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Y3 NEUROLOGY > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Behaviour and vital signs (blood pressure, pulse) are reliable indicators of pain. True/False?

A

False

Neither sensitive nor specific - self-reporting is much more reliable

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2
Q

What is allodynia?

A

Pain from a stimulus that is not normally painful

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3
Q

What is hyperalgesia?

A

Pain that is beyond what is expected from a painful stimulus

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4
Q

Which drugs form the WHO ladder for treating pain?

A
  1. Non-opiods: paracetamol
  2. Non-opiods: NSAIDs
  3. Weak opiods: tramadol, codeine
  4. Strong opiods: morphine, oxycodone, hydromorphine, heroin, fentanyl
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5
Q

List some topical analgesics

A 
Capsaicin
NSAIDs (diclofenac, naproxen, ibuprofen)
Rubefacients
Levomenthol
Lidocaine 5% plaster
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6
Q

How do non-selective NSAIDs fight pain? What effect does this have?

A

Inhibit COX1 and COX2 enzymes that convert arachidonic acid into endoperoxides, which reduces prostaglandin synthesis
Reduces nociceptor sensitisation in inflammation

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7
Q

How does paracetamol work? List a side effect

A

Inhibits prostaglandin synthesis

Risk of liver toxicity

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8
Q

How do opioids work?

A

Activate descending inhibitory controls to reduce pain perception and suppress transmission of nociceptive signals in dorsal horn of spinal cord

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9
Q

Anti-depressants can be used for neuropathic pain. How do they work? Give some examples and list some side effects

A

Inhibit noradrenaline and 5-HT uptake
TCAs (amitryptiline), SSRIs (duloxetine)
Constipation, dry mouth, arrhythmias, insomnia, somnolence

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10
Q

List the two main subtypes of pain

A

Nociceptive: an appropriate physiologic response to painful stimulus via an intact nervous system
Neuropathic: an inappropriate response caused by a dysfunction in the CNS

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11
Q

How is pain rated typically in Ninewells?

A

Verbal rating

0: no pain
1: mild
2: moderate
3: severe

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12
Q

Outline the two activation routes that neurotransmitters can take to the brain

A

These neurotransmitters activate lamina 1 NK receptors which travel to the amygdala hypothalamus triggering an affective response.
The also activate lamina V NK receptors which travel to the thalamus and somatosensory cortex triggering a sensory response

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13
Q

What type of fibres are activated by nociceptive stimulus on the skin? Where do they synapse?

A

Painful stimulus on the skin triggers Adelta and C fibres which synapse in the spinal cord, and low threshold mechanoreceptors (LTMs, ABeta fibres)

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14
Q

What neurotransmitters are released when A delta and C gibres synapse?

A

Substance P and glutamate

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15
Q

How is neuropathic pain typically described?

A

Burning, shooting, tingling, sensitivity

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16
Q

List the aetiology of neuropathic pain

A 
Shingles, post-herpatic neuralgia
Surgery
Trauma
Diabetic neuropathy
Amputation
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17
Q

The brain is a fixed structure that does not evolve in the prescence of pain. True/ False?

A

False

The brain exhibits neuroplasticity

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18
Q

What is the mechanism of action of topical analgesics? List some side effects

A

Reduce pain impulses transmitted by Adelta/ C fibres (do not affect the brain)
Rash, pruritis, erythema

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19
Q

Anti-convulsants can be used for neuropathic pain. Give some examples and list some side effects

A

Carbamazepine, gabapentin, pregabalin

Sedation, dizziness, vomiting, ataxia, oedema, weight gain

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20
Q

List types of complementary therapy used in the secondary management of pain

A

PHYSICAL: massage, aromatherapy, acupuncture, TENS, nerve block, spinal cord stimulation
MIND: relaxation, breathing, stress, sleep, hypnosis
PSYCHOLOGICAL: CBT, solution based

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21
Q

Pain perception is consistent for each individual. True/ False?

A

False

Perception is variable depending on degree of nociceptor activity, level of sensory input and behavioural context

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22
Q

List the brainstem regions involved in modifying afferent input, which are excited by electrical stimulation

A

Periaqueductal grey
Nucleus raphe magnus
Locus coeruleus

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23
Q

The nucleus raphe magnus is involved in projecting what type of neurones?

A

Serotonergic neurones (5HT)

24
Q

The locus coeruleus is involved in projecting what type of neurones?

A

Noradrenergic neurones (NA)

25
Q

Where do afferent axons project to, to cause inhibition of nociceptive transmission in the dorsal cord?

A

Dorsolateral funiculus

26
Q

Name the type of receptor which mediates the action of opiods

A

G protein coupled opiod receptor (Gi/o)

27
Q

List the parts of the neurotransmission pathway inhibited by opiod action, and what subtype of Gi/o receptor they are mediated by

A 
Voltage-gated calcium channel (reduces NT release): By subunit
Potassium channel (reduce excitation of projection neurones): By subunit
Adenylate cyclase: a subunit
28
Q

List the three classification of opiod receptors, starting with the one that provides most analgesia

A

mu receptor
delta receptor
kappa receptor

29
Q

List the main respiratory side effect of opiods, and the mechanism for which it occurs

A

Apnoea

Blunting of medullary respiratory centre to CO2

30
Q

List the main CV side effect of opiods, and the mechanism for which it occurs

A

Orthostatic hypotension

Reduce sympathetic tone, bradycardia, histamin-evoked vasodilatation

31
Q

List the main GI side effects of opiods, and the mechanism for which they occur

A

Nausea, vomiting, constipation, increased intrabiliary pressure
Act on CTZ centre outside BBB, increase SM tone, reduce motility via enteric neurones

32
Q

List the main CNS side effects of opiods

A 
Confusion
Euphoria
Dysphonia
Hallucinations
Dizziness
Myoclonus
Hyperalgesia
33
Q

What class of receptor to opiod agonists act on to prolong activation time? List some examples of opiod agonists

A

Mu receptors

Morphine, diamorphine, codeine, fentanyl, pethidine, tramadol, methadone

34
Q

Where is morphine metabolised and excreted?

A

In the liver via gluconoridation into M3G (inactive) and M6G (retains analgesia and excreted by kidneys)

35
Q

What is the clinical indication for diamorphine (heroin)?

A

Used in severe post-operative pain as it enters the CNS rapidly

36
Q

Where is codeine metabolised?

A

Hepatic metabolism by demethylation to morphine by CYP2D6 and CYP3A4

37
Q

Name two semi-synthetic derivatives of codeine with a higher potency

A

Oxycodone

Hydroxycodone

38
Q

Fentanyl has an ____ potency than morphine

A

Higher

39
Q

What is the clinical indication for pethidine?

A

Acute pain during labour

40
Q

What class of drugs must not be used with pethidine and why?

A

MAO inhibitors

Causes hyperthermia, convulsions, excitement

41
Q

What opiod is a partial agonist and can be used in patient-controlled injection systems?

A

Buprenophine

42
Q

Outline the mechanism of action of tramadol

A

Potentation of descending serotonergic and adrenergic pathways

43
Q

Tramadol is contraindicated in…

A

Epilepsy

44
Q

Drugs with longer half lives are more addictive than drugs with shorter half lives. True/ False

A

True

45
Q

What is the clinical indication for methadone?

A

Chronic cancer pain

Withdrawal from strong opiods

46
Q

List some opiod antagonists

A

Naloxone
Naltrexone
Alvomopan, methylnatrexone

47
Q

What is the clinical indication for naloxone?

A

Reverse opiod toxicity (respiratory or neurological depression) with strong opiod overdose
Newborn babies with opiod toxicity due to pethidine use in labour

48
Q

Naloxone is contraindicated in…

A

Opiod addicts or patients who receive high dose opiods regularly

49
Q

It is preferential to inhibit COX2 enzyme as it has greater therapeutic benefit. How can this be achieved?

A

Using selective COX2 inhibitors ‘coxibs’

50
Q

List the to main long-term side effects of NSAID use, and the mechanism behind them

A 
GI irritation (PGE2 protects again acid environment and is produced by COX1)
Nephrotoxicity (COX2 produced by kidney)
51
Q

What is the mechanism of action of gabapentin and pregabalin?

A

Reduce cell surface expression of a2delta subunit of voltage-gated calcium channels which are upregulated in damaged sensory neurones
Reduces the production of neurotransmitters from the central terminal of nociceptive neurones

52
Q

What s the mechanism of action of TCADs? Give some examples

A

Act centrally by reducing uptake of NA

Amytryptiline, nortrypitline, desipramine

53
Q

What is the mechanism of action of SSRIs? Give some examples

A

Reduce uptake of NA
Reduce reuptake of 5HT but have no analgesic effect
Duloxetine, venlofaxine

54
Q

Outline the machanism of action of carbamazepine

A

Block voltage-gated sodium channels that are upregulated in damaged nerve cells

55
Q

Name the main clinical indication for carbamazepine

A

Trigeminal neuralgia

Y3 NEUROLOGY (22 decks)

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