Ortho > Pain Management > Flashcards

Pain Management Flashcards

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1
Q

Inpt pain management?

A
  • controlled enviro: need for pain control over at least 12 hrs
  • PCA: usually written on pre-printed order sets - usually have loading dose, PCA dose, lockout interval, 4 hr limit
  • choice of morphine, fentanyl, deluded, demerol
  • need coherent pt, attentive staff, Narcan taped to pump and bowel program
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2
Q

Pain management - inpt for sporadic pain control?

A 
- need to be able to adjust:
Toradol IM/IV
morphine IM/IV
Dilaudid IM/IV
Demerol/Phenergan IM: most pts however can usually be controlled w/ oral meds
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3
Q

Management for acute pain?

A
  • usually in ambulatory setting following injury or post op recovery
  • mix of narcotic and non-narcotic meds
  • don’t forget importance of splinting/bracing/immobilization in ortho pain management
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4
Q

How is chronic pain managed?

A
  • ground rules need to be est early
  • most cases are better dealt w/ through chronic pain providers
  • pain contracts:
    pain med - amt - time period
    drug testing
    providers
    ancillary services: behavior health, biofeedback, PT, OT, hypnosis, osteopathic medicine
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5
Q

Most common narcotics used in ortho pain?

A
  • most in combo w/ APAP
  • codeine
  • hydrocodone
  • oxycodone
  • tramadol
  • hydromorphone
  • meperidine
  • fentanyl
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6
Q

Schedule I drugs?

A
  • use: illegal/restricted to research. No accepted medical use
  • drug or other substance has high potential for abuse
  • lack of accepted safety for use
  • ex:
    hallucinogens, heroin, peyote, coca, psilocybin mushrooms
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7
Q

Schedule II drugs?

A
  • reqr Rx
  • high abuse potential: psych of physical dependence (No refills or verbal orders)
  • ex:
    codeine
    hydrocodone
    hydromorphone
    morphine
    cocaine
    fentanyl
    methadone
    meperidine
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8
Q

Schedule III drugs?

A
  • reqr a Rx
  • moderate abuse potential
  • max 5 refills/6 mos
  • verbal orders allowed
  • ex: some opioid combos
  • stimulants:
    benzphetamine
    clortemine
  • depressants:
    ketamine
    pentobarbital
    secobarbital
    sulfomethane
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9
Q

Schedule IV drugs?

A
  • reqr Rx
  • low abuse potential
  • max 5 refills/6 mos
  • verbal orders allowed
  • benzos, sedatives/hypnotics and now tramadol
  • ex:
    alprazolam
    barbital
    clonazepam
    lorazepam
    midazolam
    phenobarbital
    diazepam
    tramadol
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10
Q

Schedule V drugs?

A
  • reqr Rx or may be OTC w/ restrictions in some states
  • low abuse potential
  • currently accepted medical use in tx
    -ex:
    Robitussin AC
    lyrica
    lomotil
    potiga (anticonvulsant)
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11
Q

Combo of codeine/APAP?

A
  • opioid agonist (binds to opioid receptors)
  • used as antitussive as well
  • schedule III
  • good choice for peds
  • cost approx $15 for 30 tabs
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12
Q

What is hydrocodone? Combos?

A
  • opioid agonist
  • many combo formulations w/ APAP
    lorcet
    Vicodin
    norco
    lortab
    price: 30 tabs for $55
  • schedule II
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13
Q

Oxycodone use? Combo?

A
  • can be combo or not
  • percocet = oxycodone + APAP
  • oxycontin = no APAP: MS-contin, oral morphine sulfat - for chonic pain
  • Opioid agonist: bind APAP to opioid receptors
  • Schedule II
  • Percodan has aspirin instead of APAP
  • cose $100 for 30 tabs
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14
Q

Tramadol (ultram) MOI? combo?

A
  • APAP combo called Ultracet
  • MOA unknown, binds to opioid receptors and inhibits NE/serotonin reuptake: caution w/ seizure hx and cause cause serotonin syndrome
  • schedule IV
  • cost: 30 tabs for $60
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15
Q

Hydromorphone MOA, Schedule?

A
  • Dilaudid
  • MOA - opioid agonist
  • high abuse potential and highly sedative
  • taper dose to D/C
  • schedule II
  • cost 20 tabs/$30
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16
Q

Meperidine MOA, caution, schedule?

A
  • Demerol
  • opioid agonist
  • very sedative
  • seizure risk over time and dose
  • oral route least effective
  • avoid abrupt cessation
  • Schedule II
  • 20 tabs for $30
  • often causes N/V so give Phenergan
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17
Q

Use of Fentanyl? Schedule?

A
  • Duragesic
  • for chronic pain
  • for opioid tolerant pts only
  • major abuse potential
  • need responsible pts and/or caregiver to administer
  • schedule II
  • cost $100 for 5 patches, 1 patch= 3 days dose
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18
Q

Use of NSAIDs in ortho

A
  • anti-inflammatory
  • caution w/ concomitant anticoagulation
  • some studies have suggested NSAIDs may slow down fracture healing
  • all have warnings pertaining to CV risk, GI bleeding, kidney risk
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19
Q

Acetic acid group of NSAIDs?

A
  • Diclofenac, Etodolac, Indomethacin, Ketorolac
  • thought to inhibit cox, reducing prostaglandin and thromboxane synthesis
  • usually fairly cheap and this class is effective for management of arthritis assoc pain (rheum., osteo, ankylosing spondylitis)
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20
Q

Propionic acid groups of NSAIDs?

A
  • Naproxen, Ibuprofen
  • MC OTC grouping
  • still has BBWs
  • Cox 1 and Cox 2 inhibitor, mess w/ prostaglandins
  • can cause GI issues, kidney issues
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21
Q

Cox 2 inhibitor group of NSAIDs?

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A
  • Celebrex
  • many ortho surgeons use in adjunct w/ narcotics following total jt
  • may not interfere w/ anticoag as bad as others, or delay fx repair
  • CI in person w/ sulfa alelrgy
  • less of GI profile
22
Q

Diff steroid formulations?

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A
  • oral: medrol dose pack
    rheum: longer duration, mostly use prednisone, need to taper
  • injectable:
    Triamcinalone-kenalog
    celestone-betamethasone
    depo-medrol-methylprednisolone
23
Q

Why are oral muscle relaxants used?

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A
  • aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone and involuntary movement w/o loss of voluntary motor fxn or consciousness
  • alters the balance of synaptic excitation and inhibition the motor neuron receives
  • primarily to elicit varying degrees of skeletal muscle relaxation
24
Q

Indications for muscle relaxants?

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A
  • for relief of acute painful MSK conditions of local origin
  • as an adjunct to rest and PT
  • for the relief of acute painful MSK conditions which include muscle spasm secondary to trauma, radiculopathy, MSK strain or sprain, herniated intervertebral disc and muscle spasm of OA
25
Muscle relaxants are all ____ depressants?
- CNS depressants so caution w/ elderly - all are well absorbed orally w/ quick effects
26
Caution use of muscle relaxants w/?
- renal and hepatic insufficiency - leukopenia, thrombocytopenia, hemolytic anemia, bleeding agranulocytosis w/ long term use primarily so no initial or F/u labs unless sxs occur - freq. used w/ EToH or opioids for abusive purposes - can have withdrawl from muscle relaxants - taper off to avoid withdrawls
27
When should muscle relaxants not be used?
- in pregnancy - in kids - shouldn't be mixed w/ EToH or other CNS depressants, this will potentiate effects - should only be taken 10-14 days optimally, must revaluate need
28
Guidelines for muscle relaxants use?
- combo muscle relaxant and analgesic agent appear to be preferred - most effective therapy should consider drugs in conjunction w/ various modes of PT - all agents have potential to cause drowsiness, HA, dizziness, and blurred vision, dry mouth - pts shouldn't be tx for protracted periods: initial: 10-14 days eval after to determine need for further therapy - NSAIDs may be useful where pain predominates - for pts w/ anxiety in whom sedation is desireable - Diazepam (valium) should be considered - combo muscle relaxant and analgesics are available, equally effective and less costly: norgesic (asa/caffeine/orphenadrine)
29
What is Carisoprodol (Soma)? | MOA?
- centrally acting skeletal muscle relaxant that doesn't directly relax tense skeletal muscles - MOA: relieving acute muscle spasm of local origin has not been clearly ID, but may be related to its sedative properties - in animals: been shown to produce muscle relaxation by blocking interneuronal activity and depressing transmission of polysynaptic neurons in spinal cord and in descending reticular formation of the brain - one of products of metabolism, meprobamate, is active as an anxiolytic. Its contributing efficacy is unknown
30
Adverse effects of Carisoprodol (soma)?
- shouldn't be used for periods longer than 10-14 days, eval need for further tx - Adverse effects: drowsiness, dizziness vertigo, ataxia N/V hiccups epigastric distress tremor, agitation HA, insomnia tachycardia postural hypotension facial flushing
31
CIs to Soma? Precautions?
CI: - porphyria: inherited porphobilinogen deaminase mutation - abdominal and urinary sxs, periph. neuropathy, systemic and CNS involvement precautions: seizures
32
MOA of cyclobebenzaprine (flexeril)?
- structurally similar to TCAS - relieves skeletal muscle spasm of local origin w/o interfering w/ muscle fxn: onset of action: 1 hr, effects last up to 12 hours, has an anticholinergic effect - shouldn't be used for periods longer than 10-14 days, eval needed for further tx
33
CIs, adverse effects of Flexeril?
CI: - w/ concurrent use of MAOIs - acute phase of MI - arrhythmias - heart block MC adverse effects: - drowsiness** - dry mouth - fatigue - HA less common adverse effects: - constipation - abdominal pain - acid regurg - dizziness - nausea
34
Use of diazepam (valium) as muscle relaxant?
- used as centrally acting skeletal muscle relaxant - diazepam depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition med by GABA - among benzos, diazepam is only agent in this class to be approved for tx of muscle spasm or MSK disorders
35
Use of methocarbamol (robaxin)?
- MOA hasn't been established, may be due to CNS depression - has no direct action on contractile mechanism of striated muscle, the motor end plate or nerve fiber - less sedating than some other muscle relaxants - rx to pts w/ dizziness, risk of falling - can dial down dose as well - start w/ 6 gms/day for first 48-72 hrs and then can reduce down to 4 grams/day - should not be used longer than 10-14 days: eval need for further tx
36
Other muscle relaxants used?
- Metaxalone (skelaxin) - Tizanidine (Zanaflex): indicated for more chronic pain in conjuction w/ other meds - baclofen (Lioresal): for spinal cord injuries
37
How can ortho pain be managed?
- NSAIDs - muscle relaxants - narcotics - steroids - TCAs - GABA analog: gabapentin, valproic acid - OTC: glucosamine, Omega 3s - ice/heat - stretches/exercises - PT/OT - plain films then MRI - osteopathic manipulation/chiropractor - behavioral health for chronic pain - biofeedback/hypnosis/anti-inflam diet - splinting/bracing/immobilization
38
Tx of Grade I ankle sprain?
- most likely inversion injury w/ immediate pain and then some swelling - no sig past hx - consider: NSAIDs - ibuprofen 800 mg 1 po tid-qid or Naproxen 250mg 1-2po bid
39
Tx of Grade 2-3 ankle sprain?
- NSAIDs - ibuprofen, naproxen, indocin 25mg 1 po tid - at noc: vicodin #10 1-2 po q noc prn pain - Percocet probably little too strong but can be considered
40
SEs of vicodin?
``` - 5mg/325mg SEs: - constipation - shallow breathing, slow heartbeat - feeling light headed, fainting - confusion, fear, unusual thoughts or behavior - seizure - problems w/ urination - nausea, upper stomach pain, itching, loss of appetite, dark urine, clay colored stools, jaundice - diversion is a real problem! ```
41
Pt was lifting heavy object when he had sudden sharp, non radiating LBP. No bowel, bladder fever or saddle parasthesia - DTRs 2+ BL, neg SLR, no CVA tenderness - what would you do for this pt?
- Start NSAID: ibuprofen for 3-5 days then prn or naproxen - start a muscle relaxer: Robaxin 500 mg 1-2 po qid x 3 days then prn (Can combine w/ NSAID)
42
What is fibromyalgia? Rfs?
- widespread msk pain accompanied by fatigue, sleep, memory and mood issues - researchers believe fibromyalgia amplifies painful sensations - cause is unknown - RFs: genetics, rheum diseases, physical or emotional trauma
43
Meds for fibromyalgia?
- pain relievers - antidepressants - anti-seizure drugs
44
Pain relievers used for fibromyalgia?
- OTC meds - tylenol - ibuprofen - naproxen - tramadol - narcotics not advised
45
Antidepressants used to tx fibromyalgia?
- Amitriptyline: initial dose 10mg qhs (can icnrease to 150mg) - duloxetine (cymbalta): 30 mg qdx 1 wk then increase to 60 mg qd as tolerated - upon d/c of antidepressant therapy, gradually taper the dose - an alt to amitriptyline is Flexeril - immediate release initial dose is 5 mg, may increase up to 10 mg tid prn - doesn't tx depression
46
Anticonvulsants used to tx fibromyalgia?
- Gabapentin: 300 mg starting dose | - pregabalin: 75 mg starting dose
47
Combo tx for fibromyalgia?
- use if unresponsive to monotherapy - get psych, PT involved - directed at reducing major sxs: chronic widespread pain, fatigue, insomnia, cognitive dysfxn
48
What is reflex sympathetic dystrophy?
- disorder of body region: usually extremites - characterized by severe pain, swelling, limited ROM, and skin changes - inciting event: soft tissue injury in 40% fxs in 25% MI 12% Cerebrovascular accidents 3%
49
Meds for reflex sympathetic dystrophy?
- topical tx: capsaicin cream - glucocorticoids: prednisone 30-80mg/day may be effective - NSAIDs: motrin or naproxen - sympathetic blockers: propranolol - alpha 1 adrenoceptor antagonist: Terazosin, prazosin - opioids: for severe pain
50
How do you ID drug seeking behavior?
- distinguish medical use from abuse, monitor response to tx - know medical and nonmedical use - characteristics: request for early refills multisourcing intoxicated behaviors pressuring behaviors
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