PAIN MANAGEMENT. It is important to know as much about the man who has pain as it is to know about pain the man has Quote by Macnab et al
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1 PAIN MANAGEMENT It is important to know as much about the man who has pain as it is to know about pain the man has Quote by Macnab et al
2 DEFINATION OF PAIN International Association for the study of pain (IASP) Unpleasant sensory and emotional experience associated with actual/potential tissue damage Pts subjective experience described but not how pt in pain looks only description of his subjective feeling matters
3 PAIN Pain is a symptom Is protective in function Occur when tissue injury/damage present May form a disease or syndrome if chronic Initiated peripherally,appreciated centrally and modulated in b/w Pain perception varies from person to person Perception also affected by several factors: physiological,emotional,psychological,environme ntal,cultural,social etc
4 TYPES OF PAIN ACUTE PAIN -Hours-Several days -less than one months duration -cause known and treatable -treament logical and effective -good results and normal life expectancy Examples: postop pain,mi,colics etc
5 TYPES OF PAIN (cont) CHRONIC PAIN - Several Months -relatively uncommon -cause uncertain and difficult to treat -treatment at times only empirical with poor results -Can be-neuropathic-from nerve tissues -somatic-nonnerve tissues -psychogenic from thought disorder Examples:malignancy,post-herpertic neuralgia, sudecks atrophy etc
6 PAIN PATHWAY 3 Neuron pathway 1)Nociceptor-nerve ending Sensory nerve fibre-1 st order neurons Two types-typea fast conducting -type C slow conducting To Spinal cord-dorsal root ganglion-dorsal grey horn- substansia gelatinosa (sorting out centre)- synapse
7 PAIN PATHWAY (cont) 2) Spinothalamic tract for crossed pain fibres -2 nd order neuron to thalamus ( posterolateral ventral nucleus) -Cross Midline 3) Thalamus to cerebral cortex/higher centres -3 rd order Neuron -pain appreciated at cortical level. Several Modulations occur along the pain pathway
8 RESPONSE TO PAIN Sensory -pain perception Motor -withdrawal,immobility,involuntary muscle spasm Emotional -anxiety,fear,anger,uncooperative, depression,aggression Autonomic hypertension,tachycardia,diaphoresis, bradycardia Others urine retention,mi,git motility decrease
9 PAIN MECHANISMS 3 THEORIES 1)specific theory specific stimulus-receptors- -nerve fibres-cns areas 2)Pattern theory -pattern of impulses are programmed in the cord and interpreted in the brain
10 PAIN MECHANISM (cont) 3)Gate theory by Melzack Wall also called Modulation theory -input control in spinal cord operating as gate Explains combat analgesia,pain relief by physical rubbing of skin, topical irritants(liniments),tens, acupuncture
11 PAIN MEASUREMENT Also Subjective 1)Verbal-pt describes the pain 2)Clinical Observation of the pt 3)Visual Analogue Scale(VAS) - Pain Scale )Amount of drug delivered eg PCA
12 PAIN MANAGEMENT 3 ASPECTS INVOLVED 1)PHYSICAL 2) EMOTIONAL 3)RATIONAL
13 PHYSICAL PAIN Mx 1) Remove painful stimuli 2)Prevent neural integration of pain -natural mechanisms -ANALGESICS 3)Nerve block - use LA - -methods-many eg local infiltration,regional block, IV + TQ (Biers block)sympathetic block etc
14 PHYSICAL PAIN Mx (cont) 4)Destructive blocks -chemical blocks-intrathecal alcohol or phenol -intrathecal hypertonic saline -physical means- barbotage(repeated x15 aspiration and replacement of CSF) 5)Neurosurgical procedures
15 PHYSICAL PAIN Mx (cont) 6)Other methods -specific treatment eg tumor resection -DXT eg bone mets -Hormonal eg calcitonin(pagets),ca Breast,CA prostate etc -steroids- act on inflammation,appetite,mood -antibiotics in added infections -CXT eg Hodgkins Lymphoma -etc
16 ANALGESICS Non narcotics-act peripherally -inhibit PG synthesis via cyclo-oxygenase (COX) blockage -COX-two isoenzmes 1and 2 Narcotics -centrally acting on opiate receptors in the CNS
17 ANALGESIC WHO analgesic ladder 1) paracetamol 2)NSAIDS 3)Narcotics Co-drugs eg steroids,antidepressants,anxiolytics,etc
18 EMOTIONAL ASPECT OF PAIN MX Psychological support-gd clinician/pt relationship and explanation Drugs anxiolytics(diazepam) -antidepressants - more in chronic pain Psychosurgery- selective surgery on limbic system(emotion centre) eg cingulotomy
19 RATIONAL ASPECT PAIN Mx Pt helped to learn to live with pain eg -good pt/clinician relationship -group therapy -mental relaxation
20 PRE-EMPTIVE ANALGESIA Acute pain-easier to control when treated early than late. Neural basis-in posterior horn of spinal cord -painful stimulation produce activation of spinal neurons that persist and enhence response to repeated painful stimulation. Useful in post-op pain Mx
21 THANK YOU ALL
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