PHYSICAL PAINS

• NOCICEPTIVE PAIN
RESULT OF ACTIVATION OF SENSORY
RECEPTORS BY MECHANICAL, THERMAL
OR CHEMICAL STIMULI
• NEUROPATHIC PAIN
FROM DAMAGE TO PERIPHERAL
NERVOUS OR CNS TISSUE OR FROM
ALTERED PEROCESSING IN PAIN IN THE
CNS
 PAIN ACCORDING SOURCE:

• SOMATIC
SKELETAL MUSCLES, LIGAMENTS JOINTS
• VISCERAL
ORGANS AND SMOOTH MUSCLES
• SUPERFICIAL
SKIN AND MUCOUS MEMBRANES
VASCULAR PAIN
REFERRED PAIN

pain perceived
at a location
other than the
site of the
painful
stimulus/ origin
pain initiated or
caused by a primary
lesion, dysfunction or
transitory
perturbation of the
peripheral or central
nervous system’.
PHANTOM PAIN
pain that is felt in the area where an arm
or leg has been amputated.
CANCER PAIN
PSYCHOGENIC PAIN

physical pain that is

caused, increased, or
prolonged by mental,
emotional, or
behavioral factors.
CENTRAL PAIN
pain that is initiated by a primary lesion within
the central nervous system
GATE THEORY

• RONALD MELZACK/PATRICK WALL

• PAIN IMPULSES PASS THROUGH A
GATE LIKE STRUCTURE
THE ANALGESIC LADDER

• STEP 1- USE OF NON OPIOIDS WITH

OR WITHOUT ADJUVANTS
• STEP 2 – USE OF OPIOIDS WITH OR
WITHOUT OR WITHOUT NON OPIOIDS
• STEP 3 – USE OF OPIOIDS INDICATED
FOR MODERATE TO SEVERE PAIN
W.H.O. PAIN LADDER
STRONG OPIOIDS
Morphine, Oxycodone,
Diamorphine, Fentanyl
I

WEAK OPIOIDS
Tramadol, Codeine, Dihydrocodeine

SIMPLE ANALGESICS
Paracetamol, Aspirin, NSAIDS
ANALGESIC CEILING
EFFECT
• ONCE A SPECIFIC DOSAGE HAS BEEN
REACHED, THE DRUG PRODUCES
MAXIMUM ANALGESIA, INCREASING
THE DOSAGE PRODUCES NO
ADDITIONAL THERAPEUTIC BENEFIT
 OPIOID ANALGESICS

• NARCOTIC ANALGESICS
• PAIN RELIEVERS THAT ACT ON CNS
• THERE ARE SEVEN DIFFERENT
ALKALOIDS FROM THE OPIUM POPPY
• ONLY THREE OF IT HAS CLINICAL USE:
MORPHINE AND CODEINE (ANALGESIC
ACTION) PAPAVERINE (SMOOTH MUSCLE
RELAXANT)
POPPY PLANT
 CHEMICAL
CLASSIFICATION OF OPIOID
ANALGESICS
CHEMICAL CATEGORY OPIOID DRUG

Meperidine, fentanyl, remifentanyl, sufentanil,

Meperidine- like drugs
alfentanil

Methadone-like drugs Methadone, propoxyphene

Morphine, heroin, hydromorphone,

Morphine-like drugs oxymorphone, levorphanol, codeine,
hydrocodone, oxycodone

Others Tramadol
 MECHANISM OF ACTION:

• AGONIST
• PARTIAL AGONIST ( AGONIST
ANTAGONIST / MIXED AGONIST)
• ANTAGONIST
OPIATE

• DRUGS DERIVED FROM OPIUM

• NARCOTIC (OUTDATED TERM)
NARCOTIC

• PAIN MODULATING CHEMICAL THAT

TENDS TO CAUSE INSENSIBILITY
AND STUPOR
EFFECTS INCLUDE:
ANALGESIA-
SEDATION
EUPHORIA AND DYSPHORIA
BUTORPHANOL

• More potent than morphine

• Less cardiovascular effects and respiratory
sensitivity
• Synthetic opiate
• Used to manage pain during labor; migrane
headaches (intranasally)
 CODEINE

• Primarily used as an antitussive/antidiarrheal

medicine
• FENTANYL
• Administered as a patch (Duragesic) and as
lozenge (Actiq)
• Used for chronic pain management
HYDROMORPHONE

• Chronic pain; preferred over morphine

because of superior solubility and speed of
onset
• Less vomiting and nausea
MEPERIDINE
• Control mild to moderate pain, less nausea
• Syrup should be diluted; adjunct to
anesthesia
NALBUPHINE

• Injected into a large muscle and inhibits

pain pathways by changing perception of
pain; labor
OXYCODONE
Relieve mild to severe pain; combined with
other analgesics
causes CNS depression, impedes mental
abilities
OXYMORPHONE

• Semi synthetic compound; three times as

potent as oral morphine
PENTAZOCINE
sold only in combination with other drugs;
more likely to cause hallucinations
TAPENTADOL

• Chronic Malignant pain

• TRAMADOL- more potent version
• Only used for 18 years above
• Nausea, dizziness, vomiting, drowsiness

• PALLIATIVE
ANESTHETICS
DRUGS THAT DEPRESS THE CNS
OR PNS PRODUCING LESSENED
CONSCIOUSNESS, LOSS OF
RESPONSIVENESS TO
SENSORY STIMULATION AND
MUSCLE RELAXATION BY
INTERFERING WITH NERVE
CONDUCTION
 GENERAL
ANESTHETICS

LOCAL
ANESTHETICS
GENERAL ANESTHETICS

• ALTERS THE CNS, RESULTING IN

VARYING DEGREES IN PAIN RELIEF,
DEPRESSION OF CONSCIOUSNESS,
RELAXATION OF SKELETAL
MUSCLES, REDUCTION OF REFLEXES
TWO ROUTES :

• INHALATION
VOLATILE LIQUIDS OR GASES
THAT ARE VAPORIZED IN OXYGEN
AND INHALED
• INJECTABLE
ADMINISTERED INTRAVENOUSLY
LOCAL ANESTHETICS

• CAUSE A SPECIFIC PART OF THE

BODY TO BECOME SENSITIVE TO
PAIN WITHOUT MAJOR REDUCTION
OF CNS FUNCTIONS AND LEVEL ON
CONSCIOUSNESS
LOCAL ANESTHETICS

• TOPICAL
APPLIED DIRECTLY TO THE SKIN AND
MUCOUS MEMBRANES; AVAILABLE IN
CREAMS, SOLUTIONS, OINTMENTS, GELS
AND POWDERS
• PARENTERAL
GIVEN IV OR AS SPINAL INJECTIONS
The depth of anesthesia has been Loss ofpain
sensation , I
divided into four sequential stages: 2 PAIN_
---1\'

II
Stage 1: Analgesia (induction ) Combative
behJvfor

Stage 2:Excitement 111 OR

Surgical
al'll!sthesia i,
z 1-1,...J
Stage 3:Surgical anesthesia
IV

Stage 4: Medullary paralysis Medull;1ry

par lysis
0ndd1?ath

Lippincott's pharmacology-4th edition

 Stage of analgesia ( from beginning of
anaesthetic administration to the loss of
V
consciousness) L"""'"""'
_...., I

• Stage of delirium (From loss of consciousness -----

to beginning of regular respiration). Apparent II
excitement is seen- patient 1nayshout, stn1ggle and hold his breath; muscle
tone increases, jaws are tightly closed, breathing is jerky; von1iting,
involuntary micturition or defecation may occur. Heart rate and BP may rise
and pupils dilate due to sympathetic stimulation. V
• Surgical anaesthesia (from regular respiratior °·
1
R•l....
to cessation of spontaneous breathing). lnOllheJu
11
: -,..

Progressively- 1nuscle tone decreases, BP falls, HR increases with ,-vea k pulse,

respiration decreases in depth and later in frequency also. IV
V
• Medullary paralysis ( Cessation of breathing :
to failure of circulation and death). Pupil is widelydilated,
muscles are totally flabby, pulse is thready or imperceptible and BP is very low.
ilndde.Mh
-
Resuscitaion of p a t i e n t if r e a c h
fourth s t a g e anest hesi a

• Stop anesthetic

• Artificial respiration

• Analeptic drugs (drugs stimulate medullary

centers) e.g. doxapram IV infusion
IMMUNE
SYSTEM
 Frequent
heartbeat
Blood
vessels to d ilate

Histamine
Swelling and
inflam m at io n

Bronchoconstriction
Adrenaline
is released

Increases the per meabilit y

of the capillaries
ALLERGIC REACTION

• ACQUIRED, ABDNORMAL OVER-

REACTION BY THE IMMUNE SYSTEM
TO AN OTHERWISE HARMLESS
SUBSTANCE THAT RESULTS IN
HYPERSENSITIVITY
COMMON CAUSES OF ALLERGIES
AND ANAPHYLAXIS

• ENVIRONMENTAL IRRITANTS
(POLLEN, MOLDS)
• ANIMAL DANDERS
• MEDICATIONS
• CHEMICALS
• BLOOD TRANSFUSION
BIG 8 FOOD ALLERGENS
MILD ALLERGIC REACTION

• TYPICALLY RESULTS IN LOCAL

DERMATOLOGICAL (FACE/NECK).
NASAL MUCOSA/ CONGESTION ARE
ALSO COMMON
• SYMPTOMS MAY TAKE MINUTES,
HOURS EVEN DAYS TO DEVELOP
• EFFECTS DISAPPEAR WITH TIME
OVER TREATMENT
SYMPTOMS

• PRURITUS
• FLUSHED SKIN
• RASH/HIVES (URTICARIA)
• WATERY RED EYES
• NASAL CONGESTION
• INCREASED HEART RATE
• TINGLING IN/AROUND MOUTH
• FATIGUE
 MODERATE ALLERGIC
REACTION
• EFFECTS INCLUDE THOSE IN A MILD
REACTION BUT MORE PRONOUNCED
• RESPIRATORY AND GASTROINTESTINAL
SYSTEMS ARE USUALLY INVOLVED
• SYMPTOMS MAY TAKE MINUTES, HOURS
EVEN DAYS TO DEVELOP
• EFFECTS MIGHT DISAPPEAR OVER TIME
OR INCREASE IN SEVERITY, DEPENDING
ON RESPONSE
SYMPTOMS

• ANXIETY AND CONFUSION

• THROAT TIGHTNESS
• DIFFICULTY IN SWALLOWING AND
BREATHING
• WHEEZING
• RASH, HIVES, SWELLING IN THE
FACE, NECK CHEST ARMS
SYMPTOMS

• PERSISTENT ITCHING
• ANGIOEDEMA
• ABDOMINAL PAIN/CRAMPING
• NAUSEA/VOMITING
• ELEVATED VITAL SIGNS
 SEVERE ALLERGIC
REACTION
• CAUSES MASSIVE INFLAMMATORY
RESPONSE IN THE RESPIRATORY
INTEGUMENTARY CIRCULATORY AND
GASTROINTESTINAL SYSTEMS DUE TO
MASSIVE HISTAMINE RELEASE
• EFFECTS ARE IMMEDIATE- SECONDS OR
MINUTES
• IF NOT TREATED, COULD LEAD TO
ANAPHYLACTIC SHOCK AND DEATH
SYMPTOMS

• SEVERE ANXIETY
• DECREASED LEVEL OF
RESPONSIVENESS
• SEVERE RESPIRATORY DISTRESS
• SEVER ANGIOEDEMA, HIVES
• ABNORMAL LUNGS SOUNDS
• INABILITY TO SWALLOW
• TACHYCARDIA, WEAK PULSE
• HYPOTENSION, PALLOR, CYANOSIS
unpleasantfeeling
of apprehension
causedby
perceived or real
dangerthat
threatensth1e
security of the
person
GENERALIZED ANXIETY
DISORDER
• EXCESSIVE AND UNREALISTIC WORRY
ABOUT LIFE
• PSYCHOLOGICAL ( TENSION, FEAR,
DIFFICULTY IN CONCENTRATING,
APPREHENSION)
• PHYSICAL ( TACHYCARDIA,
PALPITATIONS, TREMORS, SWEATING,
GI UPSET)
PANIC DISORDER

• characterized by unexpected and

repeated episodes of intense fear
accompanied by physical symptoms
that may include chest pain, heart
palpitations, shortness of breath,
dizziness, or abdominal distress
SIMPLE PHOBIA

• IRRATIONAL FEARS OF A SPECIFIC

OBJECT ACTIVITY OR SITUATION
 OBSESSIVE COMPULSIVE
DISORDER
• characterized by recurrent, unwanted thoughts
(obsessions) and/or repetitive behaviors
(compulsions). Repetitive behaviors such as
hand washing, counting, checking, or cleaning
are often performed with the hope of preventing
obsessive thoughts or making them go away.
Performing these so-called "rituals," however,
provides only temporary relief, and not
performing them markedly increases anxiety.
 GENERIC USE/ SIDE
OUTCOME
( BRAND ) CONTRAINDICATION EFFECTS
ALPRAZOLAM Treatment of panic disorder; Drowsiness,
(Xanax) treatment of patients with hangover,
reduced hepatic function or in sedation
older adults

Do not administer on First

Trimester
ARRHYTHMIA
• ANY VARIATION FROM THE
NORMAL RHYTHM OF THE HEART
• HEARTBEAT IS TOO SLOW OR TOO
FAST
• WHEN CONTRACTIONS OF THE
VENTRICLES AND ATRIA ARE NOT
SYNCHRONIZED
• A MAJOR CLASS OF NATURAL AND
SYNTHETIC PHARMACEUTICAL AGENTS
THAT KILL OR INHIBIT THE GROWTH OF
INFECTION-CAUSING
MICROORGANISMS
• ANTISEPTIC
- SUBSTANCE THAT KILLS OR
INHIBITS THE GROWTH OF DRUGS ON
THE OUTSIDE OF THE BODY

DISINFECTANTS
- AGENT THAT DESTROYS
INFECTIOPUS ORGANISMS ON NON
LIVING OBJECTS
 BACTERIA

microscopic, single-celled
organisms that thrive in
diverse environments.
These organisms can live
in soil, the ocean and
inside the human gut.
•Aerobic
•Anaerobic

•Nosocomial
• Size and shape of bacterium
rod
cocci
curved or spiral
spirochetes
• Staining property of the bacterium
gram-positive ( purple)
gram negative ( red)
CLASSES OF ANTIBIOTICS

• SULFONAMIDES
• PENICILLIN
• CEPHALOSPORINS
• TERTACYCLINES/TIGECYCLINE
• MACROLIDES
• KETOLIDES
• QUINOLONES
CLASSES OF ANTIBIOTICS

• STREPTOGRAMINS
• CYCLIC LIPOPEPTIDES
• VANCOMYCIN
• CLINDAMYCIN
• METRONIDAZOLE
Sulfonamides (Sulfa Drugs

• Oldest antibiotics
• Block a specific step in the pathway for
making folic acid
• Nitrofurantoin
• Uses: UTI, otitis media, ulcerative colitis,
lower respiratory infections
• Works better when taken with food
• SIDE EFFECTS:
rash, nausea, vomiting, jaundice, Steven
Johnsons Syndrome, Kidney damage
PENICILLIN

• Penicillium chrysogenum
• Kill the bacteria by preventing them from
forming the rigid cell wall
• Uses: abscesses, meningitis, otitis media,
pneumonia, respiratory infections, strep
throat, tooth and gum infections, STD,
endocarditis
Cephalosporins

• Mechanism of action similar to penicillin

• Uses: oral infections, dentistry work, heart
and pacemaker operations, neurosurgical
operations, OB/GYN procedures,
orthopedic surgery, upper respiratory
infections UTI, meningitis, intra-abdominal
infections
Tetracyclines and Tigecycline

• Produced by soil organisms

• Inhibit protein synthesis by binding into
ribosomes
• Uses: acne, anthrax, chronic bronchitis,
mycoplasma pneumonia, Chlamadia
• Side Effects: nausea, vomiting, do not take
with antacids
• TIGECLYCLINE-SKIN, INTRA
ABDOMINAL INFECTION
Macrolides

• Combine with ribosomes

• Used to primarily treat pulmonary
infections caused by Legionella and gram
positive organisms
• Uses: chlamydia, H. influenza
• Side Effects: take with food to attain faster
absorption
Ketolides

• Bind to ribosomal sub units

• Uses: mild to moderate community acquired
pneumonia, acute bacterial sinusitis
• Side Effects: blurred vision, difficulty
focusing, arrhythmia
Quinolones
• Antagonize the enzyme responsible for
coiling and replicating bacterial DNA
during growth
• Uses: bone and joint infections
• Infectious diarrhea
• Ophthalmic infections
• STD
• Upper respiratory infections
• UTI
?
X 0

Q)
'j,,

C
BLOOD CLOTS
► ►

•
Deep vein thrombosis (DVT) occurs when a blood
clot (thrombus) forms in one or more of the deep
veins in your body, usually in your legs. Deep vein
thrombosis can cause leg pain or swelling, but also
can occur with no symptoms.
Deep vein thrombosis can be very serious
because blood clots in your veins can break
loose, travel through your bloodstream and
lodge in your lungs, blocking blood flow
(pulmonary embolism).
Heparin

• Naturally occurring circulatory

antiocoagulant
• Does not dissolve a clot that has been
formed but inhibits thrombin formation
thereby reducing the ability of blood to clot
and the formation of new clot
• Protamine sulfate
Warfarin

• used to treat or prevent blood clots in veins

or arteries, which can reduce the risk of
stroke, heart attack
DEPRESSION

• CHARACTERIZED BY FEELINGS OF
PESSIMISM, WORRY, INTENSE
SADNESS, LOSS OF CONCENTRATION,
SLOWING OF MENTAL PROCESSES,
PROBLEMS WITH EATING AND
SLEEPING
SYMPTOMS

• DYSPHORIC MOOD
• LOSS OF INTEREST IN ALMOST ALL
USUAL ACTIVITIES
• LOW SELF ESTEEM
• PESSIMISM
• SELF PITY
• LOSS OF WEIGHT
SYMPTOMS

• INSOMNIA/HYPERSOMNIA
• EXTREME RESTLESSNESS
• LOSS OF ENERGY
• WORTHLESSNESS
• FEELINGS OF GUILT
• RECURRENT THOUGHTS OF DEATH
• SUICIDE ATTEMPTS
Mania

• Extreme excitement, excessive elation,

hyperactivity, agitation, increased
psychomotor activity
Bipolar Disorder

• Mood swings that alternate between periods

of major depression and periods of mild to
severe chronic agitation
1$ NEUROTRANSMITTERS
SERATONIN DOPAMINE ADRENALINE NORADRENALINE
MO O D PL EASURE FIGHT OR FLIGHT CON CEN TRATION

GABA ACETYLCHOLINE GLUTAMINE ENDORPHINS

C ALMI NG MEM ORY EUPHORIA
ANTI EMETIC
DRUGS
• VOMITING CENTER IN THE BRAIN –
MEDULLA
• CHEMORECEPTOR TRIGGER ZONE
RECEIVES INPUT FROM THE VAGUS
NERVE OR THE TENTH CRANIAL NERVE
• MAIN NEUROTRAMITTERS: SEROTONIN,
DOPAMINE, ACETYLCHOLINE