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Dealing with Pain and Fever in the Pharmacy Pain: Latin. poena = “punishment” (reflects the deleterious effects that can be inflicted upon the body) “ unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ” International Association for the Study of Pain Mechanism of Perception of Pain: The sensory component of pain results from transmission of peripheral pain impulses to the CNS by nociceptors and nociceptive nerve fibers. Mechanism of Perception of Pain: Afferent pain impulses Through the dorsal route ganglion Synapse with Ascending fibres to the brain dorsal horn of spinal cord Efferent fibres to the periphery- complete the circle Many substances involved e.g. Substance P, bradykinin, histamine, prostaglandins Mechanism of Perception of Pain: normally a balance exists between excitatory and inhibitory neurotransmissions Perceived pain, either acute or chronic occurs when this balance changes, resulting in exaggerated responses and sensitization Pain due to Noxious stimuli (e.g.mechanical, thermal) Acute (immediate) “fight-or-flight” epinephrine release Ongoing tissue damage/diseases Release of pain-facilitating mediators: prostaglandins, histamine, bradykinen Chronic Pain Classifications Acute: • • • • Duration of 0 to 7 days. The cause may be known or unknown. usually occurs as part of a single and treatable event. a result of traumatic injury, surgical procedure, or a medical disorder. • often (not always) associated with autonomic nervous system responses (tachycardia, hypertension, diaphoresis). • decreases with time. • Examples of diagnoses that are associated with acute pain include: fractured femur, appendicitis, burns, procedural pain. 9 Acute exacerbation of a recurring painful condition: Pain can occur over any duration of time. Pain is due to chronic organic nonmalignant pathology. Examples of diagnoses that include acute exacerbation of a recurring painful condition are the following: sickle cell pain episodes and migraine headache. There are pain-free episodes between the exacerbations. 10 Chronic/persistent pain: Chronic (persistent) pain is pain that lasts longer than the expected time of healing. There is continuous pain or the pain recurs at intervals for months or years. In some cases, there are acute exacerbations of chronic pain problems. The cause is often unknown. Examples of chronic/persistent pain include the following: low back pain, diabetic neuropathy, post herpetic neuralgia, multiple sclerosis, and phantom pain. Cancer pain: Pain caused by “conditions that are potentially life- threatening.” The causes of cancer pain are: cancer itself, treatment of cancer and concurrent disease. Examples of cancer pain include the following: cancer of the pancreas, spinal cord compression caused by tumor infiltration, postsurgical pain associated with cancer treatment, post mastectomy syndrome. 11 Management of Pain: Acute and chronic malignant: - indications for aggressive drug therapy. - Take analgesics on a regular basis to prevent the recurrence of pain not “as needed” > “i-e after the pain recurs” - Sometimes additional mechanisms are involved- inflammation > NSAID Types of Pain Somatic Visceral Neuropathic Pain of all three types can be either acute or chronic. Pain-associated conditions responsive to OTC analgesics: Headache Myalgia Periarticular pain Arthralgia Headache: A symptom: primary or secondary Results from dysfunction, injury or displacement of pain-sensitive cranial structures. Headache Muscle contraction.Tension HA Vascular HA / Migraine Other Types of HA Vascular/ Muscle Contraction HA Traction HA e.g. Side effect, sinus HA, eye strain, dental pain Chronic daily HA (medication overuse) Headache: 1. Muscle Contraction / Tension HA: - Results from tight muscles at upper back, neck, occiput or scalp. - Bilateral, diffuse- at top of head- extend. Aching ‘tight’ pressing- gradual in onset, worsens through the day. - Associated with emotional stress/anxiety- may last several days (Acute or chronic) - OTC analgesics for acute types - Chronic types: physical therapy + relaxation NOTE In 2005, neurological research has isolated the temporalis muscle as the primary center of tension headache pain and possibly common migraine pain (Boyd, 2005) 2. Migraine HA (vascular HA) - Mainly women (3 times more) Attack: 3 hrs--- up to 3 days (av. 24 hrs) Migraine: recurrent, hemicranial, throbbing Triggers: stress, fatigue, oversleeping, fasting, vasoactive substances in food, caffeine, alcohol. Menses and changes in BP; - Maybe caused by medications: nitrates, OCPs, indomethacin, HRTs) - IHS: recognises 7 types of migraine BUT for practicality classical OR common Classic Migraine (with aura) Accounts for < 25% of migraine cases visual or neurological aura over 5-20 minutes and can last for up to 1 hour Within 60 min of aura ending HA starts Pain unilateral, throbbing, moderate to severe, sometimes generalized and diffuse. Physical activity and movement intensify pain. Nausea (1/3 sickness). Photophobia, Phonophobia, fatigue, concentrating difficulty. Migraine Phases (1) Premonitory (prodrome phase): occur hours or possibly days before the headache. Change in the mood or behaviour. Feelings of wellbeing, yawning, poor concentration and food craving. Those features are highly individual but are relatively consistent to each patient. (2) HA with or without aura (3) HA subsides, the patient may feel lethargic, tired and drained before recovery which may take several hours and is termed the ‘resolution phase’. Types of Aura • Visual aura: scotomas (blind spots) or fortification spectra (zig-zag lines) or flashing and flickering lights. • Neurological: pins and needles typically starts in the hand, migrating up the arm before jumping into face and lips. Flashing lights scotoma Fortification spectra Common Migraine (without aura) 75% of sufferers No aura All other symptoms the same 3. Cluster headache Predominantly affects men aged 40-60 HA occurs same time each day, last 10 min-3h 50% of patients: night-time Woken 2-3 h after sleep with steady intense unilateral orbital pain. Conjunctivitis and nasal congestion (watery) is experienced at same side of head as HA Ch.ch: periods of acute attack, typically a number of weeks- few months (1-3 attacks per week) Nausea is usually absent and family history uncommon Referral to the doctor. OTC unlikely to be effective 4. Vascular- Muscle contraction HA: - - Patients with daily tension headaches and occasional migraines Either type can precipitate the other 5. Other Causes of HA **Sinus Headache: - infection/blockage of the paranasal sinuses > - inflammation/distension of the sensitive sinus walls. Localised: peri-orbital, forehead area with stooping, blowing nose. Upon awakening, subside after a while OTC analgesics + decongestants Persistent > bacterial infection> Dr. Headache: - All secondary causes of HA except sinusitis need to be referred. - Fever, hangover, some NSAIDS (like what?) - eye strain, infection (e.g. meningitis), depression, anxiety, glucoma > OTC not effective - Temporal arteritis, raised ICP - ‘weekend’HA Secondary HA: Glucoma: frontal HA with pain in the eye. Sometimes, but not often, the eye appears red and is painful. Vision is blurred and the cornea can look cloudy. In addition, the patient may notice halos around the vision. Meningitis: severe generalized HA associated with fever, an obviously ill patient, neck stiffness, a positive kernig’s sign (pain behind both knees when extended) and latterly a pupuric rash all classically associated with meningitis Meningitis is notoriously difficult to diagnose. Any child has a difficulty in placing the chin on the chest, has a headache and is running a temperature over 38.9 Referred urgently Meningitis When to Refer? HA unresponsive to analgesics HA in children < 12 y/o with stiff neck or skin rash HA occurs after recent (1-3 months) trauma injury HA that lasted for > 2 weeks Nausea and/or vomiting in the absence of migraine symptoms Neurological symptoms (in absence of migrain) especially change in conciousness New or severe HA in patients over 50 Symptoms indicative of cluster HA Very sudden or severe onset of HA Myalgia Dull, constant diffuse pain of the muscles cause by: Systemic infection (e.g. infuenza, measles) Strenous exersion Prolonged tonic contraction (e.g. exercise, poor posture) • OTC analgesics should be started soon after the injury. Adjunctive: heat, massage. • Remobilisation after injury healed is important, otherwise: weak, tight, overly contracted muscles, trigger points may arise •R.I.C.E: beneficial. ice, vapo-coolant spray, trigger point injections (= Local anaesthetic to facilitate mobilisation) Periarticular Pain: injury or inflammation to the tissues surrounding the joint ( joint capsule, ligaments, tendons, bursae) Localised tenderness, pain associated with movement of structure. knee, shoulder, elbow Responds well to OTC analgesics and limitation of movement Arthralgia: Joint pain often caused by synovitis (inflammation of synovial membrane). Cartilage loss may occur (e.g. in DJD, RA). • Osteoarthritis (DJD) • Reumatoid Arthritis (RA) -In wt bearing joints: hips, knee, lumbar spine -mainly: multiple joints, fingers, hands, wrist and feet -Paracetamol is analgesic of choice, wt loss - joints warm, red, swollen, -For acute flares: NSAIDs, local heat -more than OTC (NSAIDs): education, physical therapy, motion limited > deformity Pain Assess the patient's level of pain or discomfort. Doctor/Pharmacist should enquire about: - Aetiology Duration Location Severity Factors that or pain Acute Pain “The Patient’s Pain Is What They Say It Is” Measuring Acute Pain Adults Verbal Rating Scales None Mild Severe Numerical Rating Scales 0 = no pain Moderate 10 = worst pain ever Visual Analogue Scales Measuring Acute Pain Children 3-7 yrs Assessment of Pain: It is important to use validated scales for pain assessment: Visual Analogue Scale (VAS): marking on a 10cm line distance that represents pain, measure then record 1-100 Verbal numerical rating scale 0----------10 Treatment of Pain Fever Fever is defined as a body temperature that is higher than the normal core temperature of 37.8ºC (average 36.4 ºC –37.2 ºC ) Rectal > 38.8 ºC Oral >37.8 ºC Axillary > 37.2 ºC Complications of Fever: Serious complications are rare Harmful effects: dehydration, delirium, seizures, irreversible neurologic/muscular damage and coma If > 41.1ºC However, even lower temp can be lifethreatening: infants, people with heart D, brain tumor or haemorrhage, CNS infections, preexisting neurologic disorder >> febrile seizures Febrile Seizures: seizures associated with fever in the absence of another cause (e.g. acute metabolic syndrome, CNS inflammation) in 2-4% of children (6mths-5 years) • Simple • Complex -No longer than 15 mins -> 15 mins - do not recur during single episode - repetitive during the episode - no focal features - in children of -No neurologic sequelae - exhibit focal features/signs preexisiting/latent epilepsy Febrile Seizures: although magnitude and rate of temp are determinants of febrile seizures, however, the temp at which the child will seize is unpredictable. high risk: previous seizure, family Hx, documented CNS disorder. Prophylaxis: antiepileptics (DOC: valproate, diazepam) are reserved for those at high risk. Prevalence of epilepsy may be higher after a febrile seizure. Measurement of body temperature Measurement of body temperature Axillary, tympanic, oral, rectal - During the course of illness > use same thermometer wash hands thoroughly before and after Types of thermometers: Mercury-in-glass Electronic thermometer Tympanic thermometer Skin thermometer Types of thermometers: oral ~ bulb: thin, long to reach well under tongue rectal ~ bulb: short, thick, permit insertion with little risk of breakage rectal ~ can be used orally Never the opposite (why?) Never use the same thermometer for both oral and rectal measurements The main indication for treatment of fever is: Patient discomfort Arguments against treatment of fever: 1. The benign and self-limited course of fever 2. The possible elimination of a diagnostic or prognostic sign 3. The untoward effects of antipyretic drugs 4. Fever is not associated with harmful effects unless temperature exceeds 41.1 ° C 5. The attenuation of enhanced host defenses (i.e. possible therapeutic effects of fever) Arguments against treatment of fever: An evidence: fever is an adaptive response & elevated body temperature maybe beneficial: A. certain microbes may be thermolabile, growth is impaired by higher-than-normal temperature Clinical evidence: treatment of chickenpox with paracetamol, or rhinovirus with ASA: resulted in longer duration of symptoms than no treatment B. Low grade fever may also have beneficial effects on host defense mechanisms (e.g. antigen recognition, T-helper lymphocyte function, leukocyte motility) - But these effects have not been shown to favorably alter the course of infectious diseases Treatment Goals The major goal of self-treatment is to alleviate the discomfort of fever by reducing the body temperature to a normal level General Approach: antipyretic around the clock and continued for at least 24 hours + nonpharmacologic measures Exclusions for self-treatment of fever: 1. 2. 3. 4. 5. 6. 7. patients > 3 months old with rectal temperature ≥ 40 ° C children < 3 months old Symptoms of infection impaired O2 utilization (e.g. severe COPD, respiratory distress, heart failure) Impaired immune function (e.g. cancer, HIV) CNS damage (e.g. head trauma, stroke) Children with Hx of febrile seizures or seizures Non-pharmacologic: - light clothing, remove blankets, room temp (25.6° C) - Hydration: increase fluid supply (by at least 1oz/hour) - Hydrotherapy: (sponging) if > 40° Csponging with tepid water, 1 hour after antipyretic intake Not recommended in children < 40 ° C (why?) Treatment of Fever: children predisposed to seizure: - The doctor should be contacted at the 1st sign of fever - Antipyretic should be given every 4 hours with one dose during the night - Anticonvulsants given by the doctor - If febrile-seizure occurred sponge with tepid water