Download ODESSA STATE MEDICAL UNIVERSITY

ODESSA NATIONAL MEDICAL UNIVERSITY
FAMILY MEDICINE AND GENERAL PRACTICE DEPARTMENT
Subject Title: “General Practice - Family Medicine”
Students’ Study Guidelines for practical sessions for 6th year Medical Faculty
students
MODULE 1: «ORGANIZATIONAL ASPECTS OF PRIMARY HEALTHCARE IN
UKRAINE, ITS PRIORITY ROLE IN THE DEVELOPMENT AND REFORM OF
HEALTHCARE. FEATURES OF OUTPATIENT CARE»
CONTEXT MODULE 5: “Emergency Medical Aid in an Outpatient Setting”
LESSON 11: «FIRST AID FOR THE PAIN SYNDROME IN FAMILY PRACTICE»
Year: 6 th
Faculty: Medical
Approved
By the department methodical board
“____”_____________20__
Protocol № ______
Department Head
___________Velichko V.I., M.D., PhD.
Odessa
PRACTICAL SESSION AT THE THEME:
«FIRST AID FOR THE PAIN SYNDROME IN FAMILY PRACTICE » - 4
HOURS
I.
Relevance of the topic (current applicationes): Pain affects quality of life,
and sometimes represents an immediate danger to life of the patient, then immediate action from the
doctor determine the fate of the patient. With various pain syndromes found a doctor in any
specialty almost daily. It is therefore necessary knowledge of the topic by general practitioners.
Every doctor should be able to recognize the pain syndrome and identify its cause, to be able to
assess the expression of pain and the severity of the patient's condition; own methods of providing
emergency care and anesthesia for pain.
II.
Educational objectives (goals and objecties):
Know:
- Etiologic factors and classification of pain
- Clinical diagnostic features of the pain syndrome of various etiology and localization
- Methods for emergency care and anesthesia for pain syndrome, including the painful shock.
Be able to:
- Be able to assess the degree of manifestation of pain and severity of the patient,
- Identify the cause of pain,
- Make intramuscular, intravenous, subcutaneous injection, infusions injection,
- Tourniquet to stop bleeding,
- Conduct activities intensive care (mechanical ventilation, indirect heart massage),
- Provide immediate assistance when pain syndrome, including pain in shock.
Master the skills:
- Diagnosis of pain, recognition of the causes of pain,
-Determining
the
degree
of
manifestation
of
pain
and
severity
of
the
patient,
- Appointment of an adequate therapy for pain syndromes of different etiologies, necessary
manipulation,
- Prescription for medications for relief of pain.
III. Tasks for independent work:
1. Repeat anatomic structure of the nervous system and receptors.
2. Repeat phenomenon, etiology and classification (by localization, time of occurrence and other) pain,
disease and urgent conditions that can accompany pain syndrome (coronary heart disease, diabetic
neuropathy, cancer, renal colic, cholecystitis, trauma, intercostal neuralgia, talamical syndrome,
psychosomatic disorders, etc.).
3. Repeat the term "pain syndrome", its clinical manifestations, diagnosis and possible implications;
concept of "pain shock" and "traumatic shock"; vegetative and cognitive disorders accompanying pain
syndrome.
4. Explore types of pain (somatogenic, neurogenic, psychogenic), their properties, signs, diagnosis,
examination with pain syndromes.
5. Explore methods of relief of pain syndromes, including pain at the shock (pharmacotherapy, auxiliary
treatment). Repeat method for subcutaneous, intramuscular, intravenous injections and infusions.
6. To study the content of the topic.
III.
The content of the theme sessions (Topic Contents):
Worldwide, the pain is one of the most frequent reason for seeking medical help.
Pain is the most frequent symptom of the disease, psycho-physiological reaction, occurred when a
strong stimulation
of
sensory nerve
endings
embedded
in
the
organs
and
tissues
Classification of pain:
1) On the localization:
a) somatic pain
- Surface (in case of damage to the skin),
- Deep (with damage of the musculoskeletal system)
b) abdominal pain (if damaged internal organs)
c) neurogenic pain (nerve damage, spinal cord conduction pathways, or thalamus)
d) psychogenic pain.
2) At the time characteristics:
a) acute pain (new, recent pain, are inextricably linked with injury)
b) chronic pain (often acquires the status of separate diseases, continues a long period of time
even after the removal of the cause that caused severe pain.
Comparative characteristics of somatic and neuropathic pain
Somatic pain
Pain stimulus is evident.
The pain is usually well localized, visceral pain
may radiate.
Reminiscent of other somatic pain, previous.
Diminished by anti-inflammatory and narcotic
drugs. Acute somatic pain usually responds
well to treatment of non-opioid analgesics.
Opioid analgesics required to address the very
pronounced pain.
Neuropathic pain
No obvious pain stimulus.
Often poorly localized.
Unusual, unlike somatic pain.
Partly facilitated by drugs. Sensory symptoms
of neuropathic pain can be described by the
following terms: neuralgia, hyper- and
dysaesthesia, alodiniya, causalgia. Poorly
cured, using anticonvulsants, and chemical
(sympatholytic) and surgical simpatectomia,
tricyclic antidepressants.
The pain is most common in general practitioners‘ work:
• headache (migraine, chronic paroxysmal hemycrania and muscle tension headaches, secondary or
symptomatic - a consequence of the transferred traumatic brain injury, cerebrovascular pathology,
tumors, etc.)
• pain associated with inflammation of the elements of musculoskeletal (joint pain, discogenic
radiculitis, myofascial pain myalgia)
• abdominal pain
• pain in trauma (bruises, sprains)
• pain in lesions of the skin (abrasions, burns)
• dental pain and pain after dental procedures
• pain in angina pectoris
• menstrual pain
• pain in cancer patients.
Treatment of pain depends on the clarification of its reasons for launching and reinforcing factors.
The best way of coping with acute pain is addressing its causes. In order to eliminate pain using
such drugs as inhibitors of cyclooxygenase (COX), opioids, antidepressants, antipsychotics,
corticosteroids, anticonvulsants, local anesthetics.
Other methods of treatment of pain: psychotherapy, physiotherapy (heat, cold), immobilization.
The sequence of actions in appointing anesthetics:
1 First of all, a thorough medical history and careful examination of the patient with the explanation
of the effectiveness and duration of previously taken medications, presence of concomitant diseases
and drug complications. Necessary to identify the leading peripheral components of pain (tendonmuscular, neurogenic, others), to ascertain the presence of psychosocial and emotional stress
predictors of chronic pain syndrome. Analysis of the data allows you to select the primary, specific
to this patient, drug group (NSAID-nonsteroidal anti-inflammatory drugs, inhibitors reuptake of
monoamines) and create a treatment regimen.
2 Secondly, should adhere to the principle of consistency in the appointment of analgesics, which
means the following:
• Have in place a few medicines, maintaining analgesia
• Use an adequate period of time to assess the effectiveness of the drug,
• Use combinations of drugs
• If possible, to limit their side-effects.
3 Thirdly, it is necessary to use drugs only as a component of an integrated treatment of pain, i.e.
combine them with physical therapy, behavioral therapy, blockades and possibly neurosurgical
techniques.
The means for pre-hospital treatment of acute pain based on the following principles:
-Ability to obtain a clear clinical effect after a single application in most patients;
-Fast-attack effect;
-Controllability and reversibility of the effect;
-Ability to parenteral or sublingual administration, or, if necessary, the local effect without the
development of resorptive action;
- Minimum probability of adverse action or adverse interactions with other drugs prescribed
simultaneously, and accepted by patients themselves or by medical prescription.
Thus, to select the optimum for use in the prehospital phase of anesthetic necessary to know the
basic pharmacological parameters of the drug, because of pain, the main mechanism of action (level
of impact from the standpoint of a multifactor model of pain), the speed of effect, the possibility of
different routes of administration, the main path of metabolism and options unwanted
pharmacological interactions, a list of possible side effects.
Cyclooxygenase inhibitors. For oral use of COX inhibitors, such as salicylates, acetaminophen,
nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors (coxibs group). By
inhibiting COX these drugs inhibit the synthesis of prostaglandins, causing analgesic, antipyretic
and anti-inflammatory effects. COX inhibitors very effectively eliminate some types of pain,
especially after orthopedic and gynecological procedures, pointing to the important role of
prostaglandins in their genesis, as well as having an important impact on the peripheral and central
nervous system. All medications are metabolised in the liver and kidneys are derived, so in diseases
of the liver and kidneys of the dose should be reduced.
The most common such side effects of aspirin and NSAIDs as indigestion, heartburn, nausea and
indigestion. Some patients have ulcers of the gastric mucosa, which is caused by inhibition of
prostaglandin-depended mechanism of secretion of gastric mucus and bicarbonate. Other side
effects: dizziness, headache and drowsiness. With the exception of paracetamol, all COX inhibitors
disrupt platelet aggregation. Aspirin and NSAIDs may provoke bronchospasm, if patient has polyps
in the nose combined with rhinitis and asthma. Aspirin is not recommended to be used in children
under the age of 12 years, as it promotes the development of Reye syndrome. Finally, NSAIDs can
trigger the development of acute renal failure and renal papillary necrosis, especially with
concomitant renal dysfunction.
Cyclooxygenase plays a key role in the synthesis of prostaglandins. We studied the two isoforms of
the enzyme - COX-1 and COX-2. The main enzyme (COX-1) is produced in virtually all tissues,
whereas the production of COX-2 is virtually impossible without the induction of inflammatory
stimules. It is believed that COX-2, basically, is responsible for the synthesis of neurotransmitters
prostanovyh pain, inflammation and fever. It is also believed that COX-2 participates in the process
of ovulation, implantation, closure of the ductus arteriosus, as well as in the functions of the central
nervous system, particularly in the development of fever, pain sensitivity and cognitive function.
Specific inhibitors of COX-2 did not affect COX-1, and only provide anti-inflammatory and
analgesic effects. The effect of these drugs is not only focused, but also quite powerful. The main
advantage is their lack of inherent non-selective NSAID side effects as the influence on blood
coagulation and gastrointestinal tract. Low risk of complications leading to a decrease in the cost of
their prevention, treatment and other hospital costs associated with re-hospitalization, intensive
care, infusion of blood and other factors. Specific inhibitors of COX-2 may act on the central ( can
easily penetrate the blood-brain barrier) and the peripheral nervous system. Finally, the induction of
COX-2 under the influence of the stimulus, probably kept until the disappearance of peripheral
inflammation. Therefore, selective inhibition of COX-2 plays an integral role in the treatment of
pain.
Opioids (morphine 1%, omnopon 1%, promedol 2%, fentanyl 0.005%). For a moderate
postoperative pain is shown inside the appointment of opioids (as required, or at regular intervals).
Often opioids combined with inhibitors of COX, tighten analgesic effect and reduces the severity of
side effects. All opioids are biotransformation and conjugation in the liver and then eliminated by
the kidneys.
Disadvantages of opiate analgesia:
• respiratory depression, significantly for the patients with spontaneous breathing or receiving
assisted ventilation;
• hypotension usually develops on the background of hypovolemia;
• stagnation in the stomach, which patients in critical condition exacerbated when taking opiates;
• a high enough narcogenic potential;
• lack of vegetonormalizing effect in pain syndromes.
Antidepressants. The doses of these drugs used for analgesia, lower than the dose causing the
antidepressant effect. Both of these effects are due to block of presynaptic serotonin, norepinephrine
or both neurotransmitters. Drugs that effectively block the reuptake of serotonin, have the most
pronounced analgesic activity. Antidepressants are shown mostly in neuropath pain, such as
postherpetic neuralgia and diabetic neuropathy. They potentiate the action of opioids and normalize
sleep. Antidepressants differ in their side-effects caused by the following mechanisms: block of Mcholinergic receptors causes dry mouth (xerostomia), accommodation disturbances, urine retention
and constipation, the blockade of receptors (N1 and N2) - a sedative effect and increase the pH in
the stomach, the blockade of α-adrenoreceptor manifested orthostatic hypotension, and hinidin-like
effect (especially amitriptyline).
Neuroleptics. Some doctors believe that neuroleptics can eliminate neuropathic refractory pain,
especially effective when they expressed excitement and psychosis. The most frequently used
haloperidol and chlorpromazine. The mechanism of action is the blockade of dopaminergic
receptors in the mesolimbic area. Unfortunately, the blockade of dopaminergic receptors
nigrostriatal system is the cause of extrapyramidal disorders manifested masklike face, a symptom
of "gear" and bradykinesia. By slowly developing side effects include akathisia (motor restlessness)
and tardive dyskinesia. Like antidepressants, neuroleptics, most have antihistaminic, anticholinergic
(M-cholinergic receptor blockade) and antiadrenergic (α-adrenoceptor blockade) actions.
Anticonvulsants. These funds are shown in neuropathic pain, especially in trigeminal neuralgia, as
capable of suppressing spontaneous neuronal impulses, which plays a major role in the genesis of
neuropathic disorders. The most frequently used phenytoin, carbamazepine, valproic acid and
clonazepam.
Corticosteroids. These drugs are widely used in the treatment of pain, because they are
inflammatory and possibly analgesic effects. Route of administration - local, orally or parenterally
(intravenous, subcutaneous, intrabursalno, intra-articular, epidural). Preparations are distinguished
from the power main effect of relative glucocorticoid and mineralocorticoid activity, as well as the
duration of action. Increasing the dose and the extension of treatment increase the severity of side
effects. Excessive glucocorticoid activity manifested hypertension, hyperglycemia, increased
susceptibility to infections, ulcers, osteoporosis, aseptic necrosis of the femoral head, proximal
myopathy, cataracts, and rarely - psychosis. The patient may become characteristic of Cushing's
syndrome appearance. Excessive mineralocorticoid activity results in reduced sodium,
hypokaliemia, as well as provoke the development of heart failure.
Systemic application of local anesthetics. In patients with neuropathic pain, local anesthetic is
sometimes injected to induce sedation and central analgesia. The analgesic effect often exceeds the
time pharmacokinetic profile of a local anesthetic and interrupts the pain cycle. The most common
lidocaine, procaine and chlorprocaine.
In general practice rather frequent causes of acute pain syndrome first emerged is back pain, renal
colic, oncogenic pain, pain in acute coronary syndrome.
Back pain – dorsalgia- has developed as a result of degenerative, inflammatory and functional
changes in the tissues of the vertebral-motor segments and related structures: the facet joints of the
vertebrae, intervertebral disc, fascia, muscles, tendons and ligaments. The most frequently develops
as a result of the defeat of the lower cervical vertebrae followed by the defeat of radial nerve or
lumbosacral spine with the development of pain syndrome in his lower back. The primary cause of
primary back pain is spondylarthritis, which is characterized by bilateral, paravertebral pain arthralgia, increasing during prolonged standing and unbending, decreasing during walking and in
sitting position. In uncomplicated cases, the defeat of the lumbosacral spine leads to the
development of well defined symptom complex, which enables diagnosis of spondylarthritis already
on pre-hospital stage. It spondyloarthrosis is the most common cause of benign back pain in the
elderly. Myofascial syndrome as a primary cause of back pain are diagnosed with chronic local or
regional, limiting movement, muscle pain, in the presence of trigger points, local muscle tension,
lack of motor and sensory disorders. Neuropathic pain occurs as a result of prior or collateral
damage to the central nervous system. It may develop and persist in the absence of explicit
peripheral pain stimulus, often poorly localized and accompanied by various disturbances of the
surface sensitivity. Compared with nociceptive, neuropathic pain is much less susceptible to the
action of opioid analgesics.
Differential diagnosis of back pain:
-Communicable diseases (tuberculosis or nonspecific spondylitis).
-Inflammatory diseases (spondyloarthropathies, polymyalgia rheumatica);
-Metabolic diseases (osteoporosis, hyperparathyroidism, Paget's disease).
-Neoplastic diseases (primary and metastatic spinal tumors, multiple myeloma);
-Somatic diseases (aortic aneurysm, or thrombosis, diseases of the pancreas, urogenital system,
gastrointestinal tract, retroperitoneal pathology, gynecological diseases).
In renal colic, acute pain is the result of an acute violation of urine outflow, which leads to the
development of hypertension in the kidney reflex spasm of the arterial vessels of the kidney, venous
stasis and edema of the parenchyma, hypoxia and the overdistension of the fibrous capsule. The
cause of acute pain in patients with urolithiasis, often becomes ureterolitiaz. Occlusion of the ureter
may develop as in strictures, kinking and torsion ureter, with obstruction of its lumen of blood clots,
mucus or pus, caseous mass in tuberculosis kidneys rejected by necrotic papillae. Renal colic occurs
with intense colic-like periodic pain, accompanied by nausea and vomiting. The pain often
irradiates the course of the ureter in the groin and genitals, accompanied by abdominal distension
and anxiety of patients. The patients are trying to find a comfortable position, but can not find it.
The specific for renal colic behavior distinguishes renal colic from acute surgical diseases of
abdominal organs. Typically, renal colic revealed hematuria and dysuria. In patients with renal colic
for pain is advisable to apply metamizole as monotherapy or in combination with spasmolytic
drugs. Effective pain relief in renal colic does not provide for appointment of morphine and other
opioids, can distort the clinical manifestations of "acute abdomen".
Oncogenic pain
Besides the development of sustainable pain in lesions of the spine and other parts of the locomotor
apparatus in patients with cancer develop persistent pain caused by destruction of nerve trunks,
internal organs and synovial membranes. Nevertheless, the intensity of pain in cancer patients is not
directly dependent on the type and extent of lesions and in most cases - the result of summation of
nociceptive and neuropathic pain. The vast majority of patients actually oncologic pain develops in
the later stages of the disease and is essentially a persistent pain. In addition, those who receive
specific treatment, persistent pain can result from cancer therapy, with the accession of infection or
late metastasis. Prehospital phase in patients with cancer is associated with a number of challenges:
a practical and effective pain relief, which under the law should be free, is unaffordable for most
cancer patients, they are not receiving narcotic analgesics. On the other hand, cancer patients
undergoing outpatient treatment, require constant monitoring and if necessary - correction therapy,
prevention and elimination of undesirable effects of analgesics.
According to WHO recommendations, the choice of means for analgesia based on the expression of
oncogenic pain. WHO proposes "steps" scheme pain of cancer patients, according to which the
strength of analgesia increased gradually, from 1 st to 4 th level, allowing a satisfactory analgesia in
90% of patients:
Level 1: Non-opioid drugs;
Level 2: Non-opioid drugs + weak opioids.
Level 3: Non-opioid drugs + strong opioids.
Level 4: invasive methods of pain relief - spinal analgesia, the use of hypodermic applicators etc.
At any stage of treatment efficacy of analgesia in cancer patients can be enhanced using adjuvant.
These assets include not only drugs, potentiating effect of analgesics (psychotropic, hypnotics, etc.),
but also a means to correct the side effects (corticosteroids, antibiotics, antacid, and overlying, etc.).
Acute coronary syndrome
1. Sublingual nitroglycerin (again by 0.5 mg tablets or 0,4 mg per spray).
The positive effect of nitroglycerin is associated both with the vasodilating effect of the drug on the
coronary vessels, as well as with positive hemodynamic and antiplatelet effects. Nitroglycerin is
able to influence and extending to the atherosclerotic changes, and intact coronary arteries, which
improves circulation ischemic areas. According to the recommendations of the ACC (American
College of Cardiology) / AHA (American Heart Association) (2002) for the treatment of patients
with ACS (acute coronary syndrome), nitroglycerin is advisable to apply to patients with systolic
blood pressure (SBP) is not below 90 mm Hg. and in the absence of bradycardia (heart rate less
than 50 beats per minute) under the following circumstances: during the first 24-48 hours after
myocardial infarction (MI) in patients with heart failure, extensive anterior infarction, transient
myocardial ischemia and high blood pressure, after the first 48 hours in patients with recurrent
angina attacks and / or stagnation in the lungs.
Instead of nitroglycerin can use isosorbide dinitrate. The drug injected intravenously under the
control of blood pressure in the initial dose of 1-4 drops per minute. With good endurance rate of
the drug increase by 2-3 drops every 5-15 minutes.
2. Introduction of narcotic analgesics on the pre-hospital stage: the drug of choice is morphine -
intravenous slowly 1 ml of 1% solution to 20 ml of saline.
3. Introduction of narcotic analgesics in hospital: fentanyl 2 ml 0.005% solution + droperidol 1-4ml
0.25% solution intravenous or intramuscular or talomonal 1- 2 ml in 20 ml of saline.
4.Simptomatic therapy (antishock, aimed at stabilizing the hemodynamics and gas exchange,
limiting areas of necrosis).
ІV. Checklists topic:
The list of questions for the survey:
• What is pain? The phenomenon of pain and its etiological factors.
• Definition of "pain syndrome".
• Pathogenesis and classification of pain.
• Clinical characteristics and emergency care for different types of pain:
- acute back pain
- acute coronary syndrome
- acute abdomen
- renal colic
- oncology
• Pharmacotherapy of pain:
- NSAIDs, indications for use, their side effect
- Opioids, disadvantages of opiate analgesia
- Antidepressants, antipsychotics, corticosteroids, anticonvulsants, local anesthetics
• Other methods of treatment of pain (physiotherapy, psychotherapy).
V. Independent class assignments
1. Removal of painful attack of acute myocardial infarction:
- Receiving nitroglycerin sublingual absorption (again by 0.5 mg tablets or 0.4 mg aerosol)
- Introduction of narcotic analgesics in the prehospital phase: drug of choice is morphine intravenously 1 ml 1% solution of 20ml saline solution
- Introduction of narcotic analgesics in hospital: fentanil 2ml + 0.005% solution droperydol 1-4ml
0.25% solution intravenously or intramuscularly or talomonal 1-2ml in 20ml saline solution.
2. Withdrawal pain attack in traumatic shock:
- Definition of stage and degree of shock (erectile / torpedo phase offset / decompensated,
reversible / irreversible) detecting hemodynamic
- Pain Management:
a) local- Novocaini embargo, vahosympatyc blockade;
b) overall - 1% morphine hydrochloride 1 ml subcutaneously; promedol 2% 1 ml subcutaneously;
droperidol 0.25% 1 - 3 ml in 20 ml 5 - 10% solution of glucose intravenously; fentanil 0,005 ml in
2% intravenously.
- Stop bleeding, applying aseptic bandages, transport immobilization; input antishock solutions
3. Removal of pain in renal colic attack:
- First aid: Heat treatment - warmer, hot tub + reception spasmolytic and pain means: tsistenal 10-20 drops, papaverine - 0.04 g, baralhin - 1 tablet.
- Aid also began to use thermal procedures + painkillers and antispasmodic drugs: baralhinu in 5
ml intravenously or intramuscularly ,1 ml 0.1% atropine solution with 1 ml 1 - 2% solution
pantopon, promedolu, 1 ml 0 2% solution platyfilin subcutaneously.
- With a stone in the lower ureter - Introduction 40-60ml 0.5% novocaine solution in the spermatic
cord in males and uterine round ties in women (block by Epstein-Darya).
- Vishnevskiy’s pararenal blockade for use in renal colic is not recommended because of possible
break in the kidneys hard it accidentally damaged capsule.
VI.
Literature:
Main
1. Bosek V., Migner R. Year book of pain.-1995.-P.144-147.
2. MacPherson R.D. New directions in pain management// Drugs of Today.-2002.-3 (2). - P.135145.
3. McGormac K. Are COX-2 selective Ingibitors effectie analgesics? // Pain reviews. - 2001.-Vol.8,
№ 1. - P. 13-26.
4. McQuay H.J., Moore R.A. An evidence-based resource for pain relief. - Oxford Uniersity Press.
1998. -P.264.
5. Cousins M. Acute and postoperative pain// textbook of Pain.-3-rd/ Wall P., Melzak R.Philadelphia: Churchill- Livingstone.- P.357-385.
6. Study Guidelines for 6th year Medical Faculty students.-2010.-Odessa, ODMU.
Additional literature
1. Bille B. Migraine in schoolchildren // Acta Pedaiatr. Scand. Suppl., 51 (1962) 1-151.
2. Dalsgaard-Nielsen T., Holm H.E. Clinical and statistical investigations of the epidemiology of
migraine // Dan. Med. Bull. 17 (1970) 138-148.
3. McGrath P.J., Unruh A.M. Pain in Children and Adolescents // Elsevier, Amsterdam, 1997.
4. Merskey H. Classification of chronic pain: descriptions
of chronic pain syndromes and
definitions of pain terms //Pain, Suppl., 3 (1996) 51-58.
5. Waters W.E.Community studies of the prevalence of headache // Headache 9 (1990) 178-186.
6. Wildholm O.Dysmenorrhea durin adolescene //Acta Obstet. Gynecol. Scand.,87 (1999) 61-66.
Study guidelines prepared by_________________________________________________________