Pain Flashcards by Ambra Copping

Describe the first step in the WHO analgesic ladder:

Non-opioid:
Paracetamol
NSAIDs
Topical treatments (NSAIDs, lidocaine, capsaicin)
± adjuvant

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Describe the second step in the WHO analgesic ladder:

Mild opioid as an alternative or an addition:
Mild to moderate pain
Codeine/ dihydrocodeine/ tramadol
Limited potency at the MU receptor
± adjuvant

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Describe the third step in the WHO analgesic ladder:

Strong opioid to replace the mild opioid:
Moderate to severe pain
Morphine/ diamorphine/ oxycodone
Fentanyl/buprenorophine/ alfentanil
Strong potency at the MU receptor
± adjuvant

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Name and give examples of adjuvant therapies in the WHO ladder:

Anti-epileptics (neuropathic)- pregabalin, gabapentin, carbamazepine (TN)
Anti-depressants- TCA, SSRIs
Other- dexamethasone, bone pain in palliative
Non pharmaceutical- physio, exercise, psychological

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What is the evidence for the use of opioids?

Acute pain in palliative care
Limited evidence of efficacy in long term pain:
-if don’t achieve useful pain relief in 2-4 weeks unlikely to gain long term benefit
No efficacy with high dose (>120mg/ day morphine/ equivalent) due to lack of trial data

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What are the risk of treatment with weak opioids?

Metabolism of weak opioids
Cyp2D6 enzyme- converts codeine into morphine
Interpatient variability dependent on gene expression (if a supermetaboliser and breastfeeding can pass more morphine to baby)
Unpredictable variation in efficacy and toxicity

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What are the signs of overdose of an opioid?

Pinpoint pupils
Pale skin
Blue lips (cyanosis)
Unconscious
Shallow/slow breathing
Snoring/gasping for breath

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What are the aspects of the NEWS2 score that indicates an opioid overdose?

Resp rate <8bmp (normal= 12-20)
O2 sats can be <85% (96-99%)
HR= tachycardia
BP= high or low
Sedation score= VPU higher

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What does VPU stand for in the NEWS2 score?

V= verbally
P= pain
U= unconscious/unresponsive

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What is the non-pharmacological treatment for lower back pain (musculoskeletal)?

Exercise (aerobic) programmes and manual therapies- spinal manipulation, massage (as part)
Psychological therapies- CBT (as part)
Return to work programmes

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What is the pharmacological treatment for lower back pain (musculoskeletal)?

NSAIDs- look at CI
Weak opioids for acute lower back pain if NSAIDs CI or ineffective
Do not offer paracetamol alone

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What is the pharmacological treatment for sciatica?

Do not offer gabapentinoids/antiepileptics/ benzodiazepines
If already prescribed, discuss problmes and withdrawal
Limited evidence of NSAID benefit
Do not offer opioids
Epidural injections (acute and severe sciatica)

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What are the main medications indicated for neuropathic pain?

Amitriptyline
Duloxetine
Gabapentin
Pregabalin

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What are other medications that can be used for neuropathic pain?

Tramadol only if acute rescue therapy needed
Capsaicin cream for localised pain who with to avoid oral- normal for burning/stinging
Carbamazepine for trigeminal neuralgia

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What is the initial pain relief in palliative care?

24 hour pain relief- simple analgesia or strong opioid, no max dose of opioid
Begin with anticipatory (PRN) injection

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Name and state the doses of the anticipatory injection in palliative care:

Morphine SC 2.5-5mg 2-4 hrly (eGFR >60)
Oxycodone SC 1.25-2.5mg 2-4 hrly (eGFR 30-60)
Alfentanil SC 125-250mcg 2-4 hrly (eGFR <30)

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When would a patient need a syringe driver in palliative care?

If needing 3 or more injections in a 24 hour period, may be less than 3 in certain situations

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What is the treatment for breathlessness in palliative care?

Opioid/ midazolam- slows down breathing

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What should be co-prescribed with opioids in palliative care?

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Naloxone- toxicity

Which surgeries would NSAIDs not be used for pain and why?

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Not in fracture of hip or pelvis as affects bone recovery
IV paracetamol is used

When would you use oral opioids for post-operative pain?

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Moderate/severe pain expected- larger/complex procedure
Not with PCA or opiate epidural
Aids in recovery- get coughing relax back and mobilise pt quicker

When would gabapentin be used for post-operative pain?

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If neuropathic post op pain- orthopaedic/ thoracic chest drain insertion (temporary treatment)

What are the monitoring requirements for patients on PCA?

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BP/pulse/RR/sedation/pain score/nausea (opioid effects)
First 8 hours= hourly
8-24 hours= 2 hourly
48 hours- end= 4 hourly

What should be administered for N&V in PCA?

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Cyclizine (oral/IM prn)
Ondansetron (oral/IV/IM)
Can have protocols so nurse can give without prescribing

What should be administered for pruritis in PCA?

Chlorphenamine 4mg TDS

What should be administered for respiratory depression in PCA?

Oxygen and monitor sats Stop PCA Consider naloxone 200-400mcg- may need repeated admin as short t1/2

What should be administered for excessive sedation in PCA?

Remove PCA Oxygen sats, pain, sedation Ensure adequate non-opioid analgesia presented

What are epidurals co-administered with and why?

Both emergency only Naloxone Ephedrine- combat any hypotension due to epidural

What is the rescue therapy for administering IV bupivacain?

Intralipid 20% to reverse cardiac arrest risk of life threatening toxicity

What is the rescue therapy for a dural puncture headache?

Blood patch Injected with own blood in hope of creating a seal around hole

What is a dural puncture headache?

The hole has been made by the spinal needle, sometimes can cause leakage of CSF and can cause pressure in rest of fluid e.g in CNS to be decreased so can lead to severe headache- late onset

What is a tension headache?

Most common cause Thought to be due to muscle spasm in neck/scalp Can be caused by emotional stress (tension, anxiety, fatigue, dehydration)

What is the pain like in a tension headache?

Mild to moderate Non-throbbing, vice like, a feeling of 'tightness or squeezing', weight pressing down on head Usually affects both sides of the head- mainly front of head May worsen throughout the day

What is the pain like in cluster headaches?

Excruciating unilateral headache Accompanied by red eye, lacrimation, nasal congestion, rhiborrhoea (runny nose), facial sweating, miosis (pupil constriction), droopy eye lid and eye lid oedema May be mistaken for an eye injury

What is the first line treatment for headaches if they don't impact the patients life?

Paracetamol

What is the second line treatment for a headache if it does impact a patients life?

Paracetamol Codeine (30-60mg 4-6 hourly)- OTC doesn't reach evidence based dosages ±ibuprofen

What is the third line treatment for a headache if it means a patient can't carry on with every day activities?

Paracetamol Opioid e.g morphine, fentanyl, oxycodone ±Ibuprofen

What should be used for breakthrough pain with a headache?

If ongoing daily pain relief not helping- give 1/6 amount of main opioid getting in a day

Name the divisions of migraines:

Classical migraine Common migraine Abdominal migraine Migraine associated with childhood travel sickness

Describe a classical migraine:

Migraine with aura (15%) Focal neurological disturbance

Describe a common migraine:

Migraine without aura (85%)

Describe an abdominal migraine:

Migraine in children (3-10%) 50% remission after puberty Often GI symptoms- stomach cramps, withdrawing from play, not like loud noises, nausea

Describe the diagnosis points to be classed as a migraineur:

At least 5 repeated attacks of headaches lasting 4-72 hours which have these features: At least 2 of: -unilateral pain -throbbing pain -aggravated by movement -moderate/severe intensity At least 1 of: -N&V -phono/photophobia

What are the CI of the triptans?

IHD- 5HT subtypes in coronary area Uncontrolled hypertension Over 65

What are the SEs of the triptans?

Tiredness and dizziness (common) Heaviness on chest and throat

What should be the counselling points with the triptans?

If the migraine disappears but then reappears can take a second dose after 2 hours have passed If doesn't disappear originally then not effective to take a second dose

Name drugs that can be used for migraine prophylaxis:

B blockers- propranolol Pizotifen (rare) Methysergide TCA- amitriptyline Anticonvulsants (valproate/topiramate) OTC feverfew- limited evidence

Pain Flashcards

(47 cards)