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YA - Interactive seminars/University lectures > MISC - Pain management > Flashcards

MISC - Pain management Flashcards

1
Q

What is Pain?

A

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

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2
Q

(3) types of Classification of Pain

A
  1. Duration
    - Acute
    - Chronic
    - Acute on chronic
  2. Cause
    - Cancer (progressive)
    - Non cancer
  3. Mechanism
    - Nociceptive (physiological)
    - Neuropathic (pathological)
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3
Q

What is a chronic pain?

A

– Pain persisting beyond healing of injury

– Often no identifiable cause

– (Pain lasting for more than 3 months)

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4
Q

Describe nociceptive pain

A
  • Obvious tissue injury or illness
  • “Physiological pain”

• Can be further classified into
– Superficial somatic
– Deep somatic
– Visceral

• Descriptions include sharp, aching, dull, throbbing, cramping and pressure

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5
Q

Describe neuropathic pain

A
  • Nervous system damage or abnormality
  • “Pathological pain”
  • Tissue injury may not be obvious

• Description
– Burning, shooting ± numbness, pins and needles
– Not well localised

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6
Q

How is nociception not the same as pain?

A

Pain is multifactorial not only injury based.

Factors include: beliefs/concerns, psychological factors (anxiety, depression, anger), cultural issues, other illnesses, coping strategies, social factors.

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7
Q

What are the 4 steps of pain physiology (sequence)?

A

– Periphery

– Spinal cord

– Brain

– Modulation

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8
Q

What happens at the periphery as one of the 4 steps of pain physiology?

A
  • Tissue injury
  • Release of chemicals
  • Stimulation of pain receptors (nociceptors)
  • Signal travels in Aδ or C nerve to spinal cord
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9
Q

What happens at the spinal cord as one of the 4 steps of pain physiology?

A
  • Dorsal horn is the “first relay station”
  • Aδ or C nerve synapses (connects) with second nerve
  • Second nerve travels up OPPOSITE side of spinal cord (decussate at the level of spinal cord)
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10
Q

What happens at the brain as one of the 4 steps of pain physiology?

A

• Thalamus is the “second relay station”

• Connections to many parts of the brain
– Cortex
– Limbic system
– Brainstem

• Pain perception occurs in the cortex

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11
Q

What happens during modulation as one of the 4 steps of pain physiology?

A
  • Descending pathway from brain to dorsal horn

* Usually decreases pain signal

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12
Q

What is the “second relay station” for pain?

A

Thalamus

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13
Q

What is the “first relay station” for pain?

A

Dorsal horn

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14
Q

Compare peripheral vs. central neuropathic pain

A

• Peripheral
– Damaged nerves (e.g. trauma, diabetes)
– Abnormal firing of nerves

• Central
– Changes in “wiring”
– Abnormal firing
– Loss of modulation

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15
Q

List (6) medications used for analgesia

A 
Paracetamol (Acetaminophen)
NSAIDs
Opioids
Tramadol
Amitriptyline
Anti-epileptic drugs
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16
Q

Describe paracetamol as an analgesic

  • mechanism of action
  • indications
  • SE
  • drug interactions
  • monitoring
A

• Mechanism of action
– Unclear but acts in CNS
– Inhibits peripheral prostaglandin synthesis
– Analgesic and antipyretic

• Indications
– Analgesia either alone or in combination

• Adverse effects
– Hepatic necrosis

• Drug interactions
– Effects are additive with NSAIDs

• Monitoring
– Safe dose is up to 4 g per day in adult

17
Q

Describe NSAID as an analgesic

  • mechanism of action
  • indications
  • SE
  • drug interactions
  • monitoring
A

• Mechanism of action
– Non specific inhibition of COX1 & 2 to inhibit PG synthesis
– Analgesic, antipyretic, anti-inflammatory

• Indications
– Analgesia alone or in combinations

• Adverse effects 
– Peptic ulceration
– Renal impairment
– Anti platelet action
– Bronchospasm in asthmatics
– Exacerbation of CCF

• Drug interactions
– Reduce opioid requirements by 20-40%

• Monitoring
– Care with renal impairment or hypvolaemia

18
Q

Describe opioids as an analgesic

  • mechanism of action
  • indications
  • SE
  • drug interactions
  • monitoring
A

• Mechanism of action
– Mu opioid receptors to produce analgesia
– Site of action is the peripheral nociceptors, dorsal horn, cerebral cortex and descending tracts

• Indications
– Severe pain

• Adverse effects
– Sedation, respiratory depression
– Nausea, euphoria, miosis, bradycardia, postural hypotension, urinary retention

• Drug interactions
– Other sedative agents

• Monitoring
– Sedation, CV and respiratory

19
Q

Describe tramadol as an analgesic

  • mechanism of action
  • (+)
  • (-)
A

• Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation) -> hence do NOT use with SSRI/SNRI.

• Advantages
– Less respiratory depression
– Can be used with opioids and simple analgesics
– Not a controlled drug

• Disadvantages
– Nausea and vomiting

20
Q

Describe amitriptyline as an analgesic

  • mechanism of action
  • (+)
  • (-)
A

• Increases descending inhibitory signals

• Advantages
– Cheap, safe in low dose
– Good for neuropathic pain
– Also treats depression, poor sleep

• Disadvantages
– Anti-cholinergic side effects (glaucoma, urinary retention)

21
Q

Describe anti-epileptic drugs as an analgesic

  • examples
  • mechanism of action
  • indications
A
  • Carbamazepine (Tegretol)
  • Sodium valproate (Epilim)
  • Gabapentin/Pregabalin

• “Membrane stabilisers”
– Reduce abnormal firing of nerves

• Good for neuropathic pain

22
Q

What is The RAT Approach to Pain Management?

A
  • Recognize (does the pt have pain?)
  • Assess
  • Treat (non pharm & pharm)
23
Q

How do you assess pain?

A

• Measure the severity
– What is the pain score?
• At rest
• With movement

– How is the pain affecting the patient?
• Can the patient move, cough?
• Can the patient work?

Measurement of severity: verbal (mild, moderate, severe), numerical, visual

24
Q

How do you treat pain non-pharmacologically?

A 
Non-Drug Treatments
– RICE:  Rest, ice, compression, elevation of injuries – Nursing care, physiotherapy
– Surgery, acupuncture, massage, TENS 
– Psychological
• Explanation and reassurance
• Input from social worker / pastor
• Relaxation, imagery, distraction
• Coping strategies
25
Q

How do you treat mild nociceptive pain pharmacologically?

A

• Paracetamol (± NSAID)

26
Q

How do you treat moderate nociceptive pain pharmacologically?

A

• Paracetamol (± NSAID) + codeine/oxycodone/tramadol

27
Q

How do you treat severe nociceptive pain pharmacologically?

A
  • Paracetamol (± NSAID) + morphine/oxycodone
  • Regional anaesthesia
  • Adjuvants (alpha 2 agonists, NMDA antagoinists)
28
Q

How do you treat neuropathic pain pharmacologically?

A 
– Traditional drugs may not be as useful 
– Use other drugs early
• Amitriptyline
• Carbamazepine
• Gabapentinoids

Don’t forget non-drug treatments

29
Q

Which sites are you targeting in multimodal drug treatment?

A

Peripheral nociceptors

Peripheral nerves (A-delta, C)

Dorsal root ganglia

Dorsal Horn

Ascending tracts

Cortex

Descending inhibitory modulation

YA - Interactive seminars/University lectures (87 decks)

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