Tentiran Koass Nyeri
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General View of Pain Management
Emergency Department PGH
“International Association for The Study of Pain
Definition of pain:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage and expressed in terms of such damage”
What is pain?
Nociception
Spinothalamictract
Peripheralnerve
Dorsal Horn
Dorsal root ganglion
Pain
Modulation
Transduction
Ascendinginput
Descendingmodulation
Peripheralnociceptors
Trauma
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Perception
Transmission
Nociceptive afferent fiber
Normal Nerve Impulses Leading to Pain
Noxiousstimuli
Descendingmodulation
Ascendinginput
Spinal cord
Perceived pain
Activation of the Central Nervous System
at the Spinal Cord Level
Tissue DamageActivation of the
Peripheral Nervous System
Transmission of the Pain Signal to the Brain
Pain
.The Pain Response
Samad TA et al. Nature. 2001;410:471-5.
Dorsal Horn
Dorsal rootganglion
Peripheral sensoryNerve fibers
A
A
C
Largefibers
Smallfibers
There are Two Sensory Afferent Neurons
1. Large myelinated A fibers• Very fast conduction velocity • Respond to innocuous stimuli
2. Small myelinated A & C unmyelinated fibers• Slow conduction velocity • Respond to noxious stimuli
Activation
External
Stimuli
Heat
Mechanical
Chemical
VR1
Ca2+
mDEG
P2X3
Generator potentials
action potentials
Voltage gated sodium channels
Pain and auto-sensitization
Woolf & Mitchel, 2001
Transduction
ATP
Na+
Modifikasi Meliala, 2003
ACTION POTENTIALACTION POTENTIAL
KERUSAKAN JARINGAN
INFLAMASI
SSA MI NOS
SENSITISASI
AKTIFASIECT. DISC.
Si-Na+
KORNU DORSALIS
PgB5HTAdenosin
PengalamanKognitifBehaviourPsikologik
Inhibisi desenden
OTAK
PAIN – NO PAIN
R-NE
Pharmacologic Methods*Non-opioids (e.g paracetamol, aspirin,
NSAID) for mild pain *Non-opioids with weak opioid (e.g codeine) for mild – to moderate pain *Opioid / morphin for moderate to severe pain *Alternative strong opioids *Adjuvant drugs (e.g corticosteroids,
antidepressants, anticonvulsant, neuroleptics)
Current Pain Management
Route Time to Half-life Analgesic Analgesic Maximum
peak (hr) (hr) onset (hr) duration (hr) recommended
daily dose (mg)
-----------------------------------------------------------------------------------------------------------------------
Salicylates
Aspirin Oral 0.5-2 2-3 0.5-1 2-4 3,600
Propionic acids
Ibuprofen Oral 1-2 1.8-2.5 0.5 4-6 3,200
Ketoprofen Oral 0.5-2 2-4 4-6 300
Naproxen Oral 2-4 12-15 1 4-7 1,500
Acetic Acids
Indomethacin Oral 1-2 4.5 0.5 4-6 200
Ketorolac Oral/im 1 2.4-6 0.5-1 4-6 120
Nonopioid analgesics
Route Time to Half-life Analgesic Analgesic Maximum peak (hr) (hr) onset (hr) duration (hr)
recommended daily dose
(mg) -----------------------------------------------------------------------------------------------------------------------
Fenamates
(anthranilic acids)
Meclofenamate Oral 0.5-1 2 0.5-1 4-6 400
Mefenamic acid Oral 2-4 2-4 1 4-6 1,000
Oxicams
Piroxicam Oral 3-5 30-86 1 48-72 20
Phenylacetic acids
Diclofenac Oral 2-3 2 1 1.6 200
P-Aminophenols
Acetaminophen Oral 0.5-1 1.4 0.5 2-4 1,200
Phenacetin Oral 1 2,400
Selective COX-2 Inhibitors
Celecoxib Oral 2-3 1 8-12 400
Rofecoxib Oral 2-3 0.4 12-24 50
Nonopioid analgesics
Dosage (mg) Onset (hr) Peak (hr) Duration (hr) Comment
------------------------------------------------------------------------------------------------------------
Morphine 2.5-15 iv 0.125 Rapid onset, peak
Respir depr 10 min
Meperidin 50-100 im 0.12-0.5 1 2-4
Codeine 15-60 oral 0.25-1 0.5-2 3-4
Methadone 2.5-10 oral 0.5-1 1.5-5 4-8
Pentazocine 50 oral 4-7
30-60 im 0.12-0.5 1-3 3-6
Opioid Analgesics
Arachidonic Acid Cascade& COX Hypothesis
Arachidonic Acid
COX-1 COX-2
Body Homeostasis• Gastric integrity• Renal function• Platelet function
InflammationPain
Needleman P. et al. J Rheumatol 1997;24(suppl 49):6-8Fitzgerald GA et al. N Engl J Med 2001;345:433-42
Cyclooxygenase (COX)
Nonselective NSAID
COX-2 selective InhibitorX XX
COX-1 & COX-2
.