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FRCA Final > Pain medicine > Flashcards

Pain medicine Flashcards

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1
Q

UFH (s/c prophylaxis) - NAB timings

A
  • Wait following dose: 4 hours or normal APTT
  • Wait following block: 1 hour
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2
Q

Indications for RF therapy

A
  • Trigeminal neuralgia
  • Cervical cordolay
  • Cervicogenic headache
  • Spinal pain
  • Groin pain
  • Orchidalgia
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3
Q

Define complex regional pain syndrome

A

A chronic pain disorder characterised by:

  • vasomotor
  • sudomotor
  • trophic
  • inflammatory.
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4
Q

What is CRPS Type 1?

A

Symptoms preceded by tissue injury.

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5
Q

What is the previous name for CRPS Type 1?

A

Reflex sympathetic dystrophy

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6
Q

What is CRPS Type 2?

A

Symptoms proceded by major nerve injury

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7
Q

What is the previous name for CRPS Type 2?

A

Causalgia

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8
Q

What is the pathophysiology of CRPS?

A

Unknown. Involves peripheral and central sensitisation and altered sympathetic function

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9
Q

What are the sensory symptoms of CRPS?

A
  • Burning
  • allodynia
  • hyperalgesia
  • sensory defects in CRPS 2
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10
Q

What are the autonomic symptoms of CRPS?

A
  • Vasodilatation:
    • Warm
    • erythematous
    • sweaty
  • Vasoconstriction
    • cold
    • dry
    • white
  • Oedema also occurs
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11
Q

What are the trophic symptoms of CRPS?

A
  • Atrophy of hair, skin and nails
  • Joint stiffness
  • Osteoporosis.
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12
Q

What are the treatment options for CRPS?

A
  • Physiotherapy
  • Pharmacological
  • Interventional
  • Surgical
  • Psychological
  • Alternative
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13
Q

What are the pharmacological treatments options for CRPS?

A
  • Antineuropathic agents
  • Opioids in refractory cases only
  • Corticosteroids
  • Calcitonin
  • Bisphosphonates
  • Free radical scavengers - NAC IV
  • lidocaine infusions
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14
Q

What are the interventional treatment options for CRPS?

A
  • LA sympathetic block i.e. stellate ganglion block
  • Sympathectomies (RF ablation or surgically)
  • Spinal cord stimulation
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15
Q

What are the surgical treatment options for CRPS?

A
  • Surgical sympathectomy
  • Amputation (reserved for most severe cases)
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16
Q

What are the physiotherapy treatment options for CRPS?

A

Graduated exercise programmes

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17
Q

What are the psychological treatment options for CRPS?

A
  • CBT
  • Pain management programmes
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18
Q

What are the alternative treatment options for CRPS?

A

Acupuncture

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19
Q

What is the budapest criteria?

A

A diagnostic criteria for CRPS

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20
Q

What are the 4 budapest criteria categories?

A
  1. Sensory
  2. Vasomotor
  3. Sudomotor/Oedema
  4. Motor/Trophic
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21
Q

What constitutes a diagnosis of CRPS on the Budapest Criteria?

A
  1. Symptoms in excess of the original insult
  2. At least 1 sign in 2 different Budapest categories
  3. At least 1 symptom in 3 difference Budapest categories
  4. No other better explanation for the symptoms
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22
Q

What are the sensory Budapest criteria?

A
  • Allodynia
  • Hyperalgesia
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23
Q

What are the vasomotor Budapest criteria?

A
  • Temperature
  • Asymmetry
  • Skin colour changes
  • Skin colour asymmetry
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24
Q

What are the Sudomotor Budapest criteria?

A
  • Oedema
  • Sweating changes
  • Sweating asymmetry
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25
What are the Motor/Trophic Budapest criteria?
* Reduced range of motion * Motor dysfunction (weakness, tremor, dystonia) * Trophic changes (hair loss, nail changes)
26
UFH (IV treatment) - NAB timings
* Wait following dose: 4 hours or normal APTT * Wait following block: 4 hours
27
LMWH (s/c prophylaxis) - NAB timings
* Wait following dose: 12 hours * Wait following block: 4 hours
28
LMWH (s/c treatment) - NAB timings
* Wait following dose: 24 hours * Wait following block: 4 hours
29
Danaparoid prophylaxis - NAB timings
* Wait following dose: Avoid (consider anti-Xa levels) * Wait following block: 6 hours
30
Danaparoid treatment - NAB timings
* Wait following dose: Avoid (consider anti-Xa levels) * Wait following block: 6 hours
31
Bivalirudin - NAB timings
* Wait following dose: 10 h or normal APTTR * Wait following block: 6 hours
32
Argatroban - NAB timings
* Wait following dose: 4 h or normal APTTR * Wait following block: 6 hours
33
Fondaparinux prophylaxis - NAB timings
* Wait following dose: 26 - 42 hours (consider anti-Xa levels) * Wait following block: 6 - 12 hours
34
Fondaparinux treatment - NAB timings
* Wait following dose: Avoid (consider anti-Xa levels) * Wait following block: 12 hours
35
NSAIDs - NAB timings
* Wait following dose: no additional precautions * Wait following block: no additional precautions
36
Aspirin - NAB timings
* Wait following dose: no additional precautions * Wait following block: no additional precautions
37
Clopidogrel - NAB timings
* Wait following dose: 7 days * Wait following block: 6 hours
38
Prasugrel - NAB timings
* Wait following dose: 7 days * Wait following block: 6 hours
39
Ticagrelor - NAB timings
* Wait following dose: 5 days * Wait following block: 6 hours
40
Tirofiban - NAB timings
* Wait following dose: 8 hours * Wait following block: 6 hours
41
Eptifibatide - NAB timings
* Wait following dose: 8 hours * Wait following block: 6 hours
42
Abciximab - NAB timings
* Wait following dose: 48 hours * Wait following block: 6 hours
43
Dipyridamole - NAB timings
* Wait following dose: no additional precautions * Wait following block: 6 hours
44
Warfarin - NAB timings
* Wait following dose: INR less than 1.5 * Wait following block: following catheter removal
45
List the drugs that require no additional precautions with respect to neuraxial blockade
* Aspirin * NSAIDs * Dipyridamole (wait 6 hours post NAB before dosing)
46
What are the safety features of a PCA?
* Anti-syphon valves * Anti-reflux valves * Kept below level of heart * Naloxone prescription * Handover to nurses on prescription and who to call for help * Regular observations
47
Advantages of PCA
* Flexible to individual requirements * Not reliant on nursing time * Faster alleviation of pain * Patient in control * Reduced anxiety * Better satisfaction
48
Disadvantages of PCA
* Equipment error * Human error * Not suitable for some patients (OA) * Cost/Maintenance of pumps * Regular training of nurses
49
What are some of the NPSA safety recommendations for epidural use?
* Label bags * Ready-to-use bags * Separate storage for LA agents * Yellow colour coding (catheter, bags, pumps) * Rationalise dose range * Dedicated infusion pump * Regular training * Audut * Guidelines
50
What are the indications for TENS?
* Nociceptive pain * Post op * Labour * Neuropathic pain * DM neuropathy * Musculoskeletal pain * Osteoarthritis
51
What are the contraindications to TENS?
* Pacemaker * Epilepsy * Communication difficults (doesn't understand how to use)
52
How does TENS work?
* Not clear * Some evidence of gate theory * Increased endogenous opiod * Decreased descending inhibition * Effect abolished by naloxone
53
Trigeminal neuralgia
Paroxysmal, unilateral severe pain within the trigeminal sensory distribution. Often described as lancinating, sudden, severe and short lived (2 seconds - 2 minutes)
54
What is the incidence of trigeminal neuralgia?
* 5-10/100,000 * F \> M
55
List the trigeminal divisions, and their exit foramina
1. V1 Ophthalmic - **Superior orbial** fissure 2. V2 Maxillary - Foramen **rotundum** 3. V3 Mandibular - Foramen **ovale** **​**Think **SORO**
56
What are the main nuclei of the trigeminal nerve?
* Sensory * Mesencephalic nucleus (proprioception) * Main sensory nucleus (touch) * Spinal nucleus (pain/temp) * Motor nucleus
57
Where is the trigeminal ganlion located
Petrous temporal bone - Meckel's cave
58
What is the aetiology of trigeminal neuralgia?
* Nerve root compression by blood vessels at/near entry of nerve roots into pons * MRI shows blood vessel contact in 90% * Patient wake pain free following decompressive surgery * Nerve condution is immediately improved following decompression * 5% associated with MS * 2% posterior fossa tumours
59
Treatment options for trigeminal neuralgia
* Pharmacological * Carbamazapine * Phenytoin * Baclofen * Lamotrigine * Interventional * EtOH/glycerol/balloon microcompression * Very high complication rate * Sedation * Loss of corneal reflex * Masseter weakness * Dysaesthesia * Anaesthesia dolorosa * Surgery * Microvascular decompression * Gamma knife (less successful)
60
What treatment options are availible for neuropathic pain?
* Gabapentin/Amitriptyline/Duloxetine/Pregabalin * Think "GADuP" in neuropathic pain * Start with gabapentin, then move sequentially though the others. * PRN Tramadol "rescue therapy" * Capsaicin if localised * TENS * 5% lidocaine patches * Spinal cord stimulation * Pain \> 6 months, \>50/100 VAS
61
What is the cure rate for Trigeminal Neuralgia following MVD?
70% at 5 years
62
Pain management of bony metastases
* MDT/palliative care/patient and family centered * WHO analgesic ladder - include ketamine and methadone * Radiotherapy * Bisphosphonates * Percutaneous vertebral augmentation * Epidural steroids
63
Establishing palliative analgesia for the opiate naive
* Use oromorph for 24 hours * Half the dose and give as MST BD * Prescribe 1/6th total dose as breakthrough
64
What pain interventions are availible for palliative care?
* Brachial plexus catheters * Epidurals/intrathecal catheters * Fully external * External with subQ port * Fully implanted * Intrathecal neurolysis * Phenol * Alcohol * Cordotomy (C1/2 spinothalamic - mesothelioma)
65
List some pain assessment tools
* Unidimentional * Numerical Rating Scale (NRS) * Verbal Rating Scale (VRS) * Visual Analogue Scale (VAS) * Multidimentional * The Brief Pain Inventory * The McGill Pain Questionnaire * Hospital Anxiety and Depression Score * Children * COMFORT scale * Wong Baker Scale * FLACC * Patients with communication difficulty * MOBID-2 * Doloplus * PainAID * Abbey Scale
66
Describe the Brief Pain Inventory
* uses NRS (1-10) in a number of different domains * Self administered * Chronic pain is qualified by how it has been over the past 24 hours * Right now * At its best * At its worst * On average * Localisation of pain on a body chart * How much pain interfears with 7 aspects ADLs
67
What is this?
The Brief Pain Inventory
68
Describe the McGill Pain Questionnaire
* Establishes sensory and affective aspects of pain * Strengths * Multidimentional * Validated * Useful for monitoring trends * Weaknesses * Takes time * Relies on patient understanding
69
Describe HADS
* Single questionnaire with * 7 questions for anxiety * 7 questions for depression * Each ranked 0-3 * Total max score 21
70
List some tools for screening for neuropathic pain
* Self completing * LANSS * S-LANSS * Doctor completing * Pain-DETECT * DN4
71
What are the red flags for back pain?
* Signs/Symptoms of cauda equina/cord compression * Immunosupression * Trauma * Hx of cancer * Nocturnal pain * Systemic effects (weight loss, fevers, night sweats) * Thoracic pain * Abnormal gait * Age of onset \< 20 years or \> 55 years
72
What are the yellow flags for back pain?
* A - Attitudes * B - Beliefs * C - Compensation * D - Diagnosis * E - Emotions * F - Family * W - Work
73
What are the primary chemical stimulants for pain activation?
* H+ * K+ * ATP * Adenosine * NO * Histamine * Peptides * Serotonin
74
How is pain transmitted?
* C fibres (unmyelinated, slow, burning, poorly localised) * Ad fibres (myelinated, fast, sharp, well localised)
75
Where do Ad/C fibres synapse?
Rexed lamina 1, 2 (and 5) or the dorsal horn
76
What is the gate control theory of pain?
Activation of Ab fibres in the dorsal horn leads to activation of inhibitory interneurones inhibiting C fibres
77
What are the risk factors for phantom limb pain?
* Lower limb * Previous pain in limb * B/L amputation * Catastrophising * Severe post op pain
78
Treatment options for phantom limb pain
* IV Calcitonin (acute rescue therapy) * Ketamine * Morphine * Gabapentin * Amitriptyline * Sensory discrimination * Mental imagery * CBT * Surgical revision - if a clear cause
79
Pathophysiology of phantom limb pain
* Peripheral * Ectopic discharges from damaged nerves * Upregulation of Na channels * Sensory-sympathetic coupling (similar to CRPS) * Spinal * Ab fibre sprouting in DH * Sensitisation of the DH, mediated by increased NMDA receptors * Central * Cortical remapping
80
What are the complications of a coeliac plexus block?
* Severe hypotension * Bleeding 2° to aortic/caval injury * Intravascular injection * Abdominal organ puncture * Paraplegia (phenol injection into the arteries that supply the spinal cord) * Sexual dysfunction (injected solution spreads to the sympathetic chain bilaterally). * Lumbar nerve root irritation (injected solution tracks backwards towards the lumbar plexus).
81
What are the appropraite solutions for injection during a coeliac plexus block?
* Non-malignant pain: 10 ml 0.5% bupivacaine each side * Malignant pain: 5 ml 6% aqueous phenol + 5 ml 0.5% bupivacaine each side * Always inject region with radio-opaque die first to confirm correct placement
82
What are the indications for a stellate ganglion block?
* Pain syndromes * Complex regional pain syndrome type I and II * Refractory angina * Phantom limb pain * Herpes zoster * Shoulder/hand syndrome * Angina * Vascular insufficiency * Raynaud's syndrome * Scleroderma * Frostbite * Obliterative vascular disease * Vasospasm
83
What are the contraindications for a stellate ganglion block?
* Coagulopathy * Recent myocardial infarction * Pathological bradycardia * Glaucoma
84
Describe the proceedure for a stellate ganglion block
* SLIMRAG * Supine position, neck slightly extended, head turned away, jaw open * Instil a bleb of LA for skin * Needle puncture located: * Between trachea and carotid sheath * At the level of the cricoid cartilage (C6) * Palpate for Chassaignac's tubercle (TP of C6) * Retract sternocleidomastoid and carotid artery laterally as the index finger palpates Chassaignac's tubercle * Press firmly onto the tubercle to reduce the distance between the skin and bone * Direct needle onto the tubercle, then redirected medially and inferiorly toward the body of C6. After the body is contacted, withdraw 1-2 mm * Confirmed needle position by fluoroscopy: checking for spread of radiocontrast cephalad/caudad confirmed in both AP and lateral views. * Aspirate to rule out intravascular placement * Consider small adrenaline test dose as IV injection into the vertebrals can result in significant LA neurotoxicity * Cautiously inject 10-15 ml in 3 ml divided doses with intermittent aspiration * Place patient in the sitting position to facilitate the spread of anaesthesia inferiorly to the stellate ganglion * The onset of Horner's syndrome indicates a successful block.
85
What does the BPS class as weak opiods?
* Codeine * Dextropropoxyphene * Dihydrocodeine * Meptazinol

FRCA Final (21 decks)

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