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Pain (Clinical
presentation (Character
Dull, aching, poor localisation…
Pain
Clinical
presentation
Character
Dull, aching, poor localisation (visceral)
Sharp,well localised (somatic)
Tingling/burning/stabbing.shooting (neuropathic)
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Timing
Intermittent (colic, breakthrough)
Constant (somatic, neuropathic)
Exacerbating/relieving factors
Exacerbating: movement (somatic, incident)
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Classification
Pathophysiology
Colic (tube spasm)
Neuropathic (nerve damage)
Somatic (surface)
Visceral (internal organ)
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Diagnosis
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Investigations
Bedside
Obs (sats, RR, HR, BP, temp)
Pain scoring (1-10 scale, line scale, faces)
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History
HPC: SOCRATES
PMH: previous pain, med conditions
DH: usual meds, analgesia, allergies
SH: support, occupation
Definition
Pain
Unpleasant sensory/emotional experience associated with actual or potential tissue damage or described in terms of such damage
Concious, subjective experience
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Pathophysiology
Pain fibres
C-fibre: unmyelinated, slow (dull, poorly localised)
Ad-fibre: myelinated, fast (sharp, well localised)
Transmission
Dorsal horn spinal cord
Synapse with 2nd order neuron
Decussate and ascend in spinothalamic tract
Somatosensory cortex, cingulate cortex and limbic system
Management
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Medical
(WHO Pain Ladder)
Principles
By mouth (PO where possible)
By clock (fixed intervals, continuous relief)
By ladder (stepwise approach)
By individual (patient need, no max for opiates)
Attention to detail (inform pt, time carefully, monitor SEs)
Steps
Step 1 (non-opioid)
Indication: mild pain, inflammatory pain
E.g. paracetamol, NSAID
Step 2 (weak opioid)
Indication: mild-mod pain
E.g. codeine, dihydrocodeine, tramadol
Step 3 (strong opioid)
Indication: mod-severe pain, cancer pain, background pain
(long-acting e.g. MST), incident (fast acting e.g. oromorph)
E.g. morphine, diamorphine, oxycodone, fentanyl
MOA: agonise Mu receptors; short onset e.g. oromorph and and long-acting e.g. MST, zomorph
Dose: no ceiling dose; breakthrough dose = 1/6 daily dose
Route: PO, IV (including syringe drivers), SC, patches, transmucosal/buccal, nasal spray
NB: care in hepatic/renal patients
SEs: constip (laxative), nausea (anti-emetic), sedation, visual hallucinations (haloperidol), resp dep, myoclonus, mioisis, dry mouth, confusion, euphoria, itching, tolerance, depend, toxicity
Adjuvants
Indication: add on to above; good for e.g. neuropathic pain
E.g. antidepressants, anticonvulsants, steroids
Beyond ladder
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Anaesthetics
E.g. lidocaine, ketamine