Module 2v2

Browser lacks capabilities required to play.

Upgrade or switch to another browser.

Loading…

@@.whitetext; !!!VA_Pain training_2 Welcome to the second in a series of interactive scenarios to support learning during pain training. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@ [[Next->Introduction]] <<set $result to 0>> <<set $audio1 to false>> <<set $audio2 to false>> <<set $audio3 to false>> <<set $PO to false>> <<set $PCA to false>> <<set $paracetamol to false>> <<set $epidural2 to false>> <<set $epidural3 to false>> <<set $paravertebral2 to false>> <<set $paravertebral3 to false>> <<set $erectorspinae2 to false>> <<set $erectorspinae3 to false>>

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!VA_Pain training_2: Acute Pain Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "audio1" "audio/audio1.mp3">> <<cacheaudio "audio2" "audio/audio2.mp3">> <<cacheaudio "audio3" "audio/audio3.mp3">> <<cacheaudio "bleep" "audio/bleep.mp3">> <<set $history to []>> <<set $started to 0>>

!!@@.greentext;2021 Curriculum learning syllabus@@ !!!@@.greentext;Stage 1 Pain learning outcomes@@ @@.greentext; ''//Recognises, assesses and treats acute pain independently Differentiates between acute and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Can recognise, examine, assess and manage acute pain in the surgical and non-surgical patient * Is able to safely and appropriately prescribe medication for pain management * Demonstrates effective communication skills regarding pain management with patients, relatives and carers * Demonstrates the basic assessment and management of acute on chronic and chronic pain in adults * Describes the concept of biopsychosocial multi-disciplinary pain management * Describes the special circumstances in assessing and managing perioperative pain in specific patient groups including children, pregnancy and breast feeding, the elderly and frail, those with learning and communication difficulties, autism, dementia, renal and hepatic impairment and substance abuse * Demonstrates the safe use of equipment used in pain management !!!@@.greentext;Stage 2 learning outcome:@@ @@.greentext;''//Understands the aetiology and management of acute, acute on chronic and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Utilises a multi-disciplinary approach to the management of complex pain within a biopsychosocial model of care * Can confidently manage acute pain in the whole perioperative pathway in a timely manner * Is able to assess patients, interpret investigations and initiate management of chronic malignant and non-malignant pain in a timely manner under distant supervision * Can assess and manage acute on chronic and chronic inpatient pain in adults and recognise when referral to specialist pain services is appropriate * Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision * Explains the risk factors for persistent post-surgical pain including measures to minimise its occurrence !!!@@.greentext;Stage 3 learning outcome:@@ @@.greentext;''//Able to initiate complex pain management for in-patients and to sign-post to appropriate pain management services//''@@ !!!@@.greentext;Key capabilities@@ * Applies knowledge and understanding of assessment and management of pain in a multiprofessional context * Demonstrates safe effective pharmacological management of acute and procedure pain in all age groups * Acts as an effective member of the inpatient pain team * Effectively engages with multi-disciplinary primary and secondary pain services and palliative care when necessary * Recognises the need for and complications of interventional pain procedures * Prescribes appropriately in the perioperative period and recognises the long term implications of not reviewing patient analgesia in the post–operative period following discharge * Plans the perioperative management of patients for surgery who are taking high dose opioids and other drugs of potential addiction [[Back|Core clinical learning objectives]]

@@.whitetext;<p style="text-align:justify">''Q1 Which of the following statements regarding rib fractures is correct?'' </p> <<radiobutton "$choice1" "1">>  ''A.'' Trauma is leading cause of death in the first five decades of life <<radiobutton "$choice1" "2">>  ''B.'' Pneumonia rates in the elderly with rib fractures are as high as 65% <<radiobutton "$choice1" "3">>  ''C.'' The majority of rib fractures (approximately 75%) are associated with blunt trauma <<radiobutton "$choice1" "4">>  ''D.'' Seven or more fractured ribs has an associated mortality of 68% <<radiobutton "$choice1" "5">>  ''C.'' Flail chest alone is associated with a mortality of 50%@@ <<timed 59s>> <<goto Q2>> <</timed>> <<countdownTimer 60 "Q2">> <<button [[Next question->Q2]]>> <</button>>

!!!@@.greentext;Scenario learning objectives:@@ * Be aware of serious complications associated with sickle cell disease * Understand some of the issues people with sickle cell disease experience when accessing care * Consider alternative appropriate methods of pharmacological management of acute pain episodes * Be aware of the NICE guidelines on sickle cell disease * Have an overview of opioid receptors * Understand the risks associated with multiple rib-fractures including risk scoring tools * Outline the alternative methods of acute pain control for an individual with multiple rib fractures including regional techniques [[Credits and certificate|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VApain2">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

@@.whitetext;<<if $choice1 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 For the original rib fracture scoring system:''</p> <<radiobutton "$choice2" "1">>  ''A.'' Age is the only determinant of mortality, where older patients were likely to die <<radiobutton "$choice2" "2">>  ''B.'' Number of breaks in each rib is the only determinant of mortality, where patients with multiple flail segments in the same rib were likely to die <<radiobutton "$choice2" "3">>  ''C.'' The number of ribs fractured and age of patient are the most important determinants of mortality, with higher numbers of rib fractures and being older associated with a higher mortality <<radiobutton "$choice2" "4">>  ''D.'' The total number of breakages, side of break, and age were all taken into consideration for mortality and complication scoring <<radiobutton "$choice2" "5">>  ''E.'' The total number of breakages, side of break, age, mechanism of injury and pre-existing comorbidities were all taken into consideration for mortality and complication scoring @@ <<timed 59s>> <<goto Q3>> <</timed>> <<countdownTimer 60 "Q3">> <<button [[Next Question->Q3]]>> <</button>>

@@.whitetext;<<if $choice2 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q3 Early intervention with effective analgesia for rib fractures aims to prevent hypoventilation, aid deep breathing and physiotherapy, promote adequate coughing and clearance of secretions, and ultimately prevent pneumonia and ICU admissions for intubation. Regarding analgesia:''</p> <<radiobutton "$choice3" "1">>  ''A.'' All patients should be offered paracetamol, NSAID, and a regular opioid with appropriate antipyretic, antiemetic and laxative as long as there are no contraindications <<radiobutton "$choice3" "2">>  ''B.'' All patients should be offered a PCA on arrival to the emergency department <<radiobutton "$choice3" "3">>  ''C.'' All patients should be offered lidocaine plasters on admission to a ward <<radiobutton "$choice3" "4">>  ''D.'' All patients with unilateral fractured ribs should be offered a thoracic epidural as a means of pain relief <<radiobutton "$choice3" "5">>  ''E.'' All patients should be offered operative stabilization of any fractures @@ <<timed 59s>> <<goto Q4>> <</timed>> <<countdownTimer 60 "Q4">> <<button [[Next question->Q4]]>> <</button>>

@@.whitetext;<<if $choice3 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 Thoracic epidural remains the standard of care for fractured ribs where opioids are only partially working and is particularly useful for helping patients with flail chests and bilateral rib fractures. Thoracic epidurals:''</p> <<radiobutton "$choice4" "1">>  ''A.'' Infrequently cause hypotension <<radiobutton "$choice4" "2">>  ''B.'' Never cause motor block <<radiobutton "$choice4" "3">>  ''C.'' Infrequently cause urinary retention and pruritus (in presence of opioids) <<radiobutton "$choice4" "4">>  ''D.'' Should not be attempted in the presence of aspirin <<radiobutton "$choice4" "5">>  ''E.'' May be difficult to insert in a polytrauma patient@@ <<timed 59s>> <<goto Q5>> <</timed>> <<countdownTimer 60 "Q5">> <<button [[Next question->Q5]]>> <</button>>

@@.whitetext;<<if $choice4 eq "5">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q5 Other alternatives to thoracic epidurals include:'' </p> <<radiobutton "$choice5" "1">>  ''A.'' Paravertebral Block <<radiobutton "$choice5" "2">>  ''B.'' Serratus Plane Block <<radiobutton "$choice5" "3">>  ''C.'' Erector Spinae Plane Block <<radiobutton "$choice5" "4">>  ''D.'' Intercostal Block <<radiobutton "$choice5" "5">>  ''E.'' Interpleural Block <<radiobutton "$choice5" "6">>  ''F.'' All of the above@@ <<timed 59s>> <<goto Q6>> <</timed>> <<countdownTimer 60 "Q6">> <<button [[Next question->Q6]]>> <</button>>

@@.whitetext;<<if $choice5 eq "6">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q6 Sickle cell patients suffering with an acute painful episode should be treated as a medical emergency. The first step should be:''</p> <<radiobutton "$choice6" "1">>  ''A.'' Apply oxygen and start IV fluids <<radiobutton "$choice6" "2">>  ''B.'' Follow locally agreed protocols as to the assessment and management of a sickle cell acute painful episode and an individualized care plan if they have one <<radiobutton "$choice6" "3">>  ''C.'' Give IV Paracetamol, a NSAID and parenteral opioids, ideally within 30 minutes of arrival into hospital <<radiobutton "$choice6" "4">>  ''D''. Send bloods for a reticulocyte count to confirm their pain is due to an acute sickle crisis <<radiobutton "$choice6" "5">>  ''E.'' Give broad-spectrum antibiotics as episodes are frequently triggered by bacterial infections@@ <<timed 59s>> <<goto Q7>> <</timed>> <<countdownTimer 60 "Q7">> <<button [[Next question->Q7]]>> <</button>>

@@.whitetext;<<if $choice6 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q7 Hydroxyurea:'' </p> <<radiobutton "$choice7" "1">>  ''A.'' Increases the amount of HbF <<radiobutton "$choice7" "2">>  ''B.'' Decreases the incidence of acute vaso-occlusive pain episodes and acute chest syndrome, with a survival benefit shown in several studies <<radiobutton "$choice7" "3">>  ''C.'' Has no parenteral formulation <<radiobutton "$choice7" "4">>  ''D.'' Should be continued during acute admissions unless there is a significant acute kidney injury or myelosuppression <<radiobutton "$choice7" "5">>  ''E.'' All of the above @@ <<timed 59s>> <<goto "Q8">> <</timed>> <<countdownTimer 60 "Q8">> <<button [[Next question->Q8]]>> <</button>>

@@.whitetext;<<if $choice7 eq "5">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q8 When treating a patient with a sickle cell acute painful episode:'' </p> <<radiobutton "$choice8" "1">>  ''A.'' Offer a bolus dose of a strong opioid by a suitable route, in accordance with local protocols, to patients presenting with severe pain <<radiobutton "$choice8" "2">>  ''B.'' Offer all patients with moderate to severe pain a strong opioid via a PCA <<radiobutton "$choice8" "3">>  ''C.'' Paracetamol and an NSAID should be prescribed to all patients <<radiobutton "$choice8" "2">>  ''D.'' In the context of severe pain Pethidine is the subcutaneous agent of choice where IV access is not immediately available <<radiobutton "$choice8" "3">>  ''E.'' NICE recommends an individual’s pain should be reassessed four times in 24 hours@@ <<timed 59s>> <<goto "Q9">> <</timed>> <<countdownTimer 60 "Q9">> <<button [[Next question->Q9]]>> <</button>>

@@.whitetext;<<if $choice8 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q9 PCA should be considered:'' </p> <<radiobutton "$choice9" "1">>  ''A.'' Only after intermittent opioid dosing regimens have failed to adequately control the patient’s pain <<radiobutton "$choice9" "2">>  ''B.'' When a patient's regular medication includes more than 120mg oral morphine or its equivalent per 24 hours <<radiobutton "$choice9" "3">>  ''C.'' For use in ward areas where intermittent dosing of opioids is not possible <<radiobutton "$choice9" "4">>  ''D.'' If repeated bolus doses of a strong opioid are needed within 2 hours or in accordance with local protocols <<radiobutton "$choice9" "5">>  ''E.'' To achieve rapid initial pain control in patients with severe pain @@ <<timed 59s>> <<goto "Q10">> <</timed>> <<countdownTimer 60 "Q10">> <<button [[Next question->Q10]]>> <</button>>

@@.whitetext;<<if $choice9 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q10 In patients with sickle cell disease'' </p> <<radiobutton "$choice10" "1">>  ''A.'' The majority of patients should step down on their analgesia within 24 hours of admission to avoid developing tolerance to opioids <<radiobutton "$choice10" "2">>  ''B.'' Acute chest syndrome, aplastic crisis and splenic sequestration are some of the many possible concurrent or sole causes for a patient’s pain that clinicians should be alert to <<radiobutton "$choice10" "3">>  ''C.'' Steroids are indicated during acute admissions as in studies they reduce length of stay <<radiobutton "$choice10" "4">>  ''D.'' Opioid-misuse is a common problem in patients with sickle cell disease and should be suspected in patients who request frequent doses of strong opiates or present often <<radiobutton "$choice10" "5">>  ''E.'' Are at low risk of thromboembolic events due to the chronically low haematocrit seen in sickle cell disease @@ <<timed 59s>> <<goto "Done!">> <</timed>> <<countdownTimer 60 "Done!">> <<button [[Done!->Done!]]>> <</button>>

<<if $choice10 eq "2">><<set $result to $result + 1>> <</if>> You've scored <<print $result>> out of 10 <<set $result1 to $result>> [[Time for work]]

You quickly close the MCQ down and sprint up the stairs to Alison's office. She's waiting for you inside. "Hi $firstname, I've printed the list of who we have to see this morning and here's your bleep." She hands you a printed list and battered bleep with the battery held in with Sellotape. "Where to first?" Alison asks you. You take a look at [[the list]]

It's 7:45am. You're grabbing a quick coffee before your shift starts. An email notification pings on your phone. [[take a look->email1]]

@@.typing;''From:'' Alison Burrows ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Today Hi $firstname I saw you’re down to join me on the acute pain round this morning. I thought it might be helpful for you to have a look at ten multiple-choice questions to get you in the zone. Sorry I meant to send them yesterday and you've only got ten minutes to get them done! There’s no negative marking so just give them a go. I know ten minutes isn't long but it will get you making fast, accurate decisions under pressure. See you at eight outside my office. Alison Dr Alison Burrows, BM MSc FRCA FFPMRCA Consultant in Anaesthesia and Pain Medicine, UK @@ [[www.onlinepainMCQ.ac.uk->Q1]] [[I'll skip those thanks->Time for work]]

@@.whitetext;<p style="text-align:justify">''Q1 Which of the following statements regarding rib fractures is correct?'' </p> <label><<radiobutton "$choice1" "one">>  ''A.'' Trauma is leading cause of death in the first five decades of life</label> <label><<radiobutton "$choice1" "two">>  ''B.'' Pneumonia rates in the elderly with rib fractures are as high as 65%</label> <label><<radiobutton "$choice1" "three">>  ''C.'' The majority of rib fractures (approximately 75%) are associated with blunt trauma</label> <label><<radiobutton "$choice1" "four">>  ''D.'' Seven or more fractured ribs has an associated mortality of 68%</label> <label><<radiobutton "$choice1" "five">>  ''E.'' Flail chest alone is associated with a mortality of 50% </label> @@ <br> <<button [[Next question->Q2post]]>> <</button>> <<set $result to 0>>

@@.whitetext;<<if $choice1 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 For the original rib fracture scoring system:'' </p> <label><<radiobutton "$choice2" "one">>  ''A.'' Age is the only determinant of mortality, where older patients were likely to die</label> <label><<radiobutton "$choice2" "two">>  ''B.'' Number of breaks in each rib is the only determinant of mortality, where patients with multiple flail segments in the same rib were likely to die</label> <label><<radiobutton "$choice2" "three">>  ''C.'' The number of ribs fractured and age of patient are the most important determinants of mortality, with higher numbers of rib fractures and being older associated with a higher mortality</label> <label><<radiobutton "$choice2" "four">>  ''D.'' The total number of breakages, side of break, and age were all taken into consideration for mortality and complication scoring</label> <label><<radiobutton "$choice2" "five">>  ''E.'' The total number of breakages, side of break, age, mechanism of injury and pre-existing comorbidities were all taken into consideration for mortality and complication scoring</label> <br> <<button [[Next Question->Q3post]]>> <</button>>

@@.whitetext;<<if $choice2 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q3 Early intervention with effective analgesia for rib fractures aims to prevent hypoventilation, aid deep breathing and physiotherapy, promote adequate coughing and clearance of secretions, and ultimately prevent pneumonia and ICU admissions for intubation. Regarding analgesia:''</p> <label><<radiobutton "$choice3" "one">>  ''A.'' All patients should be offered paracetamol, NSAID, and a regular opioid with appropriate antipyretic, antiemetic and laxative as long as there are no contraindications</label> <label><<radiobutton "$choice3" "two">>  ''B.'' All patients should be offered a PCA on arrival to the emergency department</label> <label><<radiobutton "$choice3" "three">>  ''C.'' All patients should be offered lidocaine plasters on admission to a ward</label> <label><<radiobutton "$choice3" "four">>  ''D.'' All patients with unilateral fractured ribs should be offered a thoracic epidural as a means of pain relief</label> <label><<radiobutton "$choice3" "five">>  ''E.'' All patients should be offered operative stabilization of any fractures</label> <br> <<button [[Next Question->Q4post]]>> <</button>>

@@.whitetext;<<if $choice3 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 Thoracic epidural remains the standard of care for fractured ribs where opioids are only partially working and is particularly useful for helping patients with flail chests and bilateral rib fractures. Thoracic epidurals:''</p> <label><<radiobutton "$choice4" "one">>  ''A.'' Infrequently cause hypotension </label> <label><<radiobutton "$choice4" "two">>  ''B.'' Never cause motor block</label> <label><<radiobutton "$choice4" "three">>  ''C.'' Infrequently cause urinary retention and pruritus (in presence of opioids)</label> <label><<radiobutton "$choice4" "four">>  ''D.'' Should not be attempted in the presence of aspirin</label> <label><<radiobutton "$choice4" "five">>  ''E.'' May be difficult to insert in a polytrauma patient</label> <br> <<button [[Next Question->Q5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q1 Which of the following statements regarding rib fractures is correct?''</p> <label><<radiobutton "$choice1" "one" `$choice1 is "one" ? 'checked' : ''`>>  ''A.'' Trauma is leading cause of death in the first five decades of life</label> <label><<radiobutton "$choice1" "two" `$choice1 is "two" ? 'checked' : ''`>>  ''B.'' Pneumonia rates in the elderly with rib fractures are as high as 65%</label> <label><<radiobutton "$choice1" "three" `$choice1 is "three" ? 'checked' : ''`>>  ''C.'' The majority of rib fractures (approximately 75%) are associated with blunt trauma </label> <label><<radiobutton "$choice1" "four" `$choice1 is "four" ? 'checked' : ''`>>  ''D.'' Seven or more fractured ribs has an associated mortality of 68%</label> <label><<radiobutton "$choice1" "five" `$choice1 is "five" ? 'checked' : ''`>>  ''E.'' Flail chest alone is associated with a mortality of 50%</label> <br> <<if $choice1 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify"> Rib fractures are very common and are detected in at least 10% of all injured patients, the majority of which are as a consequence of blunt thoracic trauma (75%) with road traffic collisions being the main cause. The remaining 25% are due to penetrating injuries. The elderly are particularly prone to rib fractures from moderate trauma as a result of osteoporosis, reduced muscle mass, cartilage degeneration and reduced elasticity. Most other statistics for fractured ribs are around 30%: pneumonia rates in the elderly are around 31%, patients with seven or more fractured ribs have a mortality of around 29%; and flail chest alone has a mortality of 33%.</p> @@ <<button [[Next question->answerQ2post]]>> <</button>>

@@.whitetext;<<if $choice4 eq "five">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q5 Other alternatives to thoracic epidurals include:''</p> <label><<radiobutton "$choice5" "one">>  ''A.'' Paravertebral Block</label> <label><<radiobutton "$choice5" "two">>  ''B.'' Serratus Plane Block</label> <label><<radiobutton "$choice5" "three">>  ''C.'' Erector Spinae Plane Block</label> <label><<radiobutton "$choice5" "four">>  ''D.'' Intercostal Block</label> <label><<radiobutton "$choice5" "five">>  ''E.'' Interpleural Block</label> <label><<radiobutton "$choice5" "six">>  ''F.'' All of the above</label> <br> <<button [[Next Question->Q6post]]>> <</button>>

@@.whitetext;<<if $choice5 eq "six">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q6 Sickle cell patients suffering with an acute painful episode should be treated as a medical emergency. The first step should be:''</p> <label><<radiobutton "$choice6" "one">>  ''A.'' Apply oxygen and start IV fluids</label> <label><<radiobutton "$choice6" "two">>  ''B.'' Follow locally agreed protocols as to the assessment and management of a sickle cell acute painful episode and an individualized care plan if they have one</label> <label><<radiobutton "$choice6" "three">>  ''C.'' Give IV Paracetamol, a NSAID and parenteral opioids, ideally within 30 minutes of arrival into hospital</label> <label><<radiobutton "$choice6" "four">>  ''D.'' Send bloods for a reticulocyte count to confirm their pain is due to an acute sickle crisis </label> <label><<radiobutton "$choice6" "five">>  ''E.'' Give broad-spectrum antibiotics as episodes are frequently triggered by bacterial infections</label> <br> <<button [[Next Question->Q7post]]>> <</button>>

@@.whitetext;<<if $choice6 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q7 Hydroxyurea:''</p> <label><<radiobutton "$choice7" "one">>  ''A.'' Increases the amount of HbF</label> <label><<radiobutton "$choice7" "two">>  ''B.'' Decreases the incidence of acute vaso-occlusive pain episodes and acute chest syndrome, with a survival benefit shown in several studies</label> <label><<radiobutton "$choice7" "three">>  ''C.'' Has no parenteral formulation</label> <label><<radiobutton "$choice7" "four">>  ''D.'' Should be continued during acute admissions unless there is a significant acute kidney injury or myelosuppression </label> <label><<radiobutton "$choice7" "five">>  ''E.'' All of the above </label> <br> <<button [[Next Question->Q8post]]>> <</button>>

@@.whitetext;<<if $choice7 eq "five">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q8 When treating a patient with a sickle cell acute painful episode:''</p> <label><<radiobutton "$choice8" "one">>  ''A.'' Offer a bolus dose of a strong opioid by a suitable route, in accordance with local protocols, to patients presenting with severe pain</label> <label><<radiobutton "$choice8" "two">>  ''B.'' Offer all patients with moderate to severe pain a strong opioid via a PCA</label> <label><<radiobutton "$choice8" "three">>  ''C.'' Paracetamol and an NSAID should be prescribed to all patients </label> <label><<radiobutton "$choice8" "four">>  ''D.'' In the context of severe pain Pethidine is the subcutaneous agent of choice where IV access is not immediately available </label> <label><<radiobutton "$choice8" "five">> ''E.'' NICE recommends an individual’s pain should be reassessed four times in 24 hours</label> <br> <<button [[Next Question->Q9post]]>> <</button>>

@@.whitetext;<<if $choice8 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q9 PCA should be considered:''</p> <label><<radiobutton "$choice9" "one">>  ''A.'' Only after intermittent opioid dosing regimens have failed to adequately control the patient’s pain</label> <label><<radiobutton "$choice9" "two">>  ''B.'' When a patient's regular medication includes more than 120mg oral morphine or its equivalent per 24 hours</label> <label><<radiobutton "$choice9" "three">>  ''C.'' For use in ward areas where intermittent dosing of opioids is not possible </label> <label><<radiobutton "$choice9" "four">>  ''D.'' If repeated bolus doses of a strong opioid are needed within 2 hours or in accordance with local protocols</label> <label><<radiobutton "$choice9" "five">>  ''E.'' To achieve rapid initial pain control in patients with severe pain</label> <br> <<button [[Next Question->Q10post]]>> <</button>>

@@.whitetext;<<if $choice9 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q10 In patients with sickle cell disease:''</p> <label><<radiobutton "$choice10" "one">>  ''A.'' The majority of patients should step down on their analgesia within 24 hours of admission to avoid developing tolerance to opioids</label> <label><<radiobutton "$choice10" "two">>  ''B.'' Acute chest syndrome, aplastic crisis and splenic sequestration are some of the many possible concurrent or sole causes for a patient’s pain that clinicians should be alert to</label> <label><<radiobutton "$choice10" "three">>  ''C.'' Steroids are indicated during acute admissions as in studies they reduce length of stay </label> <label><<radiobutton "$choice10" "four">>  ''D.'' Opioid-misuse is a common problem in patients with sickle cell disease and should be suspected in patients who request frequent doses of strong opiates or present frequently </label> <label><<radiobutton "$choice10" "five">>  ''E.'' There is a low risk of thromboembolic events due to the chronically low haematocrit seen in the disease </label> <br> <<button [[Submit->results2]]>> <</button>>

<<if $choice10 eq "two">><<set $result to $result + 1>> <</if>> You scored <<print $result>> out of 10! <<set $result2 to $result>> <<button [[Answers|answerQ1post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q2 For the original rib fracture scoring system:''</p> <label><<radiobutton "$choice2" "one" `$choice2 is "one" ? 'checked' : ''`>>  ''A.'' Age is the only determinant of mortality, where older patients were likely to die</label> <label><<radiobutton "$choice2" "two" `$choice2 is "two" ? 'checked' : ''`>>  ''B.'' Number of breaks in each rib is the only determinant of mortality, where patients with multiple flail segments in the same rib were likely to die</label> <label><<radiobutton "$choice2" "three" `$choice2 is "three" ? 'checked' : ''`>>  ''C.'' The number of ribs fractured and age of patient are the most important determinants of mortality, with higher numbers of rib fractures and being older associated with a higher mortality</label> <label><<radiobutton "$choice2" "four" `$choice2 is "four" ? 'checked' : ''`>>  ''D.'' The total number of breakages, side of break, and age were all taken into consideration for mortality and complication scoring</label> <label><<radiobutton "$choice2" "five" `$choice2 is "five" ? 'checked' : ''`>>  ''E.'' The total number of breakages, side of break, age, mechanism of injury and pre-existing comorbidities were all taken into consideration for mortality and complication scoring</label> <br> <<if $choice2 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">Most hospitals use a variation of the following formula to determine which adults are at higher risk, which is itself a variation of the injury severity score. The formula: <center> !!!Rib Fracture Score = (breaks x sides) + age factor </center> Where: breaks is the total number of fractures (there may be multiple fractures on each rib), sides scores 1 for unilateral and 2 for bilateral, and ages are grouped between 0 and 4, with elderly scoring higher. These scores give an assessment of the potential mortality and complication rate for the patient and help determine the analgesic technique and the level of monitoring. Some hospital variants take into account pre-existing comorbidities, or have some option for the assessor to increase the score based on other factors, but the original scoring system did not have these options. Please check your local hospital guidance to see how to score rib fractures in your hospital and how to manage them, or contact your acute pain nurses.</p> @@ <<button [[Next question->answerQ3post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q3 Early intervention with effective analgesia for rib fractures aims to prevent hypoventilation, aid deep breathing and physiotherapy, promote adequate coughing and clearance of secretions, and ultimately prevent pneumonia and ICU admissions for intubation. Regarding analgesia:''</p> <label><<radiobutton "$choice3" "one" `$choice3 is "one" ? 'checked' : ''`>>  ''A.'' All patients should be offered paracetamol, NSAID, and a regular opioid with appropriate antipyretic, antiemetic and laxative as long as there are no contraindications</label> <label><<radiobutton "$choice3" "two" `$choice3 is "two" ? 'checked' : ''`>>  ''B.'' All patients should be offered a PCA on arrival to the emergency department</label> <label><<radiobutton "$choice3" "three" `$choice3 is "three" ? 'checked' : ''`>>  ''C.'' All patients should be offered lidocaine plasters on admission to a ward</label> <label><<radiobutton "$choice3" "four" `$choice3 is "four" ? 'checked' : ''`>>  ''D.'' All patients with unilateral fractured ribs should be offered a thoracic epidural as a means of pain relief</label> <label><<radiobutton "$choice3" "five" `$choice3 is "five" ? 'checked' : ''`>>  ''E.'' All patients should be offered operative stabilization of any fractures</label> <br> <<if $choice3 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify">Almost all patients with rib fractures will require some form of opioid medication (weak or strong) and simple analgesia during the first few hours of injury whilst they are assessed and an appropriate treatment plan determined. There is no standard consensus across hospitals regarding different plans, but will be dependent on your local hospital protocols, skill mix and the rib fracture score the patient is assessed as having. Many nurses in the emergency department will be happy administering IV morphine, so a PCA may not be so practical there until the patient reaches a ward. Lidocaine plasters are not licensed for rib fractures, but are anecdotally being used and may provide some pain relief but do not decrease opioid consumption: they should not be used as standard treatment alone on admission to a ward. Thoracic epidural or other regional technique may be offered if the score is high enough, but not all patients require this. There is ongoing debate in the literature regarding operative stabilization, and this should be considered for patients with flail chest, or to expedite respiratory wean from mechanical ventilation after a discussion with a cardiothoracic team.</p> @@ <<button [[Next question->answerQ4post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q4 Thoracic epidural remains the standard of care for fractured ribs where opioids are only partially working and is particularly useful for helping patients with flail chests and bilateral rib fractures. Thoracic epidurals:''</p> <label><<radiobutton "$choice4" "one" `$choice4 is "one" ? 'checked' : ''`>>  ''A.'' Infrequently cause hypotension</label> <label><<radiobutton "$choice4" "two" `$choice4 is "two" ? 'checked' : ''`>>  ''B.'' Never cause motor block</label> <label><<radiobutton "$choice4" "three" `$choice4 is "three" ? 'checked' : ''`>>  ''C.'' Infrequently cause urinary retention and pruritus (in presence of opioids)</label> <label><<radiobutton "$choice4" "four" `$choice4 is "four" ? 'checked' : ''`>>  ''D.'' Should not be attempted in the presence of aspirin</label> <label><<radiobutton "$choice4" "five" `$choice4 is "five" ? 'checked' : ''`>>  ''E.'' May be difficult to insert in a polytrauma patient</label> <br> <<if $choice4 is "five">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: E'' <p style="text-align:justify">Thoracic epidurals can be difficult to insert even with the best positioning, but can be incredibly difficult when a patient needs to be log-rolled and is unable to position appropriately. Sometimes in these cases it is worth considering alternative analgesia techniques. Thoracic epidurals often cause sympathetic blockade with subsequent hypotension which can make distinguishing hypovolaemic shock difficult. Despite being placed relatively high, epidural spread can cause motor block, urinary retention and pruiritis especially if opioids are used. Aspirin alone in the presence of normal coagulation tests is not a contraindication to epidural anaesthesia.</p> @@ <<button [[Next question->answerQ5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q5 Other alternatives to thoracic epidurals include:''</p> <label><<radiobutton "$choice5" "one" `$choice5 is "one" ? 'checked' : ''`>>  ''A.'' Paravertebral Block</label> <label><<radiobutton "$choice5" "two" `$choice5 is "two" ? 'checked' : ''`>>  ''B.'' Serratus Plane Block</label> <label><<radiobutton "$choice5" "three" `$choice5 is "three" ? 'checked' : ''`>>  ''C.'' Erector Spinae Plane Block</label> <label><<radiobutton "$choice5" "four" `$choice5 is "four" ? 'checked' : ''`>>  ''D.'' Intercostal Block</label> <label><<radiobutton "$choice5" "five" `$choice5 is "five" ? 'checked' : ''`>>  ''E.'' Interpleural Block</label> <label><<radiobutton "$choice5" "six" `$choice5 is "six" ? 'checked' : ''`>>  ''F.'' All of the above</label> <br> <<if $choice5 is "six">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: F'' <p style="text-align:justify">All of these techniques have been shown to provide some relief for rib fractures, but their availability will depend on your local expertise and familiarity. Erector spinae catheters and paravertebral catheters are gaining popularity as safe alternatives to thoracic epidurals, especially where only one side of the chest is affected and the patient’s coagulation precludes an epidural, but the patient still needs to be positioned appropriately which may involve log rolling. Serratus plane block is an alternative that can be performed with the patient supine. Intercostal blocks can be very effective, but the multiple injection sites increase the risk of pneumothorax, vascular injury and intravascular injection. Interpleural blocks are currently being performed less as their analgesia is suboptimal in comparison to epidurals and other regional techniques. All of these blocks can be done bilaterally, but the risk of complications increases.</p> @@ <<button [[Next question->answerQ6post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q6 Sickle cell patients suffering with an acute painful episode should be treated as a medical emergency. The first step should be:''</p> <label><<radiobutton "$choice6" "one" `$choice6 is "one" ? 'checked' : ''`>>  ''A.'' Apply oxygen and start IV fluids</label> <label><<radiobutton "$choice6" "two" `$choice6 is "two" ? 'checked' : ''`>>  ''B.'' Follow locally agreed protocols as to the assessment and management of a sickle cell acute painful episode and an individualized care plan if they have one</label> <label><<radiobutton "$choice6" "three" `$choice6 is "three" ? 'checked' : ''`>>  ''C.'' Give IV Paracetamol, a NSAID and parenteral opioids, ideally within 30 minutes of arrival into hospital</label> <label><<radiobutton "$choice6" "four" `$choice6 is "four" ? 'checked' : ''`>>  ''D.'' Send bloods for a reticulocyte count to confirm their pain is due to an acute sickle crisis </label> <label><<radiobutton "$choice6" "five" `$choice6 is "five" ? 'checked' : ''`>>  ''E.'' Give broad-spectrum antibiotics as episodes are frequently triggered by bacterial infections</label> <br> <<if $choice6 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' <p style="text-align:justify">Most sickle cell acute vaso-occlusive pain episodes are managed at home by patients. Often patients will only present to hospital once they have exhausted their analgesic options at home and they are unable to cope with uncontrolled pain. You should confirm in your assessment what treatments they have already tried and when they last took any analgesia. Most trusts have protocols for managing sickle cell acute pain episodes and often patients will already have an individualized care plan available in their medical record, and this can be followed as appropriate. Strong opioids are usually required but not always. Initiation of vaso-occlusive pain episodes is a complex process and can occur spontaneously in some individuals, however triggers include: * Hypoxia, (including flying at altitude where the partial pressure of oxygen is reduced as cabin pressure is not equivalent to sea level) increases the amount polymer forming deoxygenated HbS. * Dehydration resulting in increased blood viscosity and water loss from the erythrocyte and increased intracellular HbS concentration, promoting sickling * Cold temperatures which causes peripheral vasoconstriction and increased blood viscosity * Stress * Overexertion * Infections In patients with a sudden significant drop in Hb where other causes have been considered a reticulocyte count helps to distinguish an aplastic versus sequestration crisis. Low reticulocytes would suggest reduced RBC production during an aplastic crisis, vs elevated reticulocytes seen as RBC production increases to replace cells sequestered in the lungs, spleen, or liver.</p> @@ <<button [[Next question->answerQ7post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q7 Hydroxyurea:''</p> <label><<radiobutton "$choice7" "one" `$choice7 is "one" ? 'checked' : ''`>>  ''A.'' Increases the amount of HbF</label> <label><<radiobutton "$choice7" "two" `$choice7 is "two" ? 'checked' : ''`>>  ''B.'' Decreases the incidence of acute vaso-occlusive pain episodes and acute chest syndrome, with a survival benefit shown in several studies</label> <label><<radiobutton "$choice7" "three" `$choice7 is "three" ? 'checked' : ''`>>  ''C.'' Has no parenteral formulation</label> <label><<radiobutton "$choice7" "four" `$choice7 is "four" ? 'checked' : ''`>>  ''D.'' Should be continued during acute admissions unless there is a significant acute kidney injury or myelosuppression </label> <label><<radiobutton "$choice7" "five" `$choice7 is "five" ? 'checked' : ''`>>  ''E.'' All of the above </label> <br> <<if $choice7 is "five">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: E'' <p style="text-align:justify">Hydroxyurea causes a shift in gene expression that favors the production of HbF over adult haemoglobin. This lowers the relative concentration of HbS and reduces the number of complications seen in sickle cell disease especially in those with the most clinically severe genotypes (eg Homozygous HbSS and sickle beta^^0^^ thalassemia. Myelosuppression is the major dose-limiting toxicity associated with Hydroxyurea use and patients require regular monitoring especially when initiating treatment. Dose reduction or cessation is necessary in the setting of severe neutropenia, anaemia, thrombocytopenia or acute kidney injury. There is no parenteral formulation and the oral formulation should be re-started as soon as it is safe to do so.</p> @@ <<button [[Next question->answerQ8post]]>> <</button>>

@@.whitetext; <p style="text-align:justify">''Q8 When treating a patient with a sickle cell acute painful episode:''</p> <label><<radiobutton "$choice8" "one" `$choice8 is "one" ? 'checked' : ''`>>  ''A.'' Offer a bolus dose of a strong opioid by a suitable route, in accordance with local protocols, to patients presenting with severe pain</label> <label><<radiobutton "$choice8" "two" `$choice8 is "two" ? 'checked' : ''`>>  ''B.'' Offer all patients with moderate to severe pain a strong opioid via a PCA</label> <label><<radiobutton "$choice8" "three" `$choice8 is "three" ? 'checked' : ''`>>  ''C.'' Paracetamol and an NSAID should be prescribed to all patients </label> <label><<radiobutton "$choice8" "four" `$choice8 is "four" ? 'checked' : ''`>>  ''D.'' In the context of severe pain Pethidine is the subcutaneous agent of choice where IV access is not immediately available </label> <label><<radiobutton "$choice8" "five" `$choice8 is "five" ? 'checked' : ''`>>  ''E.'' NICE recommends an individual’s pain should be reassessed four times in 24 hours</label> <br> <<if $choice8 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> '' Correct answer: A'' <p style="text-align:justify">A PCA may be necessary to treat severe pain during an acute painful episode however vascular access is frequently problematic for sickle cell patients who have often had multiple hospital admissions since early childhood. Many management protocols utilize subcutaneous opioid administration which can avoid this issue. Paracetamol and NSAIDs may be appropriate adjuncts as a part of a multimodal plan for analgesia but contraindications should be excluded before NSAIDs are commenced especially as sickle cell disease increases the incidence of acute and chronic kidney injury. Ketorolac is associated with an increased odds ratio of AKI and should be avoided. There is an increased incidence of seizures in patients with sickle cell disease given Pethidine and alternative opioids should be used. Pain treatments should be titrated at 30 min intervals until satisfactory pain relief has been achieved, and then reassessed at least every 4 hours.</p> @@ <<button [[Next question->answerQ9post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q9 PCA should be considered:''</p> <label><<radiobutton "$choice9" "one" `$choice9 is "one" ? 'checked' : ''`>>  ''A.'' Only after intermittent opioid dosing regimens have failed to adequately control the patient’s pain</label> <label><<radiobutton "$choice9" "two" `$choice9 is "two" ? 'checked' : ''`>>  ''B.'' When a patient's regular medication includes more than 120mg oral morphine or its equivalent per 24 hours</label> <label><<radiobutton "$choice9" "three" `$choice9 is "three" ? 'checked' : ''`>>  ''C.'' For use in ward areas where intermittent dosing of opioids is not possible </label> <label><<radiobutton "$choice9" "four" `$choice9 is "four" ? 'checked' : ''`>>  ''D.'' If repeated bolus doses of a strong opioid are needed within 2 hours or in accordance with local protocols</label> <label><<radiobutton "$choice9" "five" `$choice9 is "five" ? 'checked' : ''`>>  ''E.'' To achieve rapid initial pain control in patients with severe pain</label> <br> <<if $choice9 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">Local protocols and individualized care plans will frequently address the indications for a PCA or its alternatives. In general, for patients with severe pain, initial pain control should be achieved using repeated bolus doses of a strong opioid given at an interval appropriate for the agent and in a supervised and fully monitored setting. Once pain is initially controlled if a patient continues to require repeated doses of strong opioid then a PCA should be considered. Appropriate monitoring is essential, and patients should have frequent observations according to local protocols for PCA use. All patients having regular strong opioids should have regular laxatives prescribed, with antiemetics, antipruritics and Naloxone PRN. Many patients with sickle cell disease are on regular opioids and may or may not have a degree of tolerance. Standard PCA regimens designed for opioid naive patients may need to be altered to achieve adequate pain control. However, there should be constant vigilance for oversedation and respiratory depression as both the hypoxic and hypercapnic respiratory responses in the brainstem are diminished by opioids.</p> @@ <<button [[Next question->answerQ10post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q10 In patients with sickle cell disease:''</p> <label><<radiobutton "$choice10" "one" `$choice10 is "one" ? 'checked' : ''`>>  ''A.'' The majority of patients should step down on their analgesia within 24 hours of admission to avoid developing tolerance to opioids</label> <label><<radiobutton "$choice10" "two" `$choice10 is "two" ? 'checked' : ''`>>  ''B.'' Acute chest syndrome, aplastic crisis and splenic sequestration are some of the many possible concurrent or sole causes for a patient’s pain that clinicians should be alert to</label> <label><<radiobutton "$choice10" "three" `$choice10 is "three" ? 'checked' : ''`>>  ''C.'' Steroids are indicated during acute admissions as in studies they reduce length of stay </label> <label><<radiobutton "$choice10" "four" `$choice10 is "four" ? 'checked' : ''`>>  ''D.'' Opioid-misuse is a common problem in patients with sickle cell disease and should be suspected in patients who request frequent doses of strong opiates or present frequently </label> <label><<radiobutton "$choice10" "five" `$choice10 is "five" ? 'checked' : ''`>>  ''E.'' There is a low risk of thromboembolic events due to the chronically low haematocrit seen in the disease </label> <br> <<if $choice10 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' <p style="text-align:justify">One of the most important questions to ask a patient with sickle cell disease presenting with acute pain: //''Is this like your usual episodes of pain?''// There are numerous other significant complications of sickle cell disease that may present with pain: * Acute chest syndrome * Acute multi-organ failure * Acute surgical abdomen (eg bilary disease is common) * Aplastic or sequestration crisis * Delayed haemolytic transfusion reactions * Renal infarction and acute papillary necrosis * Dactylitis or bone infarction and avascular necrosis * Myocardial infarction * Infections including pneumonia, meningitis, cellulitis, septic joints and osteomyelitis * Thromboembolic events This list is not exhaustive and a high index of suspicion should remain especially in the context of pain that is atypical for an individual, abnormal vital signs, abnormal findings on examination or major changes from their baseline FBC or reticulocyte count. The routine use of steroids alongside opioid analgesics in the management of acute painful episodes is not recommended. In the limited studies that exist steroids reduce the length of admission but with an increased incidence of readmission, rebound pain, and other serious adverse effects. The incidence of opioid-misuse in individuals with sickle cell disease has been demonstrated to be similar to or less than in the general population. Where there are concerns raised about opioid overuse this should be addressed outside of an acute episode.</p> @@ <<button [[Done!->End]]>> <</button>>

"We could go and see Daniel?" You say looking down the list. "That’s a good idea." Alison nods. You make your way to [[Ward 4]]

On Ward 4 you lift a substantial set of notes onto the top of the notes trolley. Alison’s reading over your shoulder. “What’s been happening with Daniel?” You turn to the [[latest entry]]

<p style="text-align:right">''Daniel Kaine 23 High Street 29/08/1993 H789101''</p> @@.writing; ''$date 04:35 26 y Known Sickle Cell homozygous. Under Dr Houston (Haem cons) 2/7 Ago Pt on return flight from New York. Flight diverted with prolonged travel. Pt noted prodromal paresthesia in arms/legs + aching 1/7 Pain in legs and arms, 10/10 despite rescue analgesia at home so attended ED MHx/ Multiple admissions 2nd to sickle cell; Anaemia – last Hb 84 DHx/ <<link [[Hydroxyurea->latest entry]]>> <<set Dialog.setup("Hydroxyurea")>> <<set Dialog.wiki("Increases the fraction of HbF and reduces the incidence of acute pain episodes, acute chest syndrome, and other complications of sickle cell disease. Should generally be continued during acute admissions unless significant acute kidney injury or myelosuppression where dose reduction or temporary cessation may be necessary. No parenteral formulation exists and Hydroxyurea should be re-started as soon as possible in patients who have been NBM.")>> <<set Dialog.open ()>> <</link>>, Paracetamol, Ibuprofen, Oxycodone SHx/ Non-smoker, ETOH rarely O/E Alert, in obvious pain. HR 95, RR 22, Sats 94% RA, BP 120/70. Temp 36.8 Chest clear Abd soft non-tender Bloods/ Hb 86, 8% reticulocytes, WCC, LFT, U&E, Coag - NAD Imp/ SS Acute pain episode. Plan/ # Admit # 500ml Hartman’s STAT # Blood cultures # Urinalysis # Paracetamol IV QDS, PRN oxynorm 5-10mg 2 hrly # Haem R/V - Form Faxed # Pain team R/V – 07:40 Spoken to Alison Burrows, she will see this morning. Many thanks.'' <p style="text-align:right"> ''S. Smith Med SpR'' </p> [[Next->niceSS]]

"When they phoned the referral the medics said they're happy nothing [[more sinister]] going on so our job is to get on top of Daniel's pain." Alison pauses and then adds, "Have you seen the [[NICE guidance->https://www.nice.org.uk/guidance/cg143]] on managing acute painful sickle cell episodes? They're a bit old now, I think it's 2012 but why don't you have a quick look while I go and find his drug chart." She disappears off and reappears a minute later with Daniel's [[Drug chart]]

Alison puts the drug chart and Daniel's obs chart down on top of the notes. The night med reg has prescribed IV paracetamol, and 5-10mg oxynorm, PRN, maximum 2 hourly. Since he arived in the early hours he's had the opioid every two hours. "Look at this." Alison has her finger on the pain score line of the obs chart. There's a 10/10 for every set that's been done. "I bet the poor man's not had any sleep on top of everything else. Shall we [[go and see him?]]"

Daniel is lying curled up on the bed facing the window. "Hi Daniel, it's Dr Burrows the pain consultant, we met last time you were in, I think? This is my colleague Dr $firstname $surname who’s working with me today. Is it ok if Dr $surname asks you a few questions so we can work out the best way to get on top of things this time?" Daniel nods and turns to face you. [[Ask him to tell you about his pain->audio1]] [[Ask him what he’s tried at home->audio2]] [[Ask him what worked last time->audio3]] <<audio audio1 pause>> <<audio audio2 pause>> <<audio audio3 pause>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio audio1 play>> [[Transcript->transcript1]]   [[Next->audiopost]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%202/audio/audio1.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/audio1.jpg" style="max-width: 100%;"/> </center> <<set $audio1 to true>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio audio2 play>> [[Transcript->transcript2]]   [[Next->audiopost]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%202/audio/audio2.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/audio2.jpg" style="max-width: 100%;"/> </center> <<set $audio2 to true>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio audio3 play>> [[Transcript->transcript3]]   [[Next->audiopost]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%202/audio/audio3.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/audio3.jpg" style="max-width: 100%;"/> </center> <<set $audio3 to true>>

<<if $audio1 is true>> <<else>> [[Ask him to tell you about his pain->audio1]] <</if>> <<if $audio2 is true>> <<else>> [[Ask him what he’s tried at home->audio2]] <</if>> <<if $audio3 is true>> <<else>> [[Ask him what worked last time->audio3]] <</if>> <<if $audio1 is true & $audio2 is true & $audio3 is true>> "Thank you for going over things Daniel, I'm just going to have a chat with Dr $surname outside for a brief moment and then we can work out a plan ok? We need to get you more comfortable as soon as we can.” Daniel nods and grimacing turns back to face the window. [[You both leave the room]] <</if>> <<audio audio1 pause>> <<audio audio2 pause>> <<audio audio3 pause>>

As soon as you leave the room Alison asks: "What do you think? What points did you pick up from Daniel's history? What are we going to do about his pain?" [[Case points]]

Did you pick up on these features from Daniel's history? * Pain has affected him since childhood * His experience of pain impacts his quality of life * His condition means significant lifestyle modifications * He sometimes feels he isn't believed; he wants to be listened to * He benefits from an individualised care plan and a supportive team * He worries he's seen as a drug addict or difficult patient * He wants to be trusted because he knows his condition If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? [[Next->Whats your plan?]]

<<if $PO is true>>"I think he needs..." [[some IV opioid stat->IV]] [[an opioid PCA->PCA]] <<else>> "So what are we going to do?" Alison asks you. You rack your brains for a moment on what you know about managing [[sickle cell disease->sicklecell]] "I think he needs..." [[some PO opioid stat->PO]] [[some IV opioid stat->IV]] [[an opioid PCA->PCA]] <</if>>

"I think he needs a Morphine PCA, the guy's clearly in agony and we need to get on top of that as soon as we can," you say to Alison. "OK, that's a good idea. The majority of clinical experience of opioids in SCD is with Morphine, but other strong opioids could be considered. I've seen a few small [[randomised trials and observational studies]] that show some benefits of a Morphine PCA versus intermittent doses. But to be honest this is a bit of a trick question and most places I've worked have got local clinical pathways for managing these patients and what we do should be guided by that. Sub-cut opioids, either as intermittent doses or infusions are used reasonably frequently. But we need to individualize it to him and what's worked for him in the past. Patients often come with their own individualized care plan which is a bonus." "And if that doesn't work?" She laughs "I'm asking you the questions. Let’s get plan A underway, see a couple more of these patients, and then we can grab a coffee and talk about plan B." [[Next->Plan B]] <<set $PCA to true>>

"I think he needs IV Fentanyl, the guy's clearly in agony and we need to get on top of that as soon as we can," you say to Alison. "OK, that's a good idea. But he's going to end up subtherapeutic and in pain if we just write it up PRN. I've seen a few small [[randomised trials and observational studies]] that show some benefits of a Morphine PCA versus intermittent doses. But to be honest this is a bit of a trick question and most places I've worked have got local clinical pathways for managing these patients and what we do should be guided by that. Sub-cut opioids, either as intermittent doses or infusions are used reasonably frequently. But we need to individualize it to him and what's worked for him in the past. Patients often come with their own individualized care plan which is a bonus." "And if that doesn't work?" She laughs "I'm asking you the questions. Let’s get plan A underway, see a couple more of these patients, and then we can grab a coffee and talk about plan B." [[Next->Plan B]]

@@.whitetext; ''Acute vaso-occlusive pain'' is ischaemic in origin and occurs in any bony structure containing red (erythropoietic) marrow. In patients with SCD chronic haemolytic anaemia means red marrow is distributed through a greater proportion of the skeleton and pain can occur in the ribs, sternum, vertebral bodies and skull. Over time degenerative changes, ischaemia-reperfusion injury, recurrent infections with <<link [[encapsulated bacteria->sicklecell]]>> <<set Dialog.setup("Encapsulated bacteria")>> <<set Dialog.wiki("Infection with Encapsulated bacteria due to functional asplenia. Common pathogens include: //Strep. Pneumoniae, N. Meningitis Meningitidis, H. Influenzae// type B")>> <<set Dialog.open ()>> <</link>> and avascular necrosis can lead to persistent pain. !!!DO * Use strategies to reduce pain episode frequency and manage chronic pain * Avoid triggers eg stress, extremes of temperature, dehydration * Prescribe regular analgesia including treatment for neuropathic pain if indicated * Appropriately use disease modifying therapies eg Hydroxyurea, transfusions, L-glutamine * Treat acute pain episodes with escalating therapy * Use opioids and non-opioid therapies * Manage psychological issues * Provide adequate hydration and venous thromboembolism prophylaxis during acute admissions * Be cautious with NSAIDs <<link [[why?->sicklecell]]>> <<set Dialog.setup("Ketorolac")>> <<set Dialog.wiki("Ketorolac given during an acute vaso-occlusive episode increases the risk of developing an acute kidney injury (odds ratio 1.63, 95% CI 1.08-2.47). ")>> <<set Dialog.open ()>> <</link>> !!!DO NOT * Apply cold compresses or ice * Use Pethadine <<link [[why?->sicklecell]]>> <<set Dialog.setup("Pethidine")>> <<set Dialog.wiki("Pethidine is associated with a high risk of seizures in patients with SCD.")>> <<set Dialog.open ()>> <</link>> * Forget to manage opioid side effects eg stimulant laxatives, 5-HT3 antagonists, H1-antagonists @@ [[Back->Whats your plan?]]

@@.whitetext; Acute painful episodes are the most common reason for acute presentation in people with sickle cell disease (SCD). The patient's report of the pain and its comparison to previous acute painful episodes is the gold standard for assessment. SCD can be associated with a number of serious and life-threatening complications affecting every organ system. Signs and symptoms that may indicate alternative aetiology include: * Patient reports pain atypical * Abnormal observations * Significant changes to FBC or reticulocyte count * Deranged LFTs, U&E or coagulopathy * Jaundice * Haematuria * Abdominal distention * Acute neurology * Any signs consistent with an infective cause * Any signs of acute chest syndrome (eg fever, cough, hypoxia, abnormal CXR) Furthermore complications relating to medications used in SCD can exacerbate or cause pain and should be actively considered.@@ [[Back->niceSS]]

"...we should give him some more oral opioid." Alison rases an eybrow at you. "Is that going to get on top of his pain fast enough? He says it's ten out of ten." [[try again->Whats your plan?]] <<set $PO to true>>

# E R Gonzalez 1, N Bahal, L A Hansen, D Ware, et al. Intermittent Injection vs Patient-Controlled Analgesia for Sickle Cell Crisis Pain. Comparison in Patients in the Emergency Department. //Arch Intern Med//. 1991 Jul;151(7):1373-8. # M Melzer-Lange, C Walsh-Kelly, G Lea, C Hillery, J Scott. Patient-controlled Analgesia for Sickle Cell Pain Crisis in a Pediatric Emergency Department. //Pediatr Emerg Care//. 2004 Jan;20(1):2-4. # E. van Beers, C van Tuijn, P Nieuwkerk, P Friederick, et al. Patient-controlled Analgesia Versus Continuous Infusion of Morphine During Vaso-Occlusive Crisis in Sickle Cell Disease, a Randomized Controlled Trial. //Am J Hematol//. 2007 Nov;82(11):955-60. <<if $PCA is true>>[[Back->PCA]] <<else>>[[Back->IV]] <</if>>

Two hours later and Alison is putting two mugs down on the table in front of you. "So tell me what we do if that doesn't work for Daniel? No, actually lets get more basic than that first. Tell me about opioid receptors." She rummages through her bag for a second. “Don’t panic. I’ve got a [[handout]] from a talk I did last week about opioid receptors. I’m only asking because it’s classic exam fodder so you need to know it backwards.” You sigh with relief and take a long drink of your coffee. “What about if that doesn’t work though? What else could we do for Daniel?” “We’ve used [[Ketamine]] before in cases like this where escalating doses of opioids aren’t getting the pain under control. But there isn’t a huge evidence base to support Ketamine and what there is, is mainly in paeds and adolescents, I think there's some retrospective case reviews in adults which support its use.” [[Next->bleep]] <<audio bleep pause>>

<center> !!!@@.typing;Opioid Receptors (OR)@@ </center> * Are serpentine G-protein coupled receptors (GPCR) * Were named after their anatomical location and pharmacological profiles ie: //m// orphine (//m// u, OP3, MOP), //k// etocyclazocine ((//k// appa, OP4, KOP), vas //d// eferens (//d// elta, OP1, DOP), and the opioid related nociceptin receptor (n, OP4) * Ligands include endogenous opioids, endorphins and enkephalins * OR can dimerize and oligomerize with other GPCR to alter function (eg MOR1 isoform results in analgesia while the MOR1D isoform, a heterodimer with gastrin-releasing GPCR, results in itching) <div class="notes">''Biological processes involving opioid receptors:''</div> * Analgesia * Mood * Stress * Appetite * Hormonal cycles * Immunity * Smooth muscle relaxation * Regulation of the cardiorespiratory centres. Opioids are our oldest analgesics and some of the most widely prescribed drugs today. <div class="notes">''Mechanism of action:''</div> # External signal molecule binds GPCR # Conformational change in GPCR # Interaction between GPCR and G-protein made up of alpha, beta and gamma subunits # GDP exchanged for GTP on alpha subunit of the G-protein # Interaction of alpha subunit and beta-gamma complex with signaling cascades <p style="text-align:justify">All four OR subtypes are preferentially inhibitory via: 1) Inhibition of membrane bound adenylyl cyclase and reduction of the second messenger, cAMP, decreasing the activity of protein kinase A (PKA), which reduces phosphorylation of intracellular proteins including cAMP responsive element binding protein with modulation of gene transcription (alpha subunit, G~~ai/o~~); 2) Closing voltage sensitive calcium channels (G~~By~~, PKA, cAMP); 3) Inhibition of Na^^+^^/H^^+^^ exchange (alpha subunit, G~~ai/o~~); 4) K^^+^^ efflux and hyperpolarization (G~~By~~, PKA, cAMP)</p> <div class="notes">''Response:''</div> * Decreased neuronal excitability * Changes in gene transcription * Altered synaptic plasticity and long-term potentiation processes * Modified physiological responses <center> ''Table 1: Summary of OR location & function'' | ''Receptor'' | ''Subtypes'' | ''Location''  | ''Function'' | | OP1, Delta | delta 1 & 2 | CNS, peripheral sensory neurons | analgesia, antidepressant, dependence | | OP2, Kappa | kappa 1, 2, 3 | CNS, peripheral sensory neurons | analgesia, depression, hallucinations, miosis, sedation | | OP3, Mu | Mu 1, 2, 3 | CNS, peripheral sensory neurons, PNS | analgesia & dependence (Mu1), euphoria, resp depression & reduced GI motility (Mu2), vasodilation (Mu3) | | OP4, Nociceptin | NOP | CNS | anxiety, depression, tolerance, spinal level analgesia | ''Table 2: Summary of main clinical opioids and their oral Morphine equivalent**'' | ''Drug'' | ''Dose'' | ''Approx oral Morphine equivalent'' | | Codeine | 60 mg |  6 mg  | | Dihydrocodeine | 50 mg |  5 mg  | | Tramadol | 50 mg |  5 mg  | | Oxycodone | 10 mg |  20 mg  | | Pethidine | 50 mg |  5-6.25 mg  | | Tapentadol | 50 mg |  20 mg  | | BuTrans 10 patch | 10 mcg/hr |  20 mg/24h  | | Fentanyl 50 patch | 50 mcg/hr |  135-224 mg/24h  | | SC Diamorphine  |  10 mg  |  30 mg  | ~~**Oral Morphine equivalent does not account for incomplete cross tolerance and inter-individual variability~~ </center> <p style="text-align:justify">When used in chronic pain OR are saturated at doses of oral Morphine greater than 120mg. Further increases are associated with increasing side effects without additional analgesia.</p> <div class="notes">''Receptor tachyphylaxis:''</div> * Decoupling of the receptors from G-proteins * Steric hindrance * Internalization of the receptors * Altered internal signaling cascades <p style="text-align:justify">Clinically, this results in ''tolerance'' and apparent increased opioid requirements. Opioid-induced ''hyperalgesia'' may occur. ''Addiction'' happens as the euphoric and sedative aspects of opioids increase with increasing doses, and ''physical dependence'' may manifest (“cold turkey”) if opioids are abruptly withdrawn. These effects are separate from the analgesic aspects of opioids, and make treating chronic pain difficult.</p> <div class="notes">''Side effects of commonly used opioids:''</div> * Constipation * Respiratory depression * Pituitary dysfunction (Long term opioids screen: Prolactin, Cortisol, LH, IGF1 and in men Testosterone and women estrogen & FSH) * Immune system modulation (many WBC have OR and use OR to signal between immune cells and surrounding nerve cells) !!!<p style="text-align:justify"> @@.typing;The bottom line: Opioid receptors are a group of inhibitory GPCR with multiple central and peripheral actions. The utility and risk of clinically used opioids is due to their action on OR@@</p> [[Back->Plan B]] [[Show me the evidence->ref2]] <A HREF="javascript:window.print()">Click to Print This Page</A>

@@.whitetext; !!!Ketamine for acute pain not responsive to opioids In subanaesthetic doses Ketamine may be appropriate for some patients with severe pain that has not responded to standard opioid analgesics. Both intranasal and low dose IVI Ketamine have been used in sickle cell acute pain episodes. However Ketamine is only appropriate in settings experienced with its use and according to locally established protocols. Ketamine could theoretically worsen vaso-occlusive pain via sympathetic vasoconstriction however in the setting of severe pain the sympathetic nervous system is likely to already be at maximal output. ''Palm N, Floroff C, Hassig TB, et al. Low-Dose Ketamine Infusion for Adjunct Management during Vaso-occlusive Episodes in Adults with Sickle Cell Disease: A Case Series. //J Pain Palliat Care Pharmacother// 2018; 32:20.'' Retrospective case series of five adult patients admitted to ICU with acute pain episodes. Patients reported reduced pain score and reduced opioid related adverse side effects. ''Lubega F, DeSilva M, Munube D, Nkwine R, et al. Low dose ketamine versus morphine for acute severe vaso occlusive pain in children: a randomized controlled trial. //Scand J Pain// 2017. 26;18(1):19-27'' Single centre, prospective, double-blind, active-control trial of 240, 7 to 18-year-olds admitted with severe sickle cell acute pain episodes. The Ketamine group had comparable analgesia to the IV Morphine group and a lower incidence of treatment failure. However Ketamine use was associated with a higher incidence of non-life threatening, transient side effects. ''Gowhari M, Chu A, Golembiewski J, Molokie R. Low-Dose Ketamine Infusion In Adult Patients With Sickle Cell Disease – Impact On Management Of Acute Painful Episodes //Blood// 2013. 122;21: 2249.'' Three-year retrospective case review of 30 adult patients who had received low dose Ketamine during admissions for acute pain episodes. Ketamine significantly decreased opioid use compared to before the Ketamine was started during the same admission and vs previous non-ketamine admissions. However the total opioid requirement during the entire ketamine admission was not significantly different from the total opioid requirement during the non-ketamine admission (P=0.088). !!!The bottom line: More evidence is needed to establish the use of Ketamine vs standard opioid treatment in sickle cell acute pain episodes. @@ [[Back->Plan B]]

You take a longing look at your half finished coffee and get up to [[answer your bleep]]. <<audio bleep play>>

"Hi it's Dr $surname, covering the acute pain bleep. You just bleeped me?" "Hi, thanks for getting back to me. I'm the on-call ortho reg. I’ve got a gentleman, Charles Bude, date of birth 25th August 1950, who’s fallen off a ladder. He’s stable, but his chest XR shows he’s got multiple rib fractures. We’ve done a full secondary survey and it looks like that’s his only injuries but he’s really struggling with the pain.” “What’s he had so far?” You ask as you write his details at the end of the list. “I don’t know. He’s on his way up to ward 7 as we speak, and I haven’t got his drug chart in front of me.” “OK, I’ll go up and see him.” “Thanks. Bye” the ortho reg ends the call. You lean forward and log into the computer in front of you before opening the XR viewer and typing B-U-D-E into the search bar and clicking [[Enter]] <<audio bleep pause>>

<center> [[See report->Report]]     [[Next->cold coffee]] @@.whitetext;''Mr Bude's CXR''@@ <img src="images/cxr.jpg" style="max-width: 100%;"/> ^^Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31240^^ </center>

@@.typing;Patient Name: Mr Charles Bude DOB: 25/08/1950 NHS No: 333 444 5555 Date of service: $date X-RAY: PA Chest CLINICAL HISTORY: Fall from ladder. Left lateral chest pain +++. FINDINGS: Left-sided 3rd-7th rib fractures with 6th and 8th rib fractures displaced. No pneumothorax or pleural fluid collection. Dr Harry Wallis Consultant Radiologist@@ [[Back->Enter]]

"Your coffee's cold." Alison says when you get back to where she's sitting. "What have we got?" You quickly fill her in on what you know about Mr Bude. “There was a good article in the BJA Education about rib fractures a couple of years ago.” She’s typing it into her phone “Yep, here it is, January 2016. I’ll message you the reference” You look down at your phone screen: @@.typing; L. May, C Hillermann, S Patil. Rib fracture management. BJA Ed, 2016; 16:1; 26–32. @@ “Got it. What are the highlights? Seeing as we are going to be seeing this guy in two minutes.” “I’ll tell you what I can remember on the way, actually hang on I might have the [[notes]] I made in the office, so let’s go that way and I can give you a copy.” [[Next->Mrbude]]

Notes from L. May, C Hillermann, S Patil. ''Rib fracture management''. //BJA Ed//, 2016; 16:1; 26–32. <center> !!!@@.typing;Traumatic rib fractures are common@@ </center> <div class="notes">''Risks:''</div> * Hypoventilation with reduced TV & atelectasis * Underlying lung damage with poor compliance and impaired gas exchange * Altered breathing mechanics esp. if flail segment * Poor cough with retained secretions * Respiratory complications common (Pneumonia in 30%^^1^^) * High mortality (eg Any flail segment or 7 or more fractures 30% mortality^^2, 3^^) <div class="notes">''Respiratory support:''</div> * Supplementary O2 * CPAP * Invasive ventilation (last resort) <div class="notes">''Easter formula:^^4^^''</div> <center> !!!@@.typing; Rib fracture score = (breaks × sides) + age factor@@ </center> ''Breaks'' = total number of fractures NOT number of ribs involved ''Sides'' = 1 or (unilateral or bilateral fractures) ''Age factor'' 0 = Under 50 1 = 51-60 2 = 61-70 3 = 71-80 4 = 80 Score greater than 7 should be seen by the acute pain team These scores increase awareness but ''do not'' have strong statistical validity as a risk predictor^^5^^ <div class="notes">''Analgesia for rib fractures''</div> To prevent complications analgesia should be: * Early * Effective * Multimodal @@.typing;''Step 1''@@ Regular Paracetamol, NSAID (if not contraindicated), Codeine, PRN oral Morphine @@.typing;''Step 2''@@ Titrated IV Morphine 0.1-0.2mg/kg until pain controlled then Morphine Sulphate controlled release tablets 10-20mg BD with 10-20mg oral Morphine for breakthrough pain, regular Paracetamol and NSAID @@.typing;''Step 3''@@ Morphine PCA, regular Paracetamol and NSAID, consider Gabapentin @@.typing;''Step 4''@@ Consider regional anaesthesia: Serratus anterior block/catheter, Paravertebral, Thoracic epidural. <p style="text-align:justify">Pain assessment should include ''Static'' and ''Dynamic'' pain scoring and target pain control sufficient to allow deep breathing and effective cough. Side effects of opioids should be anticipated and treated. Gabapentinoids can be opioid-sparing.</p> <div class="notes">''Thoracic epidurals''</div> <p style="text-align:justify">Better outcomes vs systemic opioids^^4, 6^^ Consider if: higher, multilevel or bilateral fractures, flail segments, chest drains or respiratory compromise due to pain^^6^^. Aim for insertion at vertebral level corresponding to middle fractured rib. Use local policy re doses with/without diamorphine.</p> <center> ''Absolute Contraindications'' | ''Epidural'' | ''Paravertebral'' | | Patient refusal @@.whitetext; Transverse ess block level @@| Patient refusal | | Local infection | Local infection | | Local anaesthetic allergy | Local anaesthetic allergy | | Spinal cord injury || | Spinal haematoma || | Thoracic vertebral fracture || | INR greater than 1.5 || | Plt less than 50x10^^9^^litre^^-1^^ |@@.whitetext; Transverse process fractures at block level @@| ''Relative Contraindications'' | ''Epidural'' | ''Paravertebral'' | | Unable to position | Unable to position | | On anticoagulants | On anticoagulants | | Unstable vertebral fractures | Unstable vertebral fractures | | Plt less than 50-100 x 10^^9^^litre^^-1^^ | Deranged clotting | | Severe traumatic brain injury || | Hypotension || | Hypovolaemia || |@@.whitetext; Transverse process fractures at block level @@| Transverse process fractures at block level | </center> <div class="notes">''Paravertebral blocks''</div> <p style="text-align:justify">Provides unilateral sensory, motor, and sympathetic block. One catheter can cover up to six consecutive fractured ribs. A second catheter can be inserted for greater than six ribs or bilateral fractures. Infusions can be continued for up to 7 days and can be effective as thoracic epidurals.</p> <div class="notes">''Serratus plane block''</div> <p style="text-align:justify">Provides anaesthesia of the hemithorax when local anaesthetic is injected into the potential space around the serratus muscle. See the article for detailed description of the anatomy and technique. Suitable for all rib fractures with very few absolute contraindications. Bilateral blocks can be performed with caution as to maximum doses of local anaesthetic.</p> Advantages: * Suitable for patients with head or spinal injuries * Can be inserted in anticoagulated or thrombolysed patients <div class="notes">''Operative fixation''</div> <p style="text-align:justify">Intubated patients with a flail chest, respiratory failure, and prolonged ventilation, or non-intubated patients with a flail with deteriorating pulmonary function^^7^^.</p> !!!<p style="text-align:justify">@@.typing;The bottom line: Reduce the risk of death and serious complications following rib fractures with multimodal analgesia including regional techniques if needed.@@ </p> [[Back->cold coffee]] [[Show me the evidence->ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

When you ender the four bedded bay on the ward you can tell which patient is Mr Bude just by looking. He's lying in the corner bed by the window, partially propped up on pillows and looks grey. His breathing is shallow. In fact, when you reach the end of the bed you can't see his chest moving at all. It's a relief when he opens his eyes to Alison’s greeting. "Hello Mr Bude, I'm Alison the acute pain consultant and this is my colleague Dr $surname. Can you tell us a bit about what’s been happening?” [[Next->MrBude2]]

# Bulger E, Edwards W, Pinto M, Klotz P, Jurkovich G. Indications and contraindications for thoracic epidural analgesia in multiply injured patients. //Acute Pain// 2008; 10: 15–22 # Holcomb J, McMullin N, Kozar R, Lygas M, Moore F. Morbidity from rib fractures increases after age 45. //J Am Coll Surg// 2003; 196: 549–55 # Nirula R, Diaz J, Trunkey D, Mayberry J. Rib fracture repair: indications, technical issues, and future directions. //World J Surg// 2009; 33: 14–22 # Pressley C, Fry W, Philp A, Berry S, Smith R. Predicting outcome of patients with chest wall injury. Am J Surg 2012; 204: 910–4 2. Easter A. Management of patients with multiple rib fractures. //Am J Crit Care// 2001; 10: 320–9 # Maxwell C, Mion L, Dietrich M. Hospitalised injured older adults; clinical utility of a rib fracture scoring system.// J Trauma Nurs// 2012; 19: 168–74 # Yeh D, Kutcher M, Knudson M, Tang J. Epidural analgesia for blunt thoracic injury—which patients benefit most? //Injury// 2012; 43: 1667–71 # Hasenboehler E, Bernard A, Bottiggi A et al. Treatment of traumatic flail chest with muscle sparing open reduction and internal fixation: description of a surgical technique. //J Trauma// 2011; 71: 494–501 [[Back->notes]]

<p style="text-align:justify"> @@.typing; I’ll get this sort of ache in my leg bones and arm bones, in my joints, in my elbows and knees, and this feeling that my energy has just drained out of me. Then I’ll just know it’s flaring up again. It’s been happening as long as I can remember. When I was a little kid it used to be my hands and feet, they’d swell up during an episode. While my mates were all out on their bikes down the park I was stuck in hospital. Once it’s started it ramps up pretty quickly. There’s this constant ache and then on top of that it’s like my bones are being sawed from the inside out, like I’m being constantly stabbed. People keep asking me how many out of ten but it’s so far off the scale of zero to ten. It’s really hard to get through to people how bad it is. It usually gets worse over a day or so and then takes five or so days before it turns a corner and gets better. At its worst I can’t walk. I can’t do stuff for myself. It’s really hard because on the outside I look like I’m completely ok and people don’t take my pain seriously. @@ </p> <center> [[Play audio->audio1]]    [[Next->audiopost]] </center> <<audio audio1 pause>>

<p style="text-align:justify"> @@.typing; I make sure I avoid stuff that triggers it. That flight didn’t help this time. I ended up tired and stressed. It was cold on the plane and I guess I didn’t get enough to drink either because we were stuck in the airport so long. I always follow the plan Dr Houston and me worked out together. I have rescue meds at home and I take them at the start of an episode. Like this time I was taking paracetamol, ibuprofen and oxycodone. I use a heat pad as well and try to rest but sometimes all that’s just not enough and it gets away from me and I have to come into the hospital. By the time I’m admitting to myself I can’t cope with it at home anymore, I’m so done. People don’t get that. I’m having to try and explain what I need while I’m just completely done. @@ </p> <center> [[Play audio->audio2]]    [[Next->audiopost]] </center> <<audio audio2 pause>>

<p style="text-align:justify"> @@.typing; People don’t always trust me to know what works. I haven’t had great experiences in some places. Like constantly having to wait and there’s this suspicion that I look ok so I must be an addict, like I’m here to score drugs. Knowing what works and asking for a specific drug and you get that suspicion. I’m not addicted to morphine, I’m addicted to not being in excruciating pain. And I can’t even defend myself because you get a reputation as a difficult patient, which just makes it worse. Sometimes I feel like I’m held to ransom and have to take the less effective drugs first to ‘prove’ that I need the stuff I need. Even when I show people my care plan sometimes I get ‘well let's try this first and see how you get on’. Staff treat me differently to people with other reasons for serious pain. It would be easier if I’d been in a car crash and the bone was sticking out of my leg because people would get that, they would see it and think ‘wow that guy is in a whole world of pain’ and give you something. I’m in that level of pain but because I can’t show people they don’t get it. It isn’t a laugh. Every time I leave, I have to rebuild my life. I have to live with a constant state of limbo, never knowing when the pain is going to take over and you have to put everything on hold again. I’ve had some good experiences, Dr Houston and Sandra my specialist nurse are great, they always come up to the ward when I’m in to make sure that my plan is working for me this time, and that it’s actually happening. They talk to people who don’t get it and try and get them to understand. The thing is that most people don’t know much about sickle cell. I’ve been on wards where most of the staff haven’t even heard of it. I just wish people would listen, listen and actually hear what I’m saying. It would make everything so much easier and make me feel like we were all on the same side. @@ </p> <center> [[Play audio->audio3]]    [[Next->audiopost]] </center> <<audio audio3 pause>>

Mr Bude looks imploringly at you both. “I can’t really, it hurts too much to talk. To be honest it hurts too much to breath.” Alison picks up the drug chart from the end of the bed. “You are due some IV Paracetamol so I’ll go and ask for that and we can work out what else to do to help.” She turns to you “Why don’t you take a bit of history while I’m sorting this out?” She turns and leaves the room. “How bad is the pain out of ten?” You ask. “When I’m still it’s a seven, if I move it’s a ten,” he replies. “Can you cough?” He looks horrified at the thought. “That would be about an 18.” You continue. “Do you have any other medical problems? Especially any lung problems?” “No, I’m normally fit and well.” “Are you allergic to anything?” “I’m allergic to broken ribs.” “Anything else?” “No, not that I know of.” “Ok, thanks Mr Bude, we will work out a plan to get you more comfortable. You need to be able to take a deep breath and have a good cough, so you don’t get a chest infection.” You go out to the corridor to find Alison. [[Next->MrBude3]]

She's on the phone at the nurse’s station and rings off as you approach. "It's interesting isn't it? The differences in how people respond to what is for them the worst pain they've experienced in their lives. I was just ringing to making sure that Ward 4 was happy with the plan for Daniel.” She adds “Mr Bude's IVs are in the pipeline. Have you worked out his <<link [[Easter Score?->MrBude3]]>> <<set Dialog.setup("Easter Score")>> <<set Dialog.wiki("Rib fracture score = (breaks × sides) + age factor")>> <<set Dialog.open ()>> <</link>> [[12->incorrect]] [[7->incorrect]] [[8->correct]]

"No, by my maths he scores eight." Alison frowns. "I seem to recall from that BJA rib fracture article that the score isn’t a great risk predictor, but it is a way of generating awareness of these patients. They have the capacity to do very badly if we don’t get things right.” She looks down at her phone screen where a message has just appeared. She gestures with her phone "I've got to go and sort this out. Just bare in mind what we've talked about and if you're not happy give me a ring on my mobile. It's your turn to make a plan." [[Next->MrBude4]]

"Yes, that's right." Alison nods. "I seem to recall from that BJA rib fracture article that the score isn’t a great risk predictor, but it is a way of generating awareness of these patients. They have the capacity to do very badly if we don’t get things right.” She looks down at her phone screen where a message has just appeared. She gestures with the phone "I've got to go and sort this out. Just bare in mind what we've talked about and if you're not happy give me a ring on my mobile. It's your turn to make a plan." [[Next->MrBude4]]

It’s up to you now. What are you going to do? [[Start a Morphine PCA->MrBude5]] [[Put in a thoracic epidural->MrBude6]] [[Put in a paravertebral catheter->MrBude7]] [[Put in erector spinae plane catheters->MrBude15]] [[Apply some Lidocaine plasters->MrBude8]] <<if $paracetamol is true>> <<else>> [[See how he gets on with just the IV Paracetamol->MrBude9]] <</if>>

You dig out a Morphine PCA prescription sheet from the filling cabinet at the nurses’ station and sign the standard dose and interval. You find the nurse looking after Mr Bude and tell them the plan. They agree to get the PCA set up straight away. You leave the ward and go off to get some lunch. [[Next->MrBude12]] <<audio bleep pause>>

You decide Mr Bude should have a thoracic epidural. [[You are happy to perform this procedure->epidural1]] [[You have some experience but could do with supervision->epidural2]] [[You watched a YouTube video once->epidural3]] <<audio bleep pause>>

You decide Mr Bude should have a paravertebral catheter. [[You are happy to perform this procedure->paravertebral1]] [[You have some experience but could do with supervision->paravertebral2]] [[You watched a YouTube video once->paravertebral3]] <<audio bleep pause>>

You decide to prescribe 5% Lidocaine plasters to be applied to Mr Bude's chest wall. The nurse looking after Mr Bude says it’s not an item that the ward stocks, or that they have ever seen before, but they can ring pharmacy and try and get hold of some. You thank them and leave the ward to get on with the rest of the reviews. [[Next->MrBude13]] <<audio bleep pause>>

You decide to see how he gets on with the IV Paracetamol and check how he is later. The bleep doesn’t stop for the rest of the day and right at the end of your shift you go back to see how Mr Bude is doing. He’s asleep when you arrive, and you don’t wake him. His observations are ok on the chart, his pain scores have been between five and seven. You reason that if he can sleep, he can’t be too uncomfortable. [[Time to head for home->MrBude10]] <<set $paracetamol to true>>

You’re doing an elective knee arthroscopy list next morning but check in to see how Mr Bude is getting on before you start the pre-op assessments. When you walk into the bay the first thing you see is that Mr Bude isn’t in his bed. Your heart sinks as nurse in the bay tells you he deteriorated in the night and was taken to ICU. You take the stairs up to the unit two at a time. [[Next->MrBude11]]

You've worked with Dr Franklin the ICU consultant who's on this week. He's standing in Mr Bude's bedspace when you arive. Your heart sinks to see the patient's been intubated. “Morning $firstname. I saw you’d written in the notes yesterday and was wondering when you’d be up.” “What happened? I saw him last thing last night. He was doing ok.” Dr Franklin sighs. “He went into type 1 respiratory failure in the early hours. The mistake is to underestimate these injuries. If someone’s got a number of rib fractures, then there’s inevitably an underlying lung injury. You combine that with hypoventilation, ensuing atelectasis and retention of secretions and they are a sitting duck for deterioration. They need really effective dynamic pain control, not just being fine sitting completely still and breathing a tidal volume of 150ml. They aren’t going to do well in the long run like that, are they?” He takes a long appraising look at you. “What would you do if you had the chance to [[do something different?->MrBude4]]”

''Textbooks:'' Rang and Dale’s Pharmacology 9th Edition Ritter J, Flower R, Henderson G, Loke YK, MacEwan D, Rang H Goodman and Gilman’s The Pharmacological Basis of Therapeutics 13th Edition Brunton L, Hilal-Dandan R, Knollmann B ''Papers:'' # McDonald J, Lambert DG. Opioid Receptors. //Continuing Education in Anaesthesia, Critical Care & Pain// 2014. 17:30129-4 # Sobczak M et al. Physiology, Signaling, and Pharmacology of Opioid Receptors and their Ligands in the Gastrointestinal Tract: Current Concepts and Future Perspectives. //J Gastroenterol// 2014. 49:24–45 # Wang S (2019). Historical Review: Opiate Addiction and Opioid Receptors. //Cell Transplant// 28(3):233-238 # Valentino, R.J., Volkow, N (2018). Untangling the Complexity of Opioid Receptor Function. //Neuropsychopharmacol// 43: 2514–2520 ''Websites:'' https://www.guidetopharmacology.org/GRAC/FamilyDisplayForward?familyId=50 IUPHAR Homepage [[Back->handout]]

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Mazin Sirelkhatim and Piotr Kucharski Our scenario 2 advisory support: Abergele Pain Service team Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Sonia Pierce and Richard Wassall Our creative director and lead programmer: Kate Wainwright !!!Well done for completing VA_Pain training_2 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

It's twenty to five. You've spent the afternoon in recovery with a patient who had contraindications to a spinal and was post-op a total knee replacement under GA. It’s been a struggle to get their pain under control. Better answer that [[bleep->bleep2]] <<audio bleep play>>

"Hi it's Dr $surname, covering the acute pain bleep. You just bleeped me?" "Hi $firstname its Alison, where are you? I've just seen Mr Bude again. He been using the PCA all afternoon but isn't getting anything like the dynamic pain control we need to let him cough and deep breath. So we need to do something else?" You pause for a moment of the phone “I think we should… [[Put in a thoracic epidural->MrBude6]] [[Put in paravertebral blocks->MrBude7]] [[Put in erector spinae plane catheters->MrBude15]] <<audio bleep pause>>

You go up to theatres to find a willing ODP and an appropriate space. After consenting Mr Bude on the ward, he comes up to theatre and you perform the procedure without incident and after a test dose start an infusion according to the hospital policy. After twenty minutes he reports being much more comfortable and when you ask him to take some deep breaths and have a cough he can do both effectively. [[Next->MrBude14]]

You go up to theatres to find a willing ODP and an appropriate space. The consultant on for emergency theatres, Dr Kelly Fraser, is happy to supervise you doing the procedure. After consenting Mr Bude on the ward, you change into scrubs and go back up to the emergency theatre anaesthetic room where Dr Fraser is waiting. “Have you got any top tips?” You ask her She laughs “If you ask any anaesthetist, you’ll probably get a different set of [[top tips]]” she rummages in a draw behind her for a moment and pulls a disembodied plastic spine out from under the collection of useful junk. The doors to the anaesthetic room swing open and Mr Bude is pushed into the room on a hospital trolley. Dr Fraser gives him a warm smile "Ah, perfect timing, Mr Bude." [[Next->paravertebral4]] <<set $paravertebral2 to true>>

You go up to theatres to find a willing ODP and an appropriate space. The consultant on for emergency theatres is Dr Kelly Fraser. She agrees to fit Mr Bude into the list and says you can do both scrub and do the procedure togather. After consenting Mr Bude on the ward, you change into scrubs and go back up to the emergency theatre anaesthetic room where Dr Fraser is waiting. “Have you got any top tips?” You ask her She laughs “If you ask any anaesthetist, you’ll probably get a different set of [[top tips]]” The doors to the anaesthetic room swing open and Mr Bude is pushed into the room on a hospital trolley. Dr Fraser gives him a warm smile "Ah, perfect timing, Mr Bude." [[Next->paravertebral4]] <<set $paravertebral3 to true>>

You go up to theatres to find a willing ODP and an appropriate space. The consultant on for emergency theatres, Dr Kelly Fraser, is happy to supervise you doing the procedure. After consenting Mr Bude on the ward, you change into scrubs and go back up to the emergency theatre anaesthetic room where Dr Fraser is waiting. “Have you been through the NAP 3 report?” she asks, continuing before you have a chance to answer. “The incidence of permanent neurological damage in thoracic epidurals was between one and six per 100,000 and was associated with multiple and failed attempts.” You nod, “Well I definitely want to avoid that. Have you got any top tips?” She laughs “If you ask any anaesthetist, you’ll probably get a different set of [[top tips]]” The doors to the anaesthetic room swing open and Mr Bude is pushed into the room on a hospital trolley. Dr Fraser gives him a warm smile "Ah, perfect timing, Mr Bude." [[Next->epidural4]] <<set $epidural2 to true>>

You go up to theatres to find a willing ODP and an appropriate space. The consultant on for emergency theatres is Dr Kelly Fraser. She agrees to fit Mr Bude into the list and says you can do both scrub and do the procedure togather. After consenting Mr Bude on the ward, you change into scrubs and go back up to the emergency theatre anaesthetic room where Dr Fraser is waiting. “Have you been through the NAP 3 report?” she asks, continuing before you have a chance to answer. “The incidence of permanent neurological damage in thoracic epidurals was between one and six per 100,00 and was associated with multiple and failed attempts." You nod, “Well I definitely want to avoid that. Have you got any top tips?” She laughs “If you ask any anaesthetist, you’ll probably get a different set of [[top tips]]” The doors to the anaesthetic room swing open and Mr Bude is pushed into the room on a hospital trolley. Dr Fraser gives him a warm smile "Ah, perfect timing, Mr Bude." [[Next->epidural4]] <<set $epidural2 to true>>

You go up to theatres to find a willing ODP and an appropriate venue. After consenting Mr Bude on the ward, he comes up to theatre and you perform the procedure without incident, and after a test dose start an infusion according to the hospital policy. After twenty minutes he reports being much more comfortable and when you ask him to take some deep breaths and have a cough he can do both effectively. [[Next->MrBude14]]

Just over a week later you are on Ward 7 seeing another patient. You spot Alison coming out of the bay Mr Bude is in. She comes over “Hello $firstname I’ve just been to see Mr Bude. He’s going home tomorrow, he asked me to thank you.” “How’s he getting on?” “Well he’s much better than a week ago and seems to have escaped any secondary complications so far. So good job. But he’s got a long road ahead of him in terms of recovery. Rib fractures are nasty.” “Never underestimate rib fractures.” Alison takes an appraising look at you “Absolutely. I couldn’t have put it better myself. Anyhow I wanted to catch you, now you’ve done a bit of pain medicine you should have another go at those MCQs, I’ve included the answers this time once you’re done.” She goes to leave but briefly pauses, “You really should consider a career in pain medicine you know.” [[Final MCQ->Q1post]]

@@.typing; ''Top Tips'' # ''Know your anatomy'' Be able to visualise what underlies the surface anatomy and where you want to place your needle. Get hold of a skeleton. Palpate lots of backs. Know the angles. # ''Think about yourself'' Don’t fall foul of the ‘I’ll just do this first’ mentality, you need to be able to concentrate so don’t start a complex procedure if the basics aren’t covered like needing a drink. # ''Make your first attempt your best attempt'' Is your position good? Not rushing? Have all the kit that you are familiar with? Do you have the right help and are you in the right location? Does your helper know the plan? Who are you calling if there’s a problem? Is the patient clear on what’s happening and what you need them to do? Is the patient optimally positioned? Do they need analgesia or sedation to tolerate the procedure? # ''Double check'' Correct patient? Correct procedure? # ''Take your time'' Look for palpable landmarks before you drape and mark what you feel with a skin marker. Visualise where you’re going with your needle. Check again after you’ve scrubbed. # ''Use plenty of local'' As you infiltrate try to identify structures. Give it time to work. # ''Keep a dialogue going'' Talk to your patient and your helper throughout the procedure so they know what’s going on. Don’t hold your breath. # ''Change something'' If you don’t get it in on the first attempt change something. Different space? Different approach? Reposition the patient? Happy with your landmarks? # ''Get help'' Two goes and its still not in? Get help it’s only fair to both you and your patient. # ''Do more'' Like any procedure, it gets easier with practice and sometimes they don’t go to plan. Take every opportunity you can to learn and do more. Follow up the patients you do procedures on, learn from them.@@ <<if $epidural2 is true>> [[Back->epidural2]] <</if>> <<if $epidural3 is true>> [[Back->epidural3]] <</if>> <<if $paravertebral2 is true>> [[Back->paravertebral2]] <</if>> <<if $paravertebral3 is true>> [[Back->paravertebral3]] <</if>> <<if $erectorspinae2 is true>> [[Back->erectorspinae2]] <</if>> <<if $erectorspinae3 is true>> [[Back->erectorspinae3]] <</if>>

A rectangle of Mr Budes back is visible in front between the crossed surgical drapes. “Why do we use a paramedian approach for mid-thoracic epdiurals?” Dr Fraser asks you while you wait for the local to kick in. “Because the spinous processed rise more steeply and the space is narrower” You reply, you turn back to your patient. “Right Mr Bude a bit of pushing now, let me know if it’s uncomfortable.” You say as you introduce the needle 1cm laterally to what you are reasonably confident is his T5 spinous process. <center> <img src="images/back2.jpg" style="max-width: 75%;"/> </center> You contact the bone of the medial transverse process and mentally note the depth, before withdrawing back to the skin and advancing 15 degrees towards the midline and slightly cephalad. “Is that Bone contact again?” Dr Fraser asks. “Yes, a bit more superficially this time.” “OK, you want to angle upwards slightly and ‘walk-off’ the lamina. Coming in paramedian doesn’t go through the supraspinous and interspinous ligaments so as soon you engage the ligamentum flavum take the stylet out and look for loss of resistance.” “…Got it…” Dr Fraser watches over your shoulder as you introduce the catheter and leave 5cm in the epidural space. “Perfect. Get a dose of local in and get it fixed down. I'm going to go and see what's going on with the rest of the emergency list.” [[Next->epidural5]]

"Hi it's Dr $surname, covering the acute pain bleep. You just bleeped me?" "Hi &firstname its Alison, where are you? I've just seen Mr Bude again. He has too many fractures to get anything like the dynamic pain control we need to let him cough and deep breath from those plasters you prescribbed. So we need to do something else?" You pause for a moment of the phone “I think we should…" [[Put in a thoracic epidural->MrBude6]] [[Put in paravertebral blocks->MrBude7]] [[Put in erector spinae plane catheters->MrBude15]] <<audio bleep pause>>

A rectangle of Mr Budes back is visible in front between the crossed surgical drapes. The local is in. “Right Mr Bude a bit of pushing now, let me know if it’s uncomfortable.” You say as you introduce the needle 2.5cm laterally to what you are reasonably confident is his T4 spinous process. <center> <img src="images/back1.jpg" style="max-width: 75%;"/> </center> Dr Fraser is watching over your shoulder as you carefully advance the needle at 90 degrees to the skin with your finger at the 3.5cm mark, you don’t want to go too far, a pneumothorax is the last thing Mr Bude needs. “Have you got bone?” She asks. The needles into your finger. “No, not yet” “Ok bring it back to the skin again and try a slight caudal angulation...now?” “No” “Try slightly cranially then.” You advance again with a cranial angulation and feel resistance as the needle meets the TP. “Got it.” “Great, now ‘walk-off’ the inferior aspect and before you advance any further take the stylet out and do a loss of resistance technique like you would with an epidural.” You feel a faint ‘click’ and the resistance changes. Dr Fraser sees the change “Did you get that? When you pass beyond the costotransverse ligament sometimes you get that ‘click’, not reliably though. You don’t want to advance more that 1cm beyond the TP and if you get a complete loss of resistance, well, you’re probably in pleural cavity and you're having a bad day.” You inject 5ml of saline to expand the space and then place the catheter with 2cm in the space. “Perfect. Get a dose of local in and get it fixed down. I'm going to go and see what's going on with the rest of the emergency list.” [[Next->paravertebral5]]

Once you're done its time to clear up and write a couple of paragraphs in the notes documenting everything. Just as you’re on your way out of theatres Dr Fraser catches you. "That catheter went in nicely, and Mr Bude seems much more comfortable in recovery, so great job $firstname. How do you fancy sticking around to help me with the rest of the emergency list?" [[Next->MrBude14]]

You decide Mr Bude should have an erector spinae catheter. [[You are happy to perform this procedure->erectorspinae1]] [[You have some experience but could do with supervision->erectorspinae2]] [[You watched a YouTube video once->erectorspinae3]] <<audio bleep pause>>

You go up to theatres to find a willing ODP and an appropriate space. The consultant on for emergency theatres, Dr Kelly Fraser, is happy to supervise you doing the procedure. After consenting Mr Bude on the ward, you change into scrubs and go back up to the emergency theatre anaesthetic room where Dr Fraser is waiting. “Have you got any top tips?” You ask her She laughs “If you ask any anaesthetist, you’ll probably get a different set of [[top tips]]” The doors to the anaesthetic room swing open and Mr Bude is pushed into the room on a hospital trolley. Dr Fraser gives him a warm smile "Ah, perfect timing, Mr Bude." [[Next->erectorspinae4]] <<set $erectorspinae2 to true>>

A rectangle of Mr Budes back is visible in front between the crossed surgical drapes. The local is in. “Some cold jelly on your back Mr Bude” you say as you place the ultrasound probe 3cm laterally to what you are reasonably confident is his T5 spinous process. <center> <img src="images/us.jpg" style="max-width: 75%;"/> </center> Dr Fraser is pointing at the snowy image that appears on the screen; “Lovely. Right, here we’ve got a nice flat squared of transverse process and you want to place your needle right on top of that right under the erector spinae fascia. Come out a bit more laterally and just look at the difference.” You bring the transducer away from the midline. “See the much more rounded acoustic shadows of the ribs with the pleura faintly visible?” You slide the transducer back. “Right Mr Bude a bit of pushing now, let me know if it’s uncomfortable.” The needle is visible coming in from the side of the screen, you advance until the tip contacts the bony TP then take the syringe of saline from the procedure trolley and inject a ml. “Looking good.” Dr Fraser says as the erector spinae muscle lifts off the tip of the TP. Once the catheter is in you put another couple of ml of saline down to check it’s in the right place and watch as the muscle lifts further. “Perfect. Get a dose of local in and get it fixed down. I'm going to go and see what's going on with the rest of the emergency list.” [[Next->erectorspinae5]]

"I think we should go and see Susan Fletcher to see how she's getting on with her rectus sheath catheters." Alison looks down at her copy of the list “Actually let’s see her after Daniel Kaine. I remember him from his last admission and acute pain episodes in sickle cell should be seen as an emergency really.” You head down to [[Ward 4]] to see Daniel.

"I think we should go and see Rachel Woodstock. I think she’s going to be a complex patient to manage." Alison looks down at her copy of the list “Actually let’s see her after Daniel Kaine. I remember him from his last admission and acute pain episodes in sickle cell should be seen as an emergency really.” You head down to [[Ward 4]] to see Daniel.

"I think we should go and see Robert Richards to see how he's getting on with his epidural." Alison looks down at her copy of the list “Actually let’s see him after Daniel Kaine. I remember him from his last admission and acute pain episodes in sickle cell should be seen as an emergency really.” You head down to [[Ward 4]] to see Daniel.

"I think we should go and see Helen Parsonage. I'm interested in the management of cancer pain.” Alison looks down at her copy of the list “Actually let’s see her after Daniel Kaine. I remember him from his last admission and acute pain episodes in sickle cell should be seen as an emergency really.” You head down to [[Ward 4]] to see Daniel.

"I think we should go and see Lisa Redbridge. I'm interested in the management of pain in pregnancy.” Alison looks down at her copy of the list “Actually let’s see her after Daniel Kaine. I remember him from his last admission and acute pain episodes in sickle cell should be seen as an emergency really.” You head down to [[Ward 4]] to see Daniel.

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_2@@

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module2.pdf]]'' [[Back|Introduction]]

<center> !!!BETA Virtual Anaesthetics_Pain training_2 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>