Chapman’s chapter develops the bridge between physiological mecha- nisms of pain and psychological practice by linking conscious perceptual processes with physiological functions buy cheap cytotec 200 mcg symptoms 7 days before period. His concept of pain is broad (and mostly addresses “intrapersonal determinants” of the experience) effective cytotec 200mcg medications kidney patients should avoid. Chap- man’s basic point is that if we want to provide good care, a more inclusive model of pain experience and its determinants needs to be employed. Recognizing that interpersonal phenomena are often more important than intrapersonal events when pain control is the issue, we discuss in chapter 4 the communication of pain by examining both a theoretical model of pain communication (Craig, Lilley, & Gilbert, 1996; Hadjistavrop- oulos & Craig, 2002; Prkachin & Craig, 1995) and important findings concern- ing illness behavior. Social influences on the pain experience and its expres- sion are also discussed. Communication of pain serves important adaptive functions for humans from the bioevolutionary standpoint. It can elicit res- cue, protection, treatment, and longer term care to facilitate recovery. Its social purposes warn others of danger and promote delivery of culture spe- cific care. Communication of pain is accomplished via verbal and nonverbal channels (e. This chapter discusses research on the ex- pression of pain, including the importance of the entire communicative rep- ertoire and the potential for deception, the judgmental skills and biases of potential allies and antagonists, and the advantages and disadvantages of current social systems designed to care for people communicating painful distress. Issues related to the communication of pain within families are covered, as are matters pertaining to populations with limited ability to communicate (e. Following the first part of the book that is largely focused on theoretical work, Gibson and Chambers outline important developmental consider- ations in the psychology of pain. Pain expression and experience transform with aging, reflecting ontogenetic maturation, socialization in specific famil- ial and cultural settings, and the impact of experiences with pain. An under- standing of the cognitive, affective, behavioral, and social challenges con- fronted during the various stages of life from birth to terminal illness is required. The earliest and latest stages of life presently carry substantial INTRODUCTION 9 risk of unnecessary or undermanaged pain because of an inadequate knowledge base, underdeveloped assessment procedures, and inadequate pain management. This chapter examines and systematizes developmental processes in pain experience, expression, and communication. A major source of individual differences (other than biological matura- tion) is culture. The chapter by Rollman considers the empirical and theo- retical literature on the impact of culture on the experience and expression of pain, delineating observed differences and ethnocultural variations in the meaning of pain. There is a focus on mechanisms responsible for varia- tions (acculturation and socialization), linking them to the biopsychosocial model. Individual differences in response to comparable tissue stress and injury are systematically related to known factors (gender, health anxiety, other personality traits). The chapter by Skevington and Mason provides a re- view of the literature and a model of social factors impacting on pain in an effort to understand the origins of individual differences. The role of intrapersonal factors such as self-efficacy and their relationship to outcomes and recovery from pain are also considered. The next section of the book addresses clinical issues more directly than the preceding chapters. The role of psychological assessment among pre- and postsurgical pain pa- tients is discussed. Bruehl and Chung move the book into an intervention focus with a state- of-the-art discussion of psychologically based interventions for acute pain (wounds, burn, other soft tissue injuries, fractures, medical procedure pain, etc. Psychological interventions represent a neces- sary feature of multidisciplinary care for patients suffering from chronic pain and pain-related disability. This chapter examines the most commonly employed approaches to the treatment of chronic pain as well as the empir- ical evidence (or lack thereof) pertaining to their efficacy. Widely used cog- nitive/behavioral approaches are featured, but psychodynamic perspec- tives are also examined. The manner in which medication usage relates to 10 HADJISTAVROPOULOS AND CRAIG psychological treatment (e. More- over, a discussion of how psychological interventions can be applied with postsurgical and presurgical pain patients is included. The last section of the volume focuses on current controversies and ethi- cal issues.

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Note the increased radiolucency of the right lung as a result of air trapping discount 100mcg cytotec amex symptoms after flu shot. Radiographic technique for the chest and upper respiratory tract Plain film radiography remains the first-line examination for the majority of respiratory conditions buy 100mcg cytotec overnight delivery medicine quinine. However, alternative imaging modalities may be used to assess the extent of a disease or confirm a diagnosis (Box 4. Its use is decreasing due to the recognition of high patient doses and the development of other imaging modalities. Ultrasound: Of little value for the respiratory system but extremely useful in the investigation of cardiac and mediastinal pathology. Computed tomography (CT): Second-line imaging modality after plain films. It provides good contrast and spatial resolution of lung parenchyma, mediastinum and bony structures but has the disadvantage that sedation is often required due to the length of examination. Magnetic resonance imaging (MRI): Useful for examining the mediastinum and the chest wall but has the disadvantage that young children will require sedation and frequently general anaes- thetic due to the relatively long imaging times. Scintigraphy: Of value in the investigation of pulmonary embolisms and bony pathology (e. Its use is on the decline as a result of improve- ments in ultrasound and MRI but it has the advantage of facilitating interventional procedures. Age (approximately) Projection Patient position Under 3 months Antero-posterior Supine 3 months to 4 years Antero-posterior Erect 4 years and older Postero-anterior Erect Choice of projection There is no difference in the diagnostic value of an antero-posterior (AP) pro- jection compared to the postero-anterior (PA) projection of the chest in a child less than 4 years of age as the thoracic cage is essentially cylindrical in young children and magnification of mediastinal organs is insignificant11. However, the AP projection is associated with a higher radiation dose to the developing breast, sternum and thyroid, and radiographers should take this into consideration when choosing the radiographic projection. In children under 4 years of age, the AP projection is often preferred due to ease of positioning, immobilisation and maintenance of patient communication. Young children like to see what is going on around them and positioning for an AP projection allows the child to watch the radiographer. A disadvantage of the AP projection is the likelihood of lordosis but this can be prevented by careful technique. This is particularly important if the child’s condition is being mon- itored radiographically as subtle radiographic changes in their condition may be difficult to interpret if the technical (positioning) factors are inconsistent. The fol- lowing descriptions of radiographic positioning are provided as a guide and may be modified depending upon equipment and accessories available. Antero-posterior (supine) The patient is positioned supine with the median sagittal plane at 90° to the image receptor. A 15° foam pad is placed under the upper chest and shoulders to prevent lordosis (Fig. The chin is raised and the arms are flexed and held on either side of the head to prevent rotation (Figs 4. Sandbags and lead rubber are placed over the hips and legs to provide immobilisation of the Fig. The cut out area helps although a 15° pad has been used, the extension of the to prevent the chin obscuring the upper patient’s arms will still result in a lordotic radiograph. Note the use of a 15° foam pad and arms positioned with elbows flexed to prevent hyperextension of the spine and lordosis. The primary beam should be centred to the area of interest thereby ensuring that effective collimation can be applied and dose reduction optimised. Antero-posterior (erect) This projection can be performed with the patient standing or seated erect. For younger children, correct positioning and immobilisation are easier to maintain with the child seated. It is important when seating a child to ensure that the legs are not extended level with the buttocks, as this will accentuate lordosis12 (Fig. Instead, a young child should be seated on a sponge/box thereby lower- ing the level of the legs and reducing lordosis (Fig. The patient is positioned initially with the posterior aspect of the chest in contact with a cassette.

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Well over 90 percent of all patients will obtain pain relief by non-operative means discount cytotec 100mcg with amex keratin intensive treatment. Activity restrictions may be implemented for those with exquisite pain and difficulty in performing routine activities cytotec 100mcg discount medicine in spanish, but should be reserved for only those cases. Commonly the patients will experience pain relief with the knee in extension rather than flexion. In very rare recalcitrant cases that have failed all previous conservative treatment, surgical removal of a portion of the inferior pole of the patella at the site of the tendon attachment may be necessary. Treatment is well within the domain of the primary care physician, with orthopedic referral reserved for those cases failing conservative regimens. Adolescence and puberty 100 Calcaneal apophysitis (Sever’s disease) Calcaneal apophysitis is the most common cause of heel pain in adolescents and teenagers. Although previously thought to be an osteochondritis, it is clearly a mechanical pain syndrome more closely related to a tendinitis with a self-limited benign prognosis. As the calcaneal apophysis begins to progressively ossify at the time of adolescence, it commonly arises from more than one center of ossification and presents as a very dense radiographic pattern not unlike that seen in other osteochondritic processes (Figure 5. Lateral radiograph of the foot demonstrating normal irregular increased density seen on the radiograph, it ossification and sclerosis within the calcaneal apophysis. The classicsite of discomfortonmedial lateral compression of the heel in calcaneal apophysitis. The youngsters in this age group will complain of pain in their heel, particularly with mechanical activities. The most characteristic distinguishing feature on physical examination is exquisite pain produced on medial and lateral compression of the heel at the site where the calcaneal apophysis attaches to the main body of the calcaneus (Figure 5. This pain is not on plantar pressure, or posterior or retrocalcaneal pressure, but on medial and lateral compression. The symptoms resolve once the calcaneal apophysis amalgamates with the main body of the calcaneus. A simple in-shoe orthotic, consisting of a soft material covered by leather that will slightly raise the heel and cushion the impact of weight bearing, will generally result in pain relief within six weeks to three months. The elevated pad also tends to relax the gastroc-soleus complex and releases tension on the calcaneal apophysis. The author’s personal preference is for a sponge-filled, leather-covered compressible heel pad that compresses down to five-eighths of an inch and is transferable into alternative shoe wear. In less than 10 percent of cases, a short leg plantar flexion cast, worn for three to four weeks, may be necessary. Properly recognized, this condition can often be managed by primary care physicians. In roughly two percent of all adults the accessory navicular persists as a complete and separate ossicle unattached to the ossified navicular and embedded in the substance of the posterior tibial tendon. The etiology of the syndrome seen in adolescence and puberty is directly related to a chronic posterior tibial tendinitis occurring in association with an accessory navicular (Figures 5. Not uncommonly a very prominent medial “cornuate-shaped” navicular may produce similar posterior tibial (b) tendinitis in the absence of any ossified Figure 5. The pain is clearly mechanical in nature and generally resolves with rest. On examination, a medial prominence is encountered at the site of the proximal medial portion of the navicular, with tenderness commonly seen along the posterior tibial tendon as it reaches its insertion onto the navicular. When pressure is applied to the plantar-medial portion of the bony prominence, exquisite pain is elicited, mimicking the patient’s symptoms (Figure 5. Adolescence and puberty 102 It was originally thought that the discomfort occurred because of a marked pronovalgus (flatfoot) deformity accompanying the accessory navicular. The pain was thought to arise from chronic pressure due to flattening of the longitudinal arch in the presence of a weak posterior tibial tendon. This explanation is untenable in light of the fact that the majority of patients with this condition do not have significant pronovalgus feet. It is likely that fewer than half of the patients with this accessory ossicle have sufficient pain to seek medical attention. Treatment initially should be conservative in nature and consist of a sponge-filled long arch orthotic that can be transferred from shoe to shoe in conjunction with anti-inflammatories and physiotherapy modalities. Although cortisone injections have been utilized, they are not commonly Figure 5.

Nausea: Treat with ondansetron buy cytotec 200mcg otc symptoms low potassium, prochlorperazine order cytotec 100 mcg fast delivery medicine 029, Commercially available bupivacaine is a racemic or low-dose naloxone. The R isomer is more Pruritus: Treat with an antihistamine, such as toxic than the S moiety. These effects can be managed by 40-µg boluses, until the desired effect is reached. Treatment with pital setting, sedation can also be reversed with boluses of adrenergic agents (phenylephrine and naloxone. If a continuous used to treat neuraxial opioid side effects but may infusion is required, dopamine is the drug of choice. Inotropic agents are preferred over “afterload” Epidural morphine and hydromorphone produce a agents that might trigger the Bezold–Jarish reflex. Reducing the concen- correct interspace (center of surgical manipulation). Hydromorphone 5–10 µg/mL Ketamine (an NMDA receptor antagonist) may Fentanyl 2–5 µg/mL increase analgesia and prolong blockade when com- Sufentanyl 1–2 µg/mL bined with epidural morphine. The best Ketorolac (a nonsteroidal anti-inflammatory drug) has effects are found with the catheter tip located at the been used to enhance epidural analgesia and duration. OTHER ADDITIVES ADJUNCTS TO EPIDURAL ANALGESIA Agents may be added to epidural preparations to Acute pain management is best served using multi- enhance efficacy. Some patients benefit from addition of the dorsal horn interneurons, producing analgesia. The recommended starting dose for epidural cloni- Care must be taken when using benzodiazepines with dine infusion is 30 µg/h. Data for doses above 40 opioids due to resulting synergy in producing respira- mg/h are lacking. Side effects of epidural clonidine include decreased Muscle spasm can complicate analgesia and may not heart rate and blood pressure. Patients receiving respond well to systemic opioids or epidural analge- epidural clonidine should be closely monitored dur- sia. Small doses of benzodiazepines (eg, diazepam ing the first 24 hours of treatment for hypotension, 2. CHRONIC PAIN PATIENT WITH ACUTE PAIN OTHER ADDITIVES UNDER INVESTIGATION Patients who chronically take pain medications at Many agents have been suggested for use as additives home pose a challenge with respect to management of to enhance epidural analgesia. Chronic pain patients on opioids often require A variety of α2 agonists (other than clonidine and epi- higher doses of opioids because of tolerance. PCA only (without a basal rate) may be insufficient 86 V ACUTE PAIN MANAGEMENT to control pain. A basal opioid infusion (equivalent tion between the ports such that all or most of the test to baseline opioid requirements) may be necessary. Chronic pain patients who use a fentanyl trans- dermal patch should continue using the patch throughout the perioperative period (it is neither PLACING THE EPIDURAL necessary nor desirable to discontinue the patch preoperatively). The midline approach is favored in the lumbar region, where the spinous processes are nearly hor- EQUIPMENT izontal in the seated patient. A paramedian approach may be advisable when Epidurals must be performed in an area designed placing a thoracic epidural, especially between T5 for cardiovascular monitoring and airway and and T9, where the spinous processes almost over- cardiopulmonary support, such as a dedicated block lap. The procedure may also midline approach, angle the needle 50°–60° (up be done in a separate area of the patient holding room from the back plane) to pass between the two adja- as long as monitoring and emergency equipment and cent spines (see Figure 18–4). Doing so could shear the catheter Most epidural catheters have a “dead space” equal to tip, leaving it in the epidural space. Modern catheters have The catheter should advance easily into the epidural centimeter markers and a radiopaque distal tip. Ease in advancing the catheter into the On removing an epidural catheter, visually inspect epidural space provides another confirmation of and record that the tip is intact. The Advancing the catheter more than 5 cm increases three-holed design may have arisen from a desire to the potential for knotting or could place the catheter produce lateral full-bore equivalent flow with the tip too far from the intended center of epidural minimum number of holes while at the same time action to allow for adequate analgesia. As manufactur- Catheters placed 3 cm or less into the epidural ing techniques improved, the holes were moved closer space have a tendency to come out.

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