Week 12 - Management of Acute (short-term) Pain Flashcards
What is pain
A sensory and emotional experience with actual or potential tissue damage
Different Types of Pain:
1. Neuropathic = nerves affected (shooting / tingling pain)
2. Noiciceptive = tissues affected (sharp, throbbing, ache)
- can be somatic (soft tissue / m.skeletal) or visceral (internal organs)
3. Nociplastic = pain pathway is altered / no evidnec of damage
4. No apparent cause
AND
1. Acute or chronic
- if short term pain isn’t managed well can become chronic pain
2. Primary (has no reason / underlying cause for pain)
3. Secondary (has underlying cause)
- treatment based on targeting this cause
Primary + secondary can exist together
Pain can be influenced by:
- pre-exisiting pain
- psychological experiences
- indiviudual perception
What is Acute pain
Pain that lasts up to 12 weeks / 3 months
- Most are self-limiting
- Need to be able distingusih difference between recurrent acute pain outbursts and chronic pain
- Becomes chronic when persists longer than 3 months, expected time frame fof healing for that injury
How do we assess acute pain
(SLE Questioning)
- Can use pain scales to self-report pain
- HOWEVER this is subjective to each patient’s perceptions
- e.g. graphic scales (smiling to sad face), numbers (1-10), terminology (mild to severe) - Behavioural changes in children, patients with dementia etc.
- Inconsolable children
SLE Questioning:
- Need to use open ended questions in consultations i.e. tell me more about pain, sites, radiating pain?
- Is there any exacerbating or relieveing factors
- Are they using any other medications
- Have they got any other symptoms
- Have they got any co-morbidities
- Severity of pain, what pain feels like
- How long pain has lasted, when did it begin (onset)
Where is acute pain a problem
- Community pharmacy - OTC sales
- menstrual pain, migraine, headache, tooth ache, back pain, sports injury - Secondary Care
- Tramua, burns, childbirth, post-op pain, sickle cell crisis etc.
When analgesics may be used ^
Probelm to treat in:
- babies + children
- elderly
- renal failure / impairment
- respiratory disease
Step Wise Approach - WHO Ladder
Has 3 Steps (which have sub steps within them)
Step 1 = mild pain
- non opiod used
- adjuvant analgesic used
Step 2 = mild to moderate pain
- weak opioid
- adjucant analgesican can be used
Step 3 = moderate to severe pain
- stronger opioid
- adjucant analgesics can be used
Can step up or step down as pain intestity changes
Step Wise Approach for Mild to Moderate Pain Management- NICE
AGE 16+
- Paracetamol (QDS)
- know doses for age, weight-related dose
- look for hepatic injury (will have to ↓ dose if severe)
- caution in alcohol dependace, malnutrition, dehydration - Replace paracetamol with ibuprofen (NSAIDs)
- 400mg TDS (OTC)
- USE LOWEST effective dose for shortest period of time - Add paracetamol (to ibuprofen)
- No improvement replace ibuprofen with naproxen (KEEP paracetamol)
- 250-500mg BD (OTC menstural pain ONLY) - No improvement ADD weak opioid to paracetmaol and/or NSAID
- e.g. codeine, tramadol
NOTE: must get to the full / max. therapeutic dose of drug before substituing / replacing that drug for another
NSAID NOTES:
- If NSAID contrainidictaed (CI) use weak opiod at step 2
- Check renal function / co-morbidities esp. in elderly
- check for allergies etc. can make asthma worse
- check for history of GI ulcers or bleeding
- CI if have svere heart failure
Avoid combination drugs as 1st line
What analgesisa is used in children (>3 months to 16)
1st Line:
Paracetamol or Ibuprofen
- ensure parents / carers using correct dose for age + weight of child
- check adherance to dosing schedule before switching therapy
- can use both (alternate dosing i.e. shorter intervals between dosing) if one alone isn’t contolling pain well
Step Wise Approach for Severe Pain Management - WHO
- Start with strong Opioid
- e.g. Morphine (oral, IV, IM)
- if have renal impairment metabolite of drug can accumulate = drowsiness, side effects
- e.g. Oxycodone and Fentanyl
- safer = NO accumulation - Work down WHO Ladder
- i.e. swap to weaker opiod, non-opiod, adjuvants
How to use opioids safely:
- Dose is titrated against effects on pain
- Observe patient for desired and adverse effects of medication
- If on weak opioid may need higher dose to get same amount of pain releief
- Consider age, weight, renal function, co-morbidietes which may alter opiods effectiveness
- Monitor for any opiod side effects
NOTE: would still use paracetamol / anagelsics
Severe pain may occur after heart attack, post-op etc.
What 2 ways do we manage post-operative pain
- PCA (patient controlled Analgesia)
- Used if have trauma, sicle cell crisis - Epidurual Analgesia
- Used in childbirth, after major surgical procedures
How does PCA manage Post-operative pain
Get a small repeated dose, press button when strt feeling pain = dose admisntered to keep them within therapeutic window
PCA may be used for 24hr to several days
- Need a large bolus dose to intitially get patient into therpeautic window
- Puts patient in control via handheld button (attached to a pump)
- Machine has lockout period (e.g. pre-set 5 min.)
- If analgesics isnt therpeutic lockout period isn’t decreased the bolus dose is increased
- Used for morphine, oxycodone and fentanyl
- Patient is observed for over sedation, drowsiess, controlled pain etc. for every hr, then every 4 hrs
- MUST be patient ONLY pressing button
How do we step down from PCA
- Step down to oral opioid
- Dose of oral is decided depending on the previous PCA use over the last 24 hrs (convert IV dose to oral dose)
- Dose may still be titrated
- Change and convert any other analgesia patient may have been taking IV
How does epidural analgesia manage post-operative pain
Before used patients are given a book + have to conset
- Given opioid + local anaesthetic via a fine catheter into the epidural space
- Needles is removed + catheter remains in place + is taped to the pateints back
- Patient is attached to pump
- Catheter position depedns on where operation site is (to block paibn signal from specific area)
- Close monitoring of patient is required
Side Effects:
- itching (as opoids can release histamine)
- nausua, vomiting, drowsiness
- respiratory depression
- hypotension, bradycardia
- headache (rare but can be severe)
- monitor for sensory block NOT motor block
Joint pain
Red flags, Treatment
Classed as mechanical (activity related) or inflammatory (osteoarthiritis)
- Common in hands, feet, hips and knees
RED FLAGS:
- Too painful to move
- Severe swelling, discolouration, bleeding
- Persistent pain, swelling
- Feeling unwell, fever
- Tingling or numbness
if have red flag need to signpost to relevant HC
TREATMENT
- 1st line = NSAIDs (OTC)
- start with topical (if NO benefit try oral ~ 2nd line)
- Should do stregthening and flexibility excercises
- Weight management (reduce pressure on joints)
Back Pain
Pain ranging from neck to lower back, bum and legs
Identifying:
- Underlying cancer diagnosis
- Recent trauma, injury
REFERAL:
- Loss of bowel / bladder clontrol
- Radiating pain down legs
- unexplained weight loss
- neuropathic pain (may require other drugs)
Treatment for mild to moderate pain:
1. Analgesics
2. Rest
3. Gentle excercise + stretching
4. Use of hot + cold packs
