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Kementerian Kesihatan
Malaysia
Edited by Dr Alif Ramli
DEFINITION OF PAIN
An unpleasant sensory and emotional experience
associated with actual and potential tissue
damage or described in terms of such damage
DEFINITION OF PAIN
NOCICEPTORS
1.
2.
A-delta fibers
myelinated
2-30 m/sec
(1st pain)
C-fibers
unmyelinated
<2 m/sec
(2nd pain)
SECOND
Sensory Cortex
3rd Order
Thalamus
Spinothalamic
Midbrain
Spinomesencephalic
Pons
Medulla
Spinoreticular
2nd Order
Dorsal Root
Nociceptors
1st Order
PAI
N
PAIN PATHWAY
Sensory
cortex
Thalamu
s
PAG / RAS
Descendin
g
inhibitory
fibres
Ascending ST
tracts
Free nerve
endings
Spinal cord
Afferent nerve ( A /
c)
5th Vital Sign: Doctors training module: Pain Physiology
Dorsal
horn
EFFECTS OF PAIN
I. Physiological
- Cardiovascular System
- Respiratory system
- Gastrointestinal system
- Genitourinary system
- Central Nervous System
- Endocrine system
II. Psychological
III. Economic
CARDIOVASCULAR SYSTEM
Increased Heart Rate
Increased Blood Pressure
increased myocardial work load
myocardial oxygen consumption
increased risk of myocardial ischaemia
RESPIRATORY SYSTEM
Inhibition of normal respiration (unable to
take deep breaths)
Atelectasis
Hypoxia
Inability to cough
Retention
of secretions
Increased risk of lung infection / pneumonia
GASTROINTESTINAL SYSTEM
Increased sympathetic and reduced
parasympathetic activity
Reduced smooth muscle + sphincter tone
Reduced gut motility
Ileus, nausea + vomiting
Impedes early feeding
GENITOURINARY SYSTEM
MUSCULOSKELETAL SYSTEM
CENTRAL NERVOUS
SYSTEM
sympathetic activity
parasympathetic activity
Hyperalgesia
ENDOCRINE SYSTEM
Stimulation of stress response
Immunosuppression
risk of infection
PSYCHOLOGICAL
Anxiety
Agitation
poor sleep
uncooperative patient
ECONOMIC
SPECTRUM OF PAIN
ACUTE
PAIN
Healing
NO PAIN
Insidious onset
CHRONIC
PAIN
ACUTE
PAIN
post-surgical syndromes /
cancer
CHRONIC
PAIN
Chronic Pain
Onset and
timing
Signal
Severity
CNS
involvement
Psychological
effects
Common
causes /
examples
ASSESSMENT OF PAIN
psychological phenomenon
The
Meaningful
HOW TO ASSESS
PAIN:
A : Aggravating factors
I : Intensity
Guideline 1
Pain Assessment Guide: Taking a Brief Pain
History
TELL ME ABOUT YOUR PAIN
P Place
A Aggravatin
g factors
I Intensity
N Nature
Neutralizin
g factors
NRS/
FLACC Scale
Wong-Baker Faces
Scale
ANALGESICS
Non Opioids
Paracetamol
NSAIDS
COX
Opioids
Weak
Strong
2 inhibitors
31
Guideline 4
Drugs in Acute Pain Management: The Analgesic Ladder
Analgesic Ladder for Acute
Pain Management
SEVERE
7-10
MODERATE
4-6
MILD
0-3
Regular
No
medicati
on or
PCM
1gm
6hrly
PRN
PCM
&/or
NSAID /
COX2
inhibitor
Regular
Weak
Opioid
PCM 1gm
QID oral
NSAID /
COX2
inhibitor
PRN
Additional
weak
opioid
Regular
Higher dose
of weak
opioid
Or
IV/SC
Morphine 510mg 4 hrly
OR
Aqueous
morphine
10-20 mg
PCM 1gm
QID oral /
rectal
NSAID /
COX2
inhibitor
PRN
IV/SC
Morphine
5-10mg
OR
Aqueous
morphine
*Oral or
SC
Morphine
may be
safely
given at
hourly
intervals
UNCONTROLLED
To refer to APS
for:
PCA or Epidural
or other form of
analgesia
3. Other Methods
i. Nerve & Nerve Plexus
Blocks
ii. Transcutaneous
Electrical
Nerve Stimulation
(TENS)
iii. Rectal NSAIDS
4. Multi-modal
Concepts
RECOMMENDED SETTINGS
(EXAMPLE )
Drug
Mode:
PCA
Loading
Bolus
dose:
Lockout
4
interval :5 minutes
EPIDURAL ANALGESIA
Introduction of
analgesic drugs into
epidural space via an
indwelling catheter
EPIDURAL ANALGESIA :
DRUGS USED
- BUPIVACAINE
OPIODS ALONE
- FENTANYL
- MORPHINE
MIXTURES (COCKTAIL)
- FENTANYL + BUPIVACAINE