effect owing to accumulation
in lipid stores, and high dosing has been
linked to muscle rigidity syndromes.
B., D., and E. Morphine has a slower onset of
action (compared to fentanyl) and longer t1/2.
It may not be suitable for hemodynamically
unstable patients because associated histamine
release may lead to vasodilatation and
hypotension. An active metabolite can accumulate
in renal insufficiency. Morphine can
also cause spasm of the sphincter of Oddi,
which may discourage its use in patients
with biliary disease. Hydromorphone has a
t1/2 similar to morphine but generates no
active metabolites and no histamine release.
All opioid analgesics are associated with
varying degrees of respiratory depression,
hypotension, and ileus.
C. Alternatives to opioids include acetaminophen
and NSAIDs. Ketorolac is the only
available intravenous NSAID. It is an
effective analgesic agent used alone or in
combination with an opioid. It is primarily
eliminated by renal excretion, so it is relatively
contraindicated in patients with
renal insufficiency. Prolonged (> 5 days)
use has been associated with bleeding
complications.

63

825. In the critically ill patient, which of the following
supports that epidural analgesia is a good
alternative for pain control?
(A) It results in more stable hemodynamics
(B) There is reduced blood loss during
surgery
(C) Better suppression of surgical stress
(D) Improved peripheral circulation
(E) All of the above

825. (E) Many benefits of epidural anesthesia have
been reported, including better suppression of
surgical stress, more stable hemodynamics,
better peripheral circulation, and reduced
blood loss. Aprospective, randomized study of
1021 abdominal surgery patients demonstrated
that epidural opioid analgesia provides better
postoperative pain relief compared with parenteral
opioids. Furthermore, in patients
undergoing abdominal aortic operations, overall
morbidity and mortality were improved and
intubation time and ICU length of stay were
shorter.

64

826. In certain populations of patients, epidural
analgesia has been associated with
(A) prolonged intubation time
(B) fewer ICU stays
(C) respiratory failure after surgery
(D) poor pain relief if initiated prior to the
surgery
(E) none of the above

826. (B) A large, multicenter, randomized investigation
of epidural narcotics compared to parenteral
narcotics performed in veterans affairs
hospitals found that patients receiving epidural
analgesia had better pain relief, shorter durations
of intubation, and fewer ICU stays. In
contrast, a multicenter trial in Australia that
included both, men and women as well as very
high-risk patients found that epidural analgesia
had no effect on mortality or length of stay.
Postoperative respiratory failure occurred significantly
less frequently, however, in the
patients receiving epidural analgesia. At a minimum,
it appears that epidural analgesia can
produce superior pain relief, particularly if it is
initiated prior to the surgical incision, and it
may be associated with fewer complications
and a lower incidence of respiratory failure
than parenteral narcotics in selected patients.

65

827. Which of the following is a reason for poor
symptom management in critically ill patients
with pain?
(A) The majority of pain scales do not
require patient self-report
(B) For these patients it is easy to titrate
sedatives and analgesics to their desired
level of consciousness, but they are not
encouraged to do so
(C) Physicians and other caregivers feel
uncomfortable about giving high doses
of sedatives, analgesics, and other
mood-altering agents
(D) No need for pain medications as long as
patient is sedated
(E) None of the above

827. (C)
A. Pain and other symptoms also may be
poorly managed because they are subjective
experiences that are not easily assessed by
objective methods. Pain and sedation scales
have been developed to quantify the levels
of pain and anxiety among patients who can
self-report. Nevertheless, some patients cannot
adequately communicate these sensations,
either because they cannot find the
words or because they are intubated and
sedated. To detect pain in these patients,
physicians and other caregivers must attend
to patient grimacing and other admittedly
nonspecific manifestations of pain, including
tachycardia and hypertension.
B. Some patients value symptom relief highly
and would prefer to be rendered unconscious
rather than to experience pain, anxiety,
or dyspnea, especially at the end of
life. Others, however, would be willing to
tolerate these symptoms or have them mitigated
only slightly in order to stay awake.
Dying patients may find it difficult to
titrate sedatives and analgesics to their
desired level of consciousness, although
they should be encouraged to do so.
Physicians and caregivers may find it even
more difficult to achieve the ideal level of
sedation and analgesia for patients who
cannot communicate or administer drugs
to themselves.
C., D., and E. Symptoms may be inadequately
managed because physicians and other caregivers
feel uncomfortable about giving high
doses of sedatives, analgesics, and other
mood-altering agents. In some instances, this
discomfort stems from a reluctance to cause
drug addiction in dying patients, a phenomenon
irrelevant to the patients’ condition.

66

828. Which of the following is a nonpharmacologic
intervention for pain relief in an ICU patient?
(A) Provoking encephalopathy that results
from the hypercapnia and hypoxia in
chronic obstructive pulmonary disease
(COPD) patients if tolerated
(B) Ketosis in terminally ill patients that
forgo nutrition and hydration
(C) Placing patients in a quiet environment
where family and friends may visit
(D) Proper treatment of anxiety and
depression
(E) All of the above

828. (E) Pain can be managed indirectly by nonpharmacologic
means. For example, placing
patients in a quiet environment where friends
and family can visit may diminish the sense of
pain, as may the proper treatment of anxiety
and depression. Although respiratory depression
caused by drugs or underlying disease
usually is undesirable in patients with COPD,
the encephalopathy that results from the hypercapnia
and hypoxia may be tolerated, if not
favored, in terminal patients because it attenuates
pain. Similarly, patients who forgo nutrition
and hydration at the end of life may
develop a euphoria that has been attributed to
the release of endogenous opioids or the analgesic
effects of ketosis.

67

829. Which of the following is a known fact about
opioid infusions?
A) Fentanyl is about 10 times more potent
than morphine
(B) Hydromorphone is more sedating than
morphine and produces more euphoria
(C) Release of histamine during morphine
administration may cause vasodilation
and hypotension
(D) Sedation, respiratory depression, constipation,
urinary retention, and nausea
are side effects that are only seen after
administration of morphine, but not
with the administration of fentanyl or
hydromorphone
(E) All of the above

829. (C) Adirect approach to pain control generally
centers on the use of opioids, and morphine is
the opioid most commonly used. In addition
to causing analgesia, morphine induces some
degree of sedation, respiratory depression, constipation,
urinary retention, nausea, and euphoria.
It also produces vasodilation, which may
cause hypotension, in part through the release
of histamine. Fentanyl, a synthetic opioid that is
approximately 100 times more potent than morphine,
does not release histamine and therefore
causes less hypotension. Hydromorphone, a
semisynthetic morphine derivative, is more
sedating than morphine and produces little
euphoria.

68

830. A 37-year-old female is at the ICU recovering
after major abdominal surgery. Patient is
breathing spontaneously, has stable vital signs,
and is not able to tolerate oral feedings at this
time. Alternatives for administration of opioids
for pain relief include
(A) IV morphine PCA
(B) oral controlled-release oxycodone
(C) transdermal hydromorphone
(D) oral immediate-release oxycodone
(E) all of the above

830. (A) Morphine, fentanyl, and hydromorphone
can be administered orally, subcutaneously, rectally,
or intravenously. Opioids usually are
given by the IV route to ICU patients, including
those who are dying. These agents may be
administered to inpatients and outpatients
alike through the technique of PCA. Longacting
oral preparations of morphine and
hydromorphone are available for outpatients.
Fentanyl can be administered orally in the form
of a lollipop. It can also be given by the transcutaneous
route, which makes this agent particularly
suitable for patients who have
difficulty with oral medications.

69

831. A33-year-old male underwent major abdominal
surgery and is transferred to the ICU for
postoperative management. Which of the following
would be the best choice for postoperative
pain management?
(A) IV hydromorphone PCA
(B) IV fentanyl infusion
(C) Controlled-release oxycodone via nasogastric
tube
(D) Bupivacaine and fentanyl mix via
epidural catheter
(E) None of the above

831. (D) Many benefits of epidural anesthesia have
been reported, including better suppression of
surgical stress, more stable hemodynamics,
better peripheral circulation, and reduced
blood loss. Aprospective, randomized study of
1021 abdominal surgery patients demonstrated
that epidural opioid analgesia provides better
postoperative pain relief compared with parenteral
opioids. Furthermore, in patients undergoing
abdominal aortic operations, overall morbidity and mortality were improved and
intubation time and ICU length of stay were
shorter.

70

832. In order to prevent atelectasis and pulmonary
complications in patients at the ICU
(A) pain management is important in maintaining
a balance between splinting and
sedation with hypoventilation
(B) it is important to titrate opioids to the
lowest possible since respiratory depression
is detrimental in these patients
(C) hyperventilation from mild to moderate
pain is beneficial for faster recovery;
opioids should not be administered during
this period of time
(D) epidural analgesia has no role in preventing
pulmonary complications and
minimizing intubation time in these
patients
(E) none of the above

832. (A) Atelectasis is most often seen in postsurgical
or immobilized patients. As alveoli collapse,
there is increased shunting with resultant
hypoxemia. Additional findings are related to
the degree of atelectasis and include diminished
breath sounds and reduced lung volume,
elevated hemidiaphragm, or consolidation on
chest radiography. Associated fever usually
abates with reinflation, but the collapsed alveoli
are prone to bacterial colonization with the
development of pneumonia. Treatment is
aimed at reexpansion of collapsed alveoli.
Maintenance of airway patency and pulmonary
toilet are of primary importance. Pain
management is pivotal to balance splinting
with sedation and hypoventilation. Pneumonia
is common in the ICU, particularly among ventilated
patients and those with direct lung
injury. The clinical presentation involves fever,
leukocytosis, hypoxia, a distinct radiographic
infiltrate, and purulent sputum with bacterial
colonization. Respiratory support, pulmonary
toilet, and antibiotics are the fundamentals of
treatment