Pain Flashcards by Eilidh Seaton

What is pain

Unpleasant sensory and emotional experience

Associated with actual or potential tissue damage

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What are simple analgesics

Paracetamol

NSAID

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What are opioids

Codeine 
Dihydrocodeine
Co-codomol (8/500 or 30/500) or codydramol
Morphine
Oxycodone
Fetanyl

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What are other options for pain relief

Tramadol - small opiate + 5HT / NA reuptake inhibitor 
TCA 
Anti-convulsants
Ketamine - NMDA receptor antagonist 
LA
Nerve block 
Spinal and epidural 
Topical - capsaicin

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Action of paracetamol

Inhibits prostaglandin synthesis

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What is it good for

Mild pain
Very effective with NSAID
Severe pain in combination with other drugs

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Almost none
Very cheap and safe
Liver damage in overdose so caution in impairment

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How is it given

Oral
Rectal
IV - adjust dose according to weight

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Action of NSAID (Ibuprofen / Aspirin / Diclofenac)

Inhibit enzyme cyclo-oxygenase which is used in prostaglandin and thromboxane synthesis

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What are NSAID good for

Nociceptive pain

In combination with paracetamol

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When do you have caution with NSAID

GI pathology - peptic ulcer
Bleeding / anti-coagulation 
Impaired renal
Sensitive asthmatics
Elderly 
Aspirin CI in children due to risk of Reye's

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What do opioids do and how do you give

Act peripherally and centrally at opioid receptor to inhibit transmission off pain (analgesia)
Can give by all route but must convert dose

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What are the SE of opioids

Resp depression as decreased sensitivity to CO2
N+V so give with anti-emetic
Constipation - decreased motility
Miosis

Other 
Headache 
Urinary retention 
Bradycardia
Hallucination 
Sedation

Release of Histamine

Bronchospasm
Hypotension (vasodilation)
Itch and wheels
Phlebitis

Endocrine

Inhibition of ACTH / prolactin / FSH / LH
Increased ADH

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Why are opioids controlled drugs

Due to addictive nature

Risk of tolerance and dependence

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What is morphine useful for

Moderate - severe acute nociceptive pain I.e. hip fracture
Give 10mg IV
Chronic cancer pain

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What are disadvantages of morphine

Significant first pass metabolism
COnstipation
Resp depresion
Addiciton

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What should oral dose of morphine be compared to IV

3x larger

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What is codeine good for

Mild-moderate acute nociceptive pain

Best given regularly with paracetamol

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What is codeine not good for

Chronic pain

Cause constipation

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What is tramadol and how does it act

Weak opioid plus inhibitor of serotonin and Na reputake

Acts at spinal cord to dampen pain transmission

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Benefits of tramadol

Less resp depression
Can be used with other opioids and simple analgesia
Not a controlled drug - now controlled

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When do you use

NO justification as first line unless other opioid CI

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Disadvantages

N+V
Caution in epilepsy as lower seizure
Caution if use with TCA / SSRI as lower seizure

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How does amitriptyline (TCA) work

Increases descending inhibitory signals

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What is it good for

Neuropathic pain | Depression / poor sleep

Disadvantages

Anti-cholinergic SE - Glaucoma - Urinary retention so do not give if BPH - CI MG

What anti-convulsants are useful for pain and what role

Gabapentin / Pregabalin = 1st line Carbamazepine Sodium valproate Membrane stabiliser so reduce abnormal firing of nerves Good for neuropathic pain

What are 4 steps of pain transmission

Periphery Spinal Cord Brain Modulation

What happens at periphery

Tissue injury Release of prostaglandin / substance P Stimulation of pain receptors Signal travel in nerves

What nerves carry pain

A delta | C

What happens at spinal cord

Nerves synapse Cross over Travel up opposite site to brain

What happens in brain

``` Synapse in thalamus Connect to many part of brain Cortex = perception Limbic Brain stem ```

What is modulation

Descending pathway from brain to dorsal horn which usually decreases pain signal

Gate theory of Pain

Distractive stimulus blocks pain fibres from going to brain

What are pathological mechanisms which can lead to increases pain

Increased receptor number Abnormal sensitisation Chemical changes in dorsal horn Loss of normal inhibitor modulation

How can you classify duration of pain

Acute Chronic Acute on chronic

Acute pain

Recent onset | Usually nociceptive

Chronic pain

>3 months After normal healing Often no identifiable cause

How do you classify mechanism of pain

Nociceptive | Neuropathic

Nociceptive pain

``` Due to stimulation of pain receptor Obvious tissue injury or illness Protective Sharp +- dull Well localised ```

Neuropathic pain

``` Caused by primary lesion or dysfunction of nervous system Leads to abnormal processing Injury may not be obvious No protective function Burning / shooting / pins and needles ```

How do you manage pain at periphery

RICE NSAID LA

How do you manage pain at spinal cord

``` Acupuncute TENS LA Opioids Ketamine ```

How do you manage at brain

Psychological Opioids Amitryptilline Paracetamol

What are non-drug Rx

``` RICE Surgery Acupuncture Physio TENS Psychological Nerve block Fracture fixation ```

What should pharmacological Rx be

``` High enough to control Flexibility to allow for fluctuation Avoid SE Polymodal as synergistic Oral where possible ```

What do you do for acute pain

WHO pain ladder

What do you do for neuropathic pain

Alternative - TCA / anti-convulsant Psychological Non-drug

What do you do for mild pain on ladder

Non-opioid Paracetamol +- NSAID

What do you do for moderate

Paracetamol +- NSAID + mild OPOID Start with codeine then dihydrocodeine - usually 30 Co-codomol (paracetamol 500+codeine 10) Co-dydromole (paracetnaol 500 + dihydrocodeine 10)

What do you do wfor severe

Paracetamol +-NSAID + Strong opioid - Morphine Miss out middle

What do you do as pain resolves

Move down ladder | Continue bottom layer

What is RAT approach

Recognise pain Assess Treat Reassess

How do you assess pain

Severity Pain score - rest and movement Type of pain - acute / chronic / cancer / nociceptive / neuropathic Other factor

What other factors affect

Physical - other illness Psychological - anger / anxiety / depression / support How is it affecting patient

How can pain relief be given

``` Oral Rectal Inhalation - entonox Sublingual SC Transdermal IM IV - bolus vs PCA Epidural ```

What is an epidural

LA + opioid into epidural space

How can LA be administered

``` Local infiltration Epidural + opiate Intrathecal + opiate Wound catheter Nerve plexus catheter ```

What should you always investigate

Unexpected level of pain Pain suddenly increasing Pain associated with change in vital signs

How can you assess pain

``` Verbal - on rest and movement Numerical Visual analogue Siling face Abbey pain ```

What do you do if opiate addicted

Contact pain team or drug and alcohol nurse | Nerve block instead ?

When is spinal analgesia good

Surgery in lower half of body

What is preferred option post-abdominal

Epidural | Helps prevent post - op resp compromise due to pain and constipation from drugs

What is PCA

Patient controlled | Morphine usual drug of choice

What is 1st line neuropathic

Amityptline or pregabalin or Gabapentin

2nd line

Both Refer to pain sepicalist Tramdaol in interim

Pain Flashcards

(66 cards)