Pain management


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Pain management

  2. 2. INTRODUCTION Pain is a warning that something is wrong. It pre empts other signals. Pain by Sherrington is “the physical adjunct of an imperative protective reflex”. It is a subjective term and can be defined as a sensory and emotional experience
  3. 3. PHYSIOLOGICOVERVIEW• The sense organs for pain are the naked nerve endings found in almost every tissue of the body.• The pain impules are transmitted to the CNS by 2 fiber systems;• Small myelinated Ad fibers {fast pain fibers}
  4. 4. PHYSIOLOGIC OVERVIEWCONTD• The neurotransmitters for both include glutamate and Substance P respectively.• Both fibers terminate on the dorsal horn.Some of the axons of the dorsal horn neurons end in the spinal cord and brainstem while others ascend in the lateral spinothalamic tract and
  5. 5. PHYSIOLOGIC OVERVIEWCONTD• The lateral spinothalamic tract fibers project to the ventral posterior nuclei of the thalamus.• From here to the cerebral cortex. As such, pain activates cortical areas( post central gyrus) on the side opposite the stimulus.
  6. 6. MANAGEMENT• The key to accurate diagnosis is a comprehensive history and detailed physical examination. HISTORYa) Explore the painb) Review the systemsc) PMH and SHd) Drug history
  7. 7. HISTORY CONTDe) Family and Social history EXAMINATIONGeneral Physical ExaminationSystemic Examination
  8. 8. INVESTIGATIONS1) Diagnostic Imaging• a) Plain film radiology• b) Fluoroscopy• c) Computed Tomography Scan• d) Magnetic Resonance imaging• e) Myelography• f) Bone Scans
  9. 9. INVESTIGATIONSCONTD• 2) Urinalysis• 3) S E/U/C• 4) FBC + ESR
  10. 10. TREATMEMTa) Pharmcologicb) Neurosurgical Interventionc) Other non-conventional methods
  11. 11. PHARMACOLOGIC:CLASSES OF PAINMEDICATIONS1) Non Steroidal Anti inflammatory drugs[NSAIDS] E.g Aspirin, Diclofenac, Apazone, Ibuprofen, Celecoxib e.t.c MECHANISM OF ACTION• Inhibition of biosythesis of prostaglandins by inhibiting cyclo- oxygenase isoforms• Inhibition of Chemotaxis• Downregulation of IL-1 production• Decreased production of free radicals and superoxide• Interference with calcium mediated
  12. 12. INDICATIONS• Acute pains;inflammatory conditions like tendonitis, bursitis and arthritis.• Pain from bone metastases in cancer patients.• Others are rheumatic fever, transient ischaemic attack,coronary artery thrombosis
  13. 13. SIDE EFFECTS• Gastric upsets, peptic ulcer disease,Elevated liver enzymes and Hepatitis e.t.c
  14. 14. 2) Acetaminophen MECHANISM OF ACTION• Weak inhibitor of Cox-1 and Cox-2 in peripheral tissues• Has no significant anti inflammatory effects• Has antipyretic activity
  15. 15. INDICATIONS• Mild to moderate pains as in headache, myalgia SIDE EFFECTS Dizziness, Hepatotoxicity with high doses etc
  16. 16. 3) Opioids• E.g Morphine, Codeine, Methadone, Fentanyl, Pentazocin, e.t.c MECHANISM OF ACTION Bind to specific G-proteins coupled receptors in the brain and spinal cord regions involved in transmission and modulation of pain.
  17. 17. INDICATIONS Pains associated withcancer SIDE EFFECTSBehavioural restlessness,respiratory depression, nausea,vomiting, constipation e.t.c
  18. 18. 4) Corticosteroids• E.g Prednisolone, Cortisone etc MECHANISM OF ACTION Phospholipase inhibitor INDICATIONS Acute pain and flare-ups of chronic inflammatory conditions like vasculitis, SLE, Sarcoidosis etc
  19. 19. SIDE EFFECTS Insomnia, behavioural changes, acute pancreatitis etc5) Anticonvulsants E.g Neurontin (Gabapentin), Lyrica (Pregabalin) INDICATIONSNeuropathic pain, Fibromyalgia
  20. 20. Local anaesthetics• A) Nerve blocks• B) Epidural anaesthesia ; Patient controlled Epidural anaesthesia (PCEA)
  21. 21. NEUROSURGICAL INTERVENTONS• A) ABLATIVE PROCEDURES• a) Peripheral neurectomy• b) Myelotomy• c) Cordotomy• d) Sympathectomy• e) Dorsal root ganglionectomy
  22. 22. B) AUGMENTATIONPROCEDURES• a) Peripheral nerve stimulation• b) Spinal cord stimulation• c) Deep brain stimulation• d) Implantable infusion systems
  23. 23. OTHER METHODS• Radiotherapy• Acupuncture• Use of ice• Rest• Elevation
  24. 24. Follow up• Chronic pain can be managed but not cured; the majority of patients will require careful and regular follow up indefinitely. Periodic review of medications and careful evaluation of the progression of any underlying disease are important.
  25. 25. CONCLUSION• It is natural to have pains. Medications are a key part of recovery and can speed healing and lead to fewer complications.