IFE TAIWO - PAIN MANAGEMENT

1. PAIN MANAGEMENT
Presented by:
Taiwo Ifedolapo
100400

2. INTRODUCTION
Definition:
Pain is an unpleasant sensory or emotional experience
associated with potential or actual tissue damage or
described in term of such damage.
Pain is an unplesant phenomenon that is uniquely
experience by each individual; it cannot be adequately
defined, identified, or measured by an obsever.
; it cannot be adequately defined, identified, or
measured by an observer

3. Benefit of Pain Sensation
• Pain is an important sensory symptom. Though it is an
unpleasant sensation, it has protective or survival
benefits such as:
1. Pain gives warning signal about the existence of a
problem or threat. It also creates awareness of injury.
2. Pain prevents further damage by causing reflex
withdrawal of the body from the source of injury
3.Pain forces the person to rest or to minimize the
activities thus enabling rapid healing of injured part.
4.Pain urges the person to take required treatment to
prevent major damage

4. Pathway of Pain
• Portion of the nervous system responsible for
sensation and perception of pain can be divided
into three;
i. Afferent pathway
ii. Central nervous system
iii. Efferent pathway
• The afferent portion is composed of:
a. Nociceptors (pain receptors)
b. Afferent nerve fibers
c. Spinal cord network

5. • First afferent neuron (first order) terminate in the dorsal horn of the
spinal cord
• Second afferent neuron creates spinal part of afferent system
(spinothalamic tract)
• The portion of CNS involved in the interpretation of the pain signals
are the;
• limbic system
• reticular formation
• thalamus
• hypothalamus
• cerebral cortex
• The efferent pathways; composed of the fibres connecting the
reticular formation, midbrain, and substantia gelatinosa, are
responsible for modulating pain sensation.

6. Pain processing
• Pain processing involves 4 elements:
1. Transduction
2. Transmission
3. Modulation
4. Perception

7. Pain processing
• Transduction: is the event whereby noxious stimulus (thermal,
chemical, electrical, or mechanical) are converted to action
potential.
• Transmission: it occurs when the action potential are conducted
through nervous system via first, second, and third order neuron
which has their cell bodies located in the dorsal root ganglion,
dorsal horn, and thalamus respectively.
• Modulation: modulation of pain transmission involves altering the
afferent neural transmission along the pain pathway. Modulation
could either be inhibition or augmentation.
• Perception is the final common pathway which results from
integration of painful input into the somatosensory cortex and
limbic cortex.

8. TYPES OF PAIN
• Duration:
i. Acute: < 3 months
ii. Chronic: > 3months
• Mechanism:
i. Nociceptive
ii. Neuropathic
• Origin:
i. Somatic
ii. Visceral
• Situation:
i. Incidental
ii. Procedural

9. ACUTE PAIN
• Pain of recent onset and limited in duration
• It gets resolved in 3months.
• It usually have an identifiable source(injury,
surgery) in most cases.
• Usually short duration and improves with time
• It’s the most commonly experienced type of pain
throughout the world.
• It serves as a protective function and promote
survival

10. Examples of Acute pain
• Toothaches
• Labour pain
• Menstrual cramp
• Acute headache
• Burn pain
• Acute postoperative
pain
• Traumatic pain
• Severe or medical
illnesses e.g. pain
from pancreatitis
• Acute pain related to
cancer or cancer
treatment

11. Clinical features of Acute pain
• Pallor
• Tachycardia
• Hypertension
• Crying
• Grimacing

12. ACUTE PAIN CHRONIC PAIN
Acute in onset Gradual or vague
Clear means of relief
Relief may not come even
with various intervention
It is protective Doesn’t serve any useful
purpose

13. Management of pain
Goal of pain management :
1. Stop or alleviate pain
2. To prevent progression and aid healing
3. To restore normal lifestyle and improve
quality of life

14. Pain Assessment
• It involves identification of:
i. Source of the pain
ii. Nature of the pain
iii. Location of the pain
iv. Intensity of the pain
• It requires:
i. Detailed history
ii. Examinations
iii. Investigation

15. • History: P Q R S T
a. P – precipitating and relieving factors
b. Q – quality of the pain (colicky, stabbing,
squeezing)
c. R - radiation
d. S - site and severity
e. T - timing and treatment hx (medication
taken)

16. • Examinations
i. Physical examination
ii. Psychological examination (for chronic)
• Investigations:
i. Abdominal ultrasound
ii. CT scan
iii. MRI

17. Pain assessment tools
1. Verbal – rating scale
2. Numerical – rating scale
3. Visual – analogue scale
4. Facial – scale

18. Verbal – rating scale
• It classified pain into:
i. No pain
ii. Mild pain
iii. Moderate pain
iv. Severe pain
v. Excruciating pain
• It’s the least scale of assessing pain

19. Numeric – rating scale
• It involves line graded from 0 to 10
i. 0 : no pain
ii. 1 – 3 : mild pain
iii. 4 – 6 : moderate pain
iv. 7 and above : severe pain

20. Visual – analogue scale
• Similar to numeric – rating scale but more
objective
• It involves plain line of 10cm (0 – 10cm)
• Patient point to the level of pain
• It require some level of cognition , therefore
its used for conscious patient and research
purposes.

21. Facial scale
• Used for paediatric patients
i. Smiley face
ii. Angry face
iii. Indifferent face

22. METHODS OF CONTROLLING
PAIN
• Pharmacological
• Non-pharmacological
• Psychological
• Supportive care

23. Pharmacological
(Analgesia)
A. Opioids
i. Strong opioids : Morphine, Pethidine, Fentanyl
ii. Weak opioids: Tramadol, Pentazocine, Codeine
B. Non-opioids
i. NSAIDS :
a. Non-selective COX inhibitors :
Salicylate(aspirin), Acetate (Diclofenac,
Indomethacin), Ibuprofen, Oxicam(Piroxicam)
b. Selective COX inhibitors : Celecoxibs,
Rofecoxib
ii. Acetaminophen

24. Tramadol
• A weak opioid
• It’s a centrally acting analgesic
• Blocks uptake of nor-adrenaline and serotonin
• Comes in 50mg/ml for injectable, 100mg/tablet
Side effects:
1. Nausea and vomiting
2. Arrhythmia
3. Sedation

25. Morphine
• A strong opioid
• Basically employed for severe or post-operative
pain
• Employed in cancer pain management
• Dose: 0.1 – 0.15mg/kg
Side effects :
1. Respiratory depression
2. Vomiting
3. Constipation

26. Acetaminophen
• Paracetamol ; a paraminophenol derivative
• Its both an analgesic and antipyretic with poor anti-
inflammatory effect
• Works by inhibiting prostaglandin synthesis via CNS
inhibition of COX
• Its metabolized in the liver
• Its hepatoxic at larger dose by inhibiting glutathione
• Comes in ; 150mg/ml for injectable, 500mg/tablet
• Dose : 10 – 15mg/kg
• 15 tablets causes hepatic necrosis

27. WHO III Strong opioids
Mild pain (0-3) :
pain not from surgery
Moderate pain (4-6) : pain from
minor surgery e.g. ganglion removal
Severe pain (7-10) : pain from
major surgery e.g. thyroidectomy,
cardiothoracic surgery
± Adjuvant
± Adjuvant
± Adjuvant
WHO IV Regional block, nerve block
TENS
WHO pain
Ladder
Updated
WHO class II Weak opioids
WHO class I NSAIDs
Worse imaginable pain
e.g. terminal pain, cancer pain

28. Conclusion
• Pain is a complex protective phenomenon
which errands most hospital presentations,
thus a need to be well equipped in the
knowledge and act of management of this
noxious stimulus.

29. References
• Class note ;Dr Olajumoke , HOD Department
of Anaesthesia, LTH
• BARASH. Clinical Anesthesia, 7th Edition
• Smith and Aitkenheads Textbook of
Anaesthesia, 6th Edition
• K Sembulingam - Essentials of Medical
Physiology, 6th Edition