-
What does PQRST stand for in terms of pain assessment?
- Provokes
- Quality
- Radiation
- Severity
- Time
-
Which drugs does pain caused by renal colic respond well to?
NSAIDs
-
Cautions and Contraindications of NSAIDs
- Caution in elderly - lowest dose for shortest time possible
- Contraindicated in previous or active gastric ulceration
- Cox-2 contraindicated in active gastric ulceration
- Cautioned in hepatic impairment - lowest dose shortest time, avoid in severe disease
- Advised avoid in pregnancy unless benefit outweighs risk, Avoid in third trimester
- Cautioned in breast feeding
- Cautioned in renal impairment - lowest dose for shortest time and monitor renal function - avoid if possible
- Cautioned in cardiac impairment due to renal imparment risk
- Contraindicated in severe heart failure
- COX-2's contraindicated/cautioned in cardiac problems
- Contraindicated in coagulation defects - inc risk thrombus
- Other drugs and disease states
- Contraindicated in allergy to aspirin or NSAIDs
-
Side effects of NSAIDs
- Gastric disturbance
- Hypersensitivity
- Headache
- Dizziness/drowsiness
- Nervousness/depression
- Worsening of asthma
- Blood disorders
- Renal failure
- Hepatic damage
- Fluid retention
-
Key principle of opioid use
Carefully titrate dose against desired effect
-
Most commonly used opiates
- Morphine
- Fentanyl
- Oxycodone
- Codeine
- Tramadol
-
Predictable problems with opioids
- Elderly - challenge high doses
- Children and babies
- Respiratory disease
- Renal failure
- Head injury - monitor
- Addiction
- Acute on chronic pain
-
Advantages of patient controlled analgesia (PCA)
- Patient is in control
- Fast onset
- Reduce side effects
- Reduction in nursing time administering drugs
-
Disadvantages of Patient controlled analgesia (PCA)
- Dexterity
- Understanding
- Safety - relatives should never administer
-
Opioid side effects
- Nausea and vomiting
- Constipation
- Drowsiness/sedation
- Dry mouth
- Pruritus
- Urinary retention
- Hallucinations
- Euphoria
-
Opioid cautions and contraindications
- Cautioned in impared respiratory function and asthma
- Avoid in COPD
- Cautioned in hypotension
- Reduced dose recommended in the elderly
- Cautioned in myasthenia gravis, hypertrophy, obstructive bowel disorders, biliary disease and convulsive disorders
- Contraindicated in acute respiratory depression
- Contraindicated in raised intercranial pressure and head injury and comatose patients
- Avoid or reduce dose in hepatic impairment
- Avoid or reduce dose in renal impairment
-
Which drugs are used for epidural anaesthesia?
Combo of opioid and local anaesthetic
- Diamorphine
- Fentanyl
- Bupivicaine
- Levobupivicaine
-
Epidural anaesthesia cannot be used in...
- patients with clotting irregularities
- allergy to the drugs used
- severe arthritis or spinal deformity
- infection (in the back)
-
Advantages of epidural anaesthesia
- Better pain relief
- If correctly placed all central pain can be blocked
- Patients able to mobilise
- Reduces many opioid side effects
-
Side effects and complications of epidural anaesthesia
- Inability to pass urine
- Itching
- N&V
- Backache
- Headache
- Respiratory depression
- Infection
-
What drugs are used when "stepping down" from epidural anaesthesia?
Oral opioids - morphine, oxycodone
-
When are corticosteroids used for pain relief?
Cancer, head and neck surgery
-
Psychological symptoms of anxiety
- Fearful anticipation
- Irritability
- Poor concentration
- Restlessness
- Sensitivity to noise
- Disturbed sleep
- Poor memory
-
Physical symptoms of anxiety
- Dry mouth
- Difficulty swallowing
- Wind
- Loose motions
- Tinitus
- Blurred vision
- Dizziness
- Constricted chest/difficulty inhaling/overbreathing
- Palpitations/heart pain/missed beats/neck throbbing
- Increased micturation
- Lack of libido/impotence
- Muscular tension
- Panic attacks
-
Panic disorder NICE guidance
Psychological therapy
- Pharmacological therapy:
- SSRI
- 2nd line tricyclics: clomipramine, imipramine
- (12 week trial for 6m then taper off)
-
Generalised Anxiety Disorder NICE guidance
- Immediate treatment
- Support/information/problem solving
- Benzodiazepines 2-4 weeks max
- Sedating antihistamines (unlicensed)
- Longer term care:
- Psychological therapy
- SSRI - start low dose
- SNRI: venlafaxine 75mg/day, duloxetine 30mg/day (max 120mg/day)
- Pregabalin 150mg/day (max 600mg/day)
- Specialists: atypical antipsychotics
- Monitoring: side effects and medication effectiveness 2,4,6,12 weeks
-
Benzodiazepine mode of action
Act on GABA receptors - agonists
-
Benzodiazepines can mask...
depression
-
Long half life benzodiazepines
- Diazepam
- Alprazolam
- Chlordiazepoxide
- Clobazam
-
Short half life benzodiazepines
-
Most addictive benzodiazepine
Lorazepam
-
Benzodiazepine side effects
- Drowsiness
- Lightheadednes
- Confusion
- Ataxia
- Amnesia
- Paroxodical increase in aggression
- Dependence with pronounced withdrawal syndrome
- Headache
- Vertigo
- Hypotension
- Salivation changes
- Gastric changes
- Rash
- Visual disturbances
- Libido changes
- Urinary retention
- Blood disorders
- Jaundice
- Apnoea
-
Symptoms of benzodiazepine dependence/toxicity
- Unsteadiness of gait
- Disarthria
- Drowsiness
- Nystagmus
-
Benzodiazepine withdrawal symptoms
- Insomnia
- Tremor
- Anxiety
- Restlessness
- Tinnitus
- Perceptual disturbances
- Convulsions
- Appetite disturbance
- Weight loss
- Sweating
- Confusion
- Toxic psychosis
-
How to stop benzodiazepines
- Switch to long acting diazepam - equivalence tables
- Reduce dose by 2mg/fortnight
- If symptoms occur maintain dose until improved
- Reduce dose in smaller steps
- Avoid other drug use if possible
-
Beta blockers can be used to treat anxiety
True - physical symptoms only
-
Buspirone in anxiety
- Short term use
- 5HT receptors
- Response takes up to 2 weeks
- Side effects:
- N&V
- dizziness/lightheaded
- headache
- nervousness/excitement
-
Prolonged action hypnotics with "hangover effects" the next day
- Nitrazepam,
- flunitrazepam,
- flurazepam,
- diazepam
-
Short acting hypnotics with little chance of "hangover effects"
- Loprazolam
- lormetazepam,
- temazpam
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