Pediatrics Exam 3

pain, endocrine

pain is…

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, Pain is whatever the person says it is, existing wherever the person says it does

Opioid tolerance

expected adaptation: a normal physiologic response that can occur with regular administration of an opioid and consists of a decrease in one or more effects of the opioid

Opioid physical dependence

withdrawal if stopped, normal response that occurs with repeated administration of the opioid

opioid addiction

physical + behavioral used for nontherapeutic reasons. influenced by genetic, psychosocial, and environmental factors.

Pseudo addiction

mistaken diagnosis of substance use disorder that occurs when a patient’s pain is not well controlled; the patient may begin to manifest symptoms suggestive of SUD: demanding behavior, escalating demands

Pain relief typically eliminates these behaviors accomplished by increasing opioid doses or decreasing intervals between doses

Pain and brain connection

Nociceptive sensory pain information transmitted to the brain along several pathways with chemical mediators (transduction, transmission, perception, modulation)

Transduction (nociception)

1. Stimulus > electrical signal

2. Mediators: prostaglandins, bradykinins

3. NSAIDs act here

Transmission (Nociception)

1. Peripheral nerves → spinal cord → brain 2. A-delta fibers: fast, sharp 3. C fibers: slow, dull

Perception

1. Occurs in brain 2. Pain becomes conscious

Modulation

1. Descending pathways 2. Endorphins reduce pain 3. Opioids act here

Factors influencing perception of pain

•  physical factors (disease, rest/fatigue, nutrition), social, spiritual, psychological (support/isolation, mental, emotional, cognitive state)

Acute pain

• Known cause ie surgery, fractures, burns

• New to a few weeks: normal healing

• Localized

• Easily Treatable

• Has observable physical response: ↑ BP ,heart rate, & respiratory rate Patient looks uncomfortable

Chronic pain

• Lasting > 3 months

• There is often not a change in BP, HR and patient may just look chronically ill, not “writhing in pain”

• Cause and onset may not be known; multiple sclerosis, diabetic neuropathy, tumors, shingles…

• intermittent and malignant

chronic intermittent pain

• migraine headaches

• IBS

chronic malignant pain

• cancer with growing tumors, worsening pain

Cutaneous nociceptive pain

local (bee sting) perceived from the skin well localized

Somatic nociceptive pain

muscle, bone, fracture pain. aching throbbing well localized

visceral pain

intestine, gastric, gall bladder pain. tumor involvement may be well localized while obstruction involvement diffuses(poorly localized) pain

Neuropathic pain examples

phantom pain, diabetic neuropathy, shingles, neurological diseases: ALS, AIDS, MS

Phantom pain

Result of peripheral nerve damage

Shingles

postherpetic neuralgia: persistent pain where you had a rash/blisters

nociceptive pain meds

• • ASA, APAP • NSAIDs • APAP/Codeine #3 • APAP/Hydrocodone • APAP/Oxycodone • Tramadol • Morphine • Oxycodone • Methadone

Types of nociceptive pain and descriptions

• cutaneous, somatic, visceral are more localized: • Cramping • Crushing • Cutting • Gnawing • Pounding • Pressing • Sharp Squeezing • Tender • Throbbing. 

types of neuropathic pain descriptions

• • Flashing • Lancinating(mix of stabbing/shooting pain)• Numb • Radiating • Burning • Shooting • Stabbing

Neuropathic pain meds

• Gabapentin, Pregablin, Tricyclic antidepressants-- desipramine ,Methadone, Corticosteroids

WHO step ladder

•  step one with mild pain: 2-4/10 ASA APAP NSaIDS +/- adjuvants, step two moderate pain: 5-7/10 (A/Codeine) tylenol/codeine (A/Hydrocodone) Vicodin (A/Oxycodone) Percocet (Tramadol) Ultram step three Severe pain: 8-10 Morphine Hydromorphone (Dilaudid) Methadone (Dolophine) Fentanyl (Duragesic) Oxycodone

Side effects of anticonvulsants

gabapentin/ pregablin:  Somnolence: feeling tired wanting to sleep, Dizziness, Depression, suicidal thoughts

Polypharmacy

meds having the same class, same route, same speed, same purpose medication. Not good!! Not acceptable!! ex:  Morphine IR15 mg PO and oxycodone IR 30 mg PO 

Common adverse opioid effects

• Constipation, dry mouth, n/v, sedation, sweats, urinary retention 

uncommon adverse opioid effects

• bad dreams/hallucinations, dysphoria/delirium, myoclonus/seizures, pruritus/ urticaria, resp depression

Basal medication

The pain medication that is given for continuous pain relief

Anterior pituitary gland

 produces hormones that affect the breasts, adrenals, thyroid, ovaries, and testes, as well as several other hormones

Posterior pituitary gland

 the kidneys. are to store and release the hormones oxytocin and vasopressin (antidiuretic hormone)

Hyperpituitarism

too much of hormone, resulting in: Cushing’s syndrome Acromegaly: excess growth hormone: growth plates open: heights growth plate closed: hands and feet grow Hyperthyroidism Hypogonadism: no sex gland hormones/very little SIADH Cushing syndrome: too much cholesterol steroid use is most common reason for this to happen + tumors

Tx hyperpituitarism

• Meds (hormone replacements), radiation Surgery: Transsphenoidal hypophysectomy

Hypopituitarism

• too little of hormone, resulting in: Addison’s disease Stunted growth Hypothyroidism Infertility / irregular Diabetes Insipidus 

Transsphenoidal Hypophysectomy

• Preferred to open craniotomy as can be done endoscopically Decreased: 1. risk of infection 2. length of stay / recovery 3. pain Assess vision pre & post surgery! Elevate HOB Test packing for glucose! 

post op for transsphenoidal hypophysectomy

• Monitor for: 1. CSF on nasal packing 2. Neuro changes Decreased LOC > Cushing’s Triad Pupil changes Seizure activity Oral care!  Meds: Phenytoin - seizure prevention Mannitol - reduce cerebral edema Lasix - decrease fluid retention Dexamethasone - decrease inflammation (iv > po, taper!!) Antibiotics - reduce risk of infection

Thyroid gland Goiter

•  enlarged thyroid with - / + thyroid function. Produces: T4 (thyroxine) with iodine. T4 goes to liver (80% and not activated produced in thyroid gland)  where T3 (triiodothyronine) is produced. (majority gets produced in the liver 20% in thyroid gland and it is active) 

• T3 and T4 regulate: Respiratory / cardiac function, temperature, carbs / fats/ protein metabolism, erythropoiesis, gut motility, growth development in fetus of major organs / nervous tissue / bones 

Hypothyroidism

Hashimoto’s disease: autoimmune disease usually diagnosed when woman wants to get pregnant,  irradiation, idiopathic (we dk) Dx: Central: Pituitary / hypothalamus - ↓TSH, ↓ T3, ↓T4 Primary hypothyroidism: thyroid gland - ↑ TSH, ↓ T3, ↓T Tx: lifelong treatment (Levothyroxine Sodium). Slowly increase dose. Symptoms decrease over several weeks. TSH, T4, T3 prn.

Hyperthyroidism

• Grave’s disease, toxic nodular goiter, inflammation, drugs Dx: - ↓TSH, ↑ T3, ↑ T4 - ↓ Cholesterol Tx: meds, radioiodine therapy, surgery Complications: Exophthalmos (from Grave’s) = abnormal protrusion of the eye Thyroid Storm - extreme increase in basic metabolic rate (BMR)

Myxedema

• Undiagnosed or undertreated hypothyroidism Dry, waxy swelling with abnormal deposits of mucin in skin and other tissues

Management of excessive thyroid hormone:

Anti-thyroid Medication (Methimazole preferred) < 18 y/o and pregnant women get Propylthiouracil (PTU) instead: impairs thyroid hormone synthesis - alleviates Graves symptoms in 4-8 weeks - agranulocytosis- increased risk of infection Radioiodine Therapy - Contraindicated in pregnancy and rarely used in children - Hypothyroidism as a complication Surgery

Thyroid Storm

extremely high metabolism High fever (104-106F) Tachycardia (>140) Hypertension Hyperreflexia Arrhythmias (AF), Heart failure, Angina Severe agitation / delirium GI distress Dyspnea EMERGENCY

Myxedema Coma

• extremely low metabolism Hypothermia Bradycardia Hypotension Hyponatremia Hypoglycemia Hypoventilation

Post-op management for Total Thyroidectomy

Lifelong hormone replacement

Subtotal Thyroidectomy post-op management

+/- hormone replacement Risks tetany, respiratory obstruction, laryngeal edema, vocal cord injury, aspiration Post-op: airway, O2, electrolytes, aware of effect on parathyroid gland (calcium depletion)

Hypoparathyroidism: Causes

 Inadvertent removal during thyroidectomy, Idiopathic, Autoimmune

Hypoparathyroidism Pathophysiology

• PTH unable to regulate calcium & phosphorus Resulting in: Tetany, painful muscle spasms Labs: ↓ Ca, ↑ Phos Tx: 10% calcium gluconate solution oral calcium and Vit D

Thyroid cancer

•  Rising incidence Women : men = 3:1, 5-year survival >98% Benign adenomas Most slow growing and palpable in exam Hard, irregular, painless, enlarged thyroid gland Dx: Fine needle aspiration, scans to find mets, TFT’s Tx: Supportive, chemotherapy, and surgery

DM T1: What

 Autoimmune destruction of pancreatic beta cells. Absolute insulin deficiency. Glucose cannot enter cells, stays in bloodstream, and causes hyperglycemia. Body switches to fat breakdown which produces ketones which leads to metabolic acidosis. Signs & symptoms: polyuria, polydipsia, polyphagia. Also weight loss, fatigue, blurred vision. Dx: Fasting glucose >126 mg/L, random glucose > 200 mg/L, A1C >6.5%

Acute Complications DM1

• 1. Diabetic Ketoacidosis (DKA) Tx: IV fluids!! IV insulin, monitor & replete potassium, cardiac monitoring. 2. Hypoglycemia Tx: Conscious > 15g fast carbs! Unconscious > glucagon IM or IV dextrose Chronic Complications: 1. Microvascular changes 2. Macrovascular changes Tx: lifelong insulin therapy

Managing DM1:

 Blood glucose monitoring: Before meals & bedtime (or more often) Continuous glucose monitors Nutrition: Carb counting Consistent meals Balance insulin w/ intake Insulin therapy: Rapid (Lispro) Short (regular) Intermediate (NPH) Long-acting (glargine) insulin pump FOOT CARE Inspect feet daily No barefoot walking Proper footwear Report wounds early Exercise Lowers glucose - ? snack before exercise

Sick day rules DM1

•  Never stop insulin Check glucose every 3–4 hrs Check ketones if glucose >250 Drink fluids Call HCP if: Persistent hyperglycemia Ketones present Vomiting IV use because of dehydration 250/hr usually. Insulin iv, glucose and potatssium. Look up how potassium decreases in the body in DKA so you give potassium to prevent arrhythmias. Insulin drip check on them every hour. Normal range 70-100 rn 

Burns priority care immediately following injury

• extinguish

• cool the burn

• remove restrictions

• cover the wound

• irrigate chemical burns

What to do with burns at facility/ambulance

• start IV (central line may be indicated)

• infuse LR

• cover with a clean sheet

• coordinate care w a burn center

• call report

Burns phases of care

emergency, acute/intermediate, rehabilitation

Emergent care burns

onset to completion of fluid resuscitation

acute/intermediate care burns

begginning of diuresis to near completion of wound closure (initiated w/in 48-72 hours)

Rehabilitation care burns

from wound closure to development of pts baseline/optimal performance

Fluid resuscitation for thermal/chemical burns equation

2mL LR x pt weight in kg x %TBSA (for 2nd, 3rd, 4th degree) within 24 hours (give first half 8 hrs second half remaining in 16 hrs)

Fluid resuscitation for electrical burns equation

Or 4mL LR x pt weight in kg x %TBSA (for 2nd, 3rd, 4th degree) within 24 hours (give first half 8 hrs second half remaining in 16 hrs)

Urinary output/changes in color what are we watching for

rhabdomyolysis

Palmar method

better for smaller/scattered/irregular burns

• Palm including fingers closed together is considered approximately 1% of their TBSA

Rule of 9’s

best for large quick assessments in adults body’s divided into equal 9%

1st degree burn

superficial:

• Sunburn, superficial scald, low-intensity flash.

·       Epidermis, possibly a portion of dermis.

·       Tingling, peeling, itching, pain. Reddened, blanches with pressure.

·       Minimal edema, Possible blisters.

·       Recovery is quick and complete (unless infection develops).

2nd degree burn

partial-thickness:

·  Scalds, flash flame, contact

·   Epidermis, portion of dermis

·    Pain, sensitivity to air

·     Blisters, mottled base, disrupted epidermis, weeping surface, edema.

·    Recovery 2-3 weeks. Scarring & depigmentation possible. May require grafting.

3rd degree burn

full thickness:

· Prolonged exposure to hot liquid, electrical current, chemical, contact

·       Epidermis, dermis, sometimes subcutaneous tissue. May involve fascia

·       Often insensate. Dry: pale, white, eschar, edema. Eschar may slough. Grafting necessary. Scarring, loss of function.

·       Shock, possible hemolysis, myoglobinuria.

4th degree burn

full thickness

·       Prolonged exposure or high voltage electrical injury

·       Deep tissue, muscle, bone

·       Shock, myoglobinuria, hemolysis

·       Charring evident

·       Amputation likely; grafting non-beneficial

Electrical burns

·       Types: Flash, conductive (travels through body), lightning

·       Visual exam not predictive of size and severity

·       Deep muscle injury may be present without obvious superficial injury

·       Compartment syndrome is common due to edema from fluid resuscitation

·       Vasculature & heart may be affected

Inhalation Burns

o   Can result from thermal or chemical irritants. Damage from smoke: heat, particulates, systemic toxins.

o   6-30% of burn center admissions have inhalation injury & doubles chances of mortality from thermal burns.

o   Mechanisms of injury: thermal damage, asphyxiation, irritation of pulmonary tissue

early lab values/critical/abnormalities

Hyperkalemia from massive cell destruction, hyponatremia from plasma loss

later lab values/critical/abnormalitites

18+ hrs afterwards Hypokalemia & hyponatremia with fluid shifts

o   Fluids, UOP, Pain, GI

•   Foley catheter to monitor for kidney function and rhabdo.

•   NGT for TBSA > 20-25% -- paralytic ileus is common in patients with large burns

•   IV analgesia Cutaneous, SQ, PO not effective in burn patients

Debridement

o   : removal of devitalized tissue. Natural, mechanical, chemical, surgical

grafting

o   Autografts (full or split thickness).

•   Homograft’s & xenografts are considered biologic dressings

o   Biosynthetic & synthetic dressings, mesh