Pain Control: Opiods

I will go over some general information regarding opioid use for analgesia. In subsequent entries I will go over different opioid use for 1) mild to moderate pain, 2) moderate to severe pain, and 3) severe pain. I would say for my practice most patients fall into the moderate to severe pain, but for a short period of time.


Key Points:

  • No ceiling effect (as a general statement this means the larger the dose, the larger the effect)
  • Tolerance can develop with chronic use
  • Overuse can lead to respiratory depression or seizures

Mild to moderate pain: codeine or tramadol
Moderate to severe pain: hydrocodone, oxycodone, hydromorphone
Severe pain: morphine, codeine, methadone

**Some of these can crossover between categories based on dosage.

Source: Handbook of Neurosurgery, Greenberg 6th ed


Pain Control: Toradol

Working in a surgical specialty, I have had to learn how to manage pain successfully.... and I must admit with some patients, I'm still learning. Pain is subjective so there is no magic recipe that works for every patient... you will have patients that 1) have intolerable side effects or allergies to your normal post op prescriptions, 2) have a history of narcotics abuse, 3) are drug seekers, 4) are people in true pain, and 5) are everything in between. It is good to have an idea of different pharmacological options to treat pain. Over the next few entries I will go over some of the main pain medications we use and some random ones as well.

TORADOL (ketoraolac tromethamine)

Key points:

  • only parenteral NSAID approved for use in pain control in US
  • Analgesic effect is more potent than anti-inflammatory
  • Single dose administration = 30mg IV or 60mg IM (in healthy adult)
  • Multiple doses = 30mg IV/IM q6hrs (max 120mg/day)
  • PO is available, but used only as a continuation of IV/IM therapy - comes in 10mg tabs
Why might you use toradol?
  • if constipation is an issue with your patient
  • if you are worried about sedation/respiratory depression 
  • patients with narcotic dependency
  • if your patient gets nausea with narcotics
  • do not use for > 72 hrs of pain control - some say 5 days is the max
  • can prolong bleeding time (secondary to platelet inhibition) in post op patients - use caution 
  • although injections bypass the GI system, patients can still get GI irritation
  • monitor for renal side effects

Source: Handbook of Neurosurgery Greenberg, 6th Ed


Autism: Nuts & Bots

Autism is a disorder that we hear a good deal about in the media and you are likely to see some kids on the spectrum during your pediatric rotation. Here are the nuts, bolts, and key terms:

  • Autism: impaired social interaction/communication/interests
  • Prevalence: 0.4% of the general population (although I have seen wild variations of this number)
  • More common in males than females (5 to 1)
  • Symptoms generally seen before the age of 3
  • Social sx: lack of peer relationships/failure to use non-verbal social cues
  • Communication sx: absent or weird speech
  • Behavioral sx: preoccupation with repetitive activities, rigid adherence to purposeless rituals, mental retardation (present in 75% of patients with autism), no parent-child bond
  • Physical exam: generally normal, may see results of self-injurious behaviors (biting/head banging)
  • Tx: family counseling, special education, antipsychotics can be considered for agitation

Source: Psychiatry for Medical Students and Residents by Nabell Kouka, MD, DO, MBA
Pic source: http://peteking.house.gov/issues/autism


What is a WADA exam?

What is a WADA exam?

A WADA exam is also known as an intracarotid amytal test. It is one of the “non-invasive” tests used to determine which hemisphere is language dominant in epileptic patients and also assess the ability of the non-affected side to maintain memory when isolated. For example, if you were to remove the R hippocampus – could the L side support language and memory alone?

No test is perfect... here are a couple of the WADA Shortcomings:

  1. If patient has a high flow AVM – reading can be inaccurate
  2. A portion of the hippocampus that you are trying to shut down could get its blood supply from posterior circulation making it hard to tell how accurately the patient will respond with full resection.

How is it done?

  1. Get angiogram (to assess cross flow – which is a contraindication to shutting down the side of primary supply)
  2. Cath ICA (usually start on lesion side)
  3. Ask pt to hold opposite arm in the arm as amobarbital is rapidly injected into the ICA
  4. What should happen? An almost immediate flaccid exam of the arm that begins to wear off in about 8 minutes. If it wears off faster (around 2 minutes) you may think about a high flow AVM.
  5. Assess language by asking pt to name objects and remember them
  6. Assess memory by asking pt to recall as many of the objects as possible 15 minutes later
  7. Procedure can be repeated on the other side if needed

Photo source: http://www.instantanatomy.net/headneck/vessels/articinskull.html
Source: Handbook of Neurosurgery, Greenberg 6th Ed


Rheumatology/Orthopedic Buzz Terms

Rheumatology. I'm not sure there is a more gray area of medicine... perhaps that's why I don't like it that much. I remember sitting in rheumatology class listening to cases thinking, "it could be any of the rheum diseases that we've talked about!" They all sound the same and there is no ONE test that gives you the answer. I find it immensely frustrating (perhaps why I ended up in a surgical field), but I tip my hats to the providers that work in it. It is so difficult to pin down a diagnosis and successfully treat a patient with rheum issues... so for me, I stick to the basics.

See below for my knowledge extent on these rheum/orthopedic PANCE/PANRE test-able gems:

Osteoarthritis (OA)
Exercise, PT
If knee joints involves - encourage weight loss indicting
Pool activities

Rheumatoid arthritis (RA)
Aspirin, other NSAIDS
methotrexate for severe cases
benefits take months to see after therapy initiation

Ankylosing Spondylitis
Bamboo spine on plain films

NSAIDs for joint symptoms
Benign cases only need supportive care
Systemic corticosteroids for serious complications
Could be a cause of thrombosis in young women (oral contraceptives can also cause this)

Vit D deficiency

Aspirate and culture
Generally start with IV antibiotics then follow with PO antibiotics

Source: Medical boards Step 2 Made Ridiculously Simple - A. Carl, MD, PhD
Photo: wiki.cns.org