Module 3v2

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@@.whitetext; !!!VA_Pain training_3 Welcome to the third 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]]@@ <<set $result to 0>> <<set $team to false>> <<set $abby to false>> <<set $lumbar to false>> <<set $ketamine to false>> <<set $lidocaine to false>> <<set $stimulator to false>> <<set $amputation to false>> <<set $crps2 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_3: CRPS 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 "team" "audio/team.mp3">> <<cacheaudio "text" "audio/text.mp3">> <<cacheaudio "abby" "audio/abby.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 The most common precipitating event for complex regional pain syndrome (CRPS) is:'' </p> <<radiobutton "$choice1" "1">>  ''A.'' Burns <<radiobutton "$choice1" "2">>  ''B.'' Insect bites <<radiobutton "$choice1" "3">>  ''C.'' Fractures <<radiobutton "$choice1" "4">>  ''D.'' Strains and sprains <<radiobutton "$choice1" "5">>  ''C.'' None, the condition most commonly presents spontaneously @@ <<timed 59s>> <<goto Q2>> <</timed>> <<countdownTimer 60 "Q2">> <<button [[Next question->Q2]]>> <</button>>

!!!@@.greentext;Scenario learning objectives:@@ * List the International Association for the Study of Pain (IASP) clinical diagnostic criteria for complex regional pain syndrome (CRPS) * Have an overview of the initial management of CRPS and be aware of the Royal College of Physicians’ 2018 guidance on the management of CRPS * Understand the role of the multi-disciplinary team in pain management * Be able to describe the structure and function of the autonomic nervous system * Be aware of the more interventional treatments for CRPS including spinal cord stimulators and lumbar sympathetic blocks * Know the sources of professional support [[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 "VApain3">> <<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 $result>> out of 10 correct <p style="text-align:justify">''Q2 CRPS more commonly presents in the:''</p> <<radiobutton "$choice2" "1">>  ''A.'' Upper limb <<radiobutton "$choice2" "2">>  ''B.'' Lower limb <<radiobutton "$choice2" "3">>  ''C.'' Either upper or lower limb @@ <<timed 59s>> <<goto Q3>> <</timed>> <<countdownTimer 60 "Q3">> <<button [[Next Question->Q3]]>> <</button>>

@@.whitetext;<<if $choice2 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q3 The differential diagnosis for CRPS is extensive and includes:''</p> <<radiobutton "$choice3" "1">>  ''A.'' Post-herpetic neuralgia <<radiobutton "$choice3" "2">>  ''B.'' Compartment syndrome <<radiobutton "$choice3" "3">>  ''C.'' Venous thromboembolism <<radiobutton "$choice3" "4">>  ''D.'' Rheumatoid arthritis <<radiobutton "$choice3" "5">>  ''E.'' All of the above @@ <<timed 59s>> <<goto Q4>> <</timed>> <<countdownTimer 60 "Q4">> <<button [[Next question->Q4]]>> <</button>>

@@.whitetext;<<if $choice3 eq "5">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 The International Association for the Study of Pain (IASP) clinical diagnostic criteria for CRPS include:''</p> <<radiobutton "$choice4" "1">>  ''A.'' Early onset progressive pain out of proportion to injury in a limb which is tense to palpation <<radiobutton "$choice4" "2">>  ''B.'' Continuing pain, which is disproportionate to any inciting event <<radiobutton "$choice4" "3">>  ''C.'' Limb pain that is worse with activity and improves with rest <<radiobutton "$choice4" "4">>  ''D.'' Pain in a dermatomal distribution of the affected limb <<radiobutton "$choice4" "5">>  ''E.'' Symmetrical hypersensitivity and dystrophic change in the extremities @@ <<timed 59s>> <<goto Q5>> <</timed>> <<countdownTimer 60 "Q5">> <<button [[Next question->Q5]]>> <</button>>

@@.whitetext;<<if $choice4 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q5 Several subtypes of CRPS exist including types I and II. Regarding CRPS type I:'' </p> <<radiobutton "$choice5" "1">>  ''A.'' There is an identified nerve lesion and it is the less common subtype <<radiobutton "$choice5" "2">>  ''B.'' There is no identified nerve lesion and it is the less common subtype <<radiobutton "$choice5" "3">>  ''C.'' There is an identified nerve lesion and it is the more common subtype <<radiobutton "$choice5" "4">>  ''D.'' There is no identified nerve lesion and it is the more common subtype @@ <<timed 59s>> <<goto Q6>> <</timed>> <<countdownTimer 60 "Q6">> <<button [[Next question->Q6]]>> <</button>>

@@.whitetext;<<if $choice5 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q6 Treatment for CRPS may include all the following except:''</p> <<radiobutton "$choice6" "1">>  ''A.'' Vasodilators <<radiobutton "$choice6" "2">>  ''B.'' Gabapentin <<radiobutton "$choice6" "3">>  ''C.'' Short-term bisphosphonates <<radiobutton "$choice6" "4">>  ''D''. Ketamine infusions <<radiobutton "$choice6" "5">>  ''E.'' Long term steroids @@ <<timed 59s>> <<goto Q7>> <</timed>> <<countdownTimer 60 "Q7">> <<button [[Next question->Q7]]>> <</button>>

@@.whitetext;<<if $choice6 eq "5">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q7 While you are on a team-building exercise at the local safari park one of the tigers escapes. Which of the following adrenoreceptors is predominantly responsible for the increase in inotropy and chronotropy you experience:'' </p> <<radiobutton "$choice7" "1">>  ''A.'' α~~1~~ <<radiobutton "$choice7" "2">>  ''B.'' α~~2~~ <<radiobutton "$choice7" "3">>  ''C.'' β~~1~~ <<radiobutton "$choice7" "4">>  ''D.'' β~~2~~ <<radiobutton "$choice7" "5">>  ''E.'' β~~3~~ @@ <<timed 59s>> <<goto "Q8">> <</timed>> <<countdownTimer 60 "Q8">> <<button [[Next question->Q8]]>> <</button>>

@@.whitetext;<<if $choice7 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q8 In the autonomic nervous system myelinated preganglionic fibres leave the brainstem or spinal cord and synapse with postganglionic neurones within autonomic ganglia. Which is the postganglionic receptor in these ganglia?'' </p> <<radiobutton "$choice8" "1">>  ''A.'' Muscarinic <<radiobutton "$choice8" "2">>  ''B.'' α-adrenergic <<radiobutton "$choice8" "3">>  ''C.'' β-adrenergic <<radiobutton "$choice8" "4">>  ''D.'' Nicotinic <<radiobutton "$choice8" "5">>  ''E.'' Dopaminergic @@ <<timed 59s>> <<goto "Q9">> <</timed>> <<countdownTimer 60 "Q9">> <<button [[Next question->Q9]]>> <</button>>

@@.whitetext;<<if $choice8 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q9 Which reflex is independent of the central nervous system?'' </p> <<radiobutton "$choice9" "1">>  ''A.'' Short reflex <<radiobutton "$choice9" "2">>  ''B.'' Somatic reflex <<radiobutton "$choice9" "3">>  ''C.'' Pain reflex <<radiobutton "$choice9" "4">>  ''D.'' Visceral reflex <<radiobutton "$choice9" "5">>  ''E.'' Oculocardiac reflex @@ <<timed 59s>> <<goto "Q10">> <</timed>> <<countdownTimer 60 "Q10">> <<button [[Next question->Q10]]>> <</button>>

@@.whitetext;<<if $choice9 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q10 Preganglionic parasympathetic fibres travel in which of the following cranial nerves?'' </p> <<radiobutton "$choice10" "1">>  ''A.'' Trochlear (CN 4) <<radiobutton "$choice10" "2">>  ''B.'' Trigeminal (CN 5) <<radiobutton "$choice10" "3">>  ''C.'' Abducens (CN VI) <<radiobutton "$choice10" "4">>  ''D.'' Facial nerve (CN VII) <<radiobutton "$choice10" "5">>  ''E.'' Vestibulocochlear (CN VIII) @@ <<timed 59s>> <<goto "Done!">> <</timed>> <<countdownTimer 60 "Done!">> <<button [[Done!->Done!]]>> <</button>>

<<if $choice10 eq "4">><<set $result to $result + 1>> <</if>> You've scored <<print $result>> out of 10 <<set $result1 to $result>> [[Next->patient1]]

<p style="text-align:justify">@@.console; !!!2 years ago: Abby squints through the rain at the screen of her running watch. That last mile was just over eleven minutes. No chance of a personal best on this trail today. After the long climb she’s slithering down the boggy path that’s more like a riverbed than a track. The mud sucks her trainers with every step. Her left foot doesn’t find solid ground on the next stride and slides. She’s suddenly off balance and reflexively her right foot stamps forward to stop the fall. Her ankle twists sideways with her full weight through it. As she goes down there’s a sickening crack. <center> !![[Race over ->patient2]] </center> @@</p>

It's just past nine in the evening and you're at home working on your computer. As you go to shut down a text notification goes off on your phone. [[take a look->text1]] <<audio text play>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 21:49@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Sorry I know its late. Journal club is tomorrow. I forgot. Would you look at what I’ve done for it? Please?? </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; So not an actual emergency? @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Please? Here's the link: [[CRPS_notes.doc->CRPSnotes]] </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; Next time I need to swap a shift you owe me! @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Thanks $firstname </p> </div> </div> </p> [[I'll skip this thanks->patient1]] <<audio text pause>>

@@.whitetext;<p style="text-align:justify">''Q1 The most common precipitating event for complex regional pain syndrome (CRPS) is:'' </p> <label><<radiobutton "$choice1" "one">>  ''A.'' Burns </label> <label><<radiobutton "$choice1" "two">>  ''B.'' Insect bites </label> <label><<radiobutton "$choice1" "three">>  ''C.'' Fractures </label> <label><<radiobutton "$choice1" "four">>  ''D.'' Strains and sprains </label> <label><<radiobutton "$choice1" "five">>  ''E.'' None, the condition most commonly presents spontaneously </label> @@ <br> <<button [[Next question->Q2post]]>> <</button>> <<set $result to 0>>

@@.whitetext;<<if $choice1 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 CRPS more commonly presents in the:'' </p> <label><<radiobutton "$choice2" "one">>  ''A.'' Upper limb </label> <label><<radiobutton "$choice2" "two">>  ''B.'' Lower limb </label> <label><<radiobutton "$choice2" "three">>  ''C.'' Either upper or lower limb </label> @@ <br> <<button [[Next Question->Q3post]]>> <</button>>

@@.whitetext;<<if $choice2 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q3 The differential diagnosis for CRPS is extensive and includes:''</p> <label><<radiobutton "$choice3" "one">>  ''A.'' Post-herpetic neuralgia </label> <label><<radiobutton "$choice3" "two">>  ''B.'' Compartment syndrome </label> <label><<radiobutton "$choice3" "three">>  ''C.'' Venous thromboembolism </label> <label><<radiobutton "$choice3" "four">>  ''D.'' Rheumatoid arthritis </label> <label><<radiobutton "$choice3" "five">>  ''E.'' All of the above </label> @@ <br> <<button [[Next Question->Q4post]]>> <</button>>

@@.whitetext;<<if $choice3 eq "five">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 The International Association for the Study of Pain (IASP) clinical diagnostic criteria for CRPS include:''</p> <label><<radiobutton "$choice4" "one">>  ''A.'' Early onset progressive pain out of proportion to injury in a limb which is tense to palpation </label> <label><<radiobutton "$choice4" "two">>  ''B.'' Continuing pain, which is disproportionate to any inciting event </label> <label><<radiobutton "$choice4" "three">>  ''C.'' Limb pain that is worse with activity and improves with rest </label> <label><<radiobutton "$choice4" "four">>  ''D.'' Pain in a dermatomal distribution of the affected limb </label> <label><<radiobutton "$choice4" "five">>  ''E.'' Symmetrical hypersensitivity and dystrophic change in the extremities </label> @@ <br> <<button [[Next Question->Q5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q1 The most common precipitating event for complex regional pain syndrome (CRPS) is:''</p> <label><<radiobutton "$choice1" "one" `$choice1 is "one" ? 'checked' : ''`>>  ''A.'' Burns </label> <label><<radiobutton "$choice1" "two" `$choice1 is "two" ? 'checked' : ''`>>  ''B.'' Insect bites </label> <label><<radiobutton "$choice1" "three" `$choice1 is "three" ? 'checked' : ''`>>  ''C.'' Fractures </label> <label><<radiobutton "$choice1" "four" `$choice1 is "four" ? 'checked' : ''`>>  ''D.'' Strains and sprains </label> <label><<radiobutton "$choice1" "five" `$choice1 is "five" ? 'checked' : ''`>>  ''E.'' None, the condition most commonly presents spontaneously </label> <br> <<if $choice1 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify"> In a large retrospective cohort study^^1^^ of 1042 patients with CRPS the precipitating event was ''fractures'' (44%), ''blunt trauma'' including sprains (21%) ''surgery'' (12%) and ''carpal tunnel'' syndrome (7%). There was no identified precipitating event in 10% of people. 1. Ott S, Maihofner C. Signs and Symptoms in 1,043 Patients with Complex Regional Pain Syndrome. //J Pain//. 2018; 19(6):599 </p> @@ <<button [[Next question->answerQ2post]]>> <</button>>

@@.whitetext;<<if $choice4 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q5 Several subtypes of CRPS exist including types I and II. Regarding CRPS type I:''</p> <label><<radiobutton "$choice5" "one">>  ''A.'' There is an identified nerve lesion and it is the less common subtype </label> <label><<radiobutton "$choice5" "two">>  ''B.'' There is no identified nerve lesion and it is the less common subtype </label> <label><<radiobutton "$choice5" "three">>  ''C.'' There is an identified nerve lesion and it is the more common subtype </label> <label><<radiobutton "$choice5" "four">>  ''D.'' There is no identified nerve lesion and it is the more common subtype </label> @@ <br> <<button [[Next Question->Q6post]]>> <</button>>

@@.whitetext;<<if $choice5 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q6 Treatment for CRPS may include all the following except:''</p> <label><<radiobutton "$choice6" "one">>  ''A.'' Vasodilators </label> <label><<radiobutton "$choice6" "two">>  ''B.'' Gabapentin </label> <label><<radiobutton "$choice6" "three">>  ''C.'' Short-term bisphosphonates </label> <label><<radiobutton "$choice6" "four">>  ''D.'' Ketamine infusions </label> <label><<radiobutton "$choice6" "five">>  ''E.'' Long term steroids </label> @@ <br> <<button [[Next Question->Q7post]]>> <</button>>

@@.whitetext;<<if $choice6 eq "five">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q7 While you are on a team-building exercise at the local safari park one of the tigers escapes. Which of the following adrenoreceptors is predominantly responsible for the increase in inotropy and chronotropy you experience:''</p> <label><<radiobutton "$choice7" "one">>  ''A.'' α~~1~~ </label> <label><<radiobutton "$choice7" "two">>  ''B.'' α~~2~~ </label> <label><<radiobutton "$choice7" "three">>  ''C.'' β~~1~~ </label> <label><<radiobutton "$choice7" "four">>  ''D.'' β~~2~~ </label> <label><<radiobutton "$choice7" "five">>  ''E.'' β~~3~~ </label> @@ <br> <<button [[Next Question->Q8post]]>> <</button>>

@@.whitetext;<<if $choice7 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q8 In the autonomic nervous system myelinated preganglionic fibres leave the brainstem or spinal cord and synapse with postganglionic neurones within autonomic ganglia. Which is the postganglionic receptor in these ganglia?''</p> <label><<radiobutton "$choice8" "one">>  ''A.'' Muscarinic </label> <label><<radiobutton "$choice8" "two">>  ''B.'' α-adrenergic </label> <label><<radiobutton "$choice8" "three">>  ''C.'' β-adrenergic </label> <label><<radiobutton "$choice8" "four">>  ''D.'' Nicotinic </label> <label><<radiobutton "$choice8" "five">> ''E.'' Dopaminergic </label> @@ <br> <<button [[Next Question->Q9post]]>> <</button>>

@@.whitetext;<<if $choice8 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q9 Which reflex is independent of the central nervous system?''</p> <label><<radiobutton "$choice9" "one">>  ''A.'' Short reflex </label> <label><<radiobutton "$choice9" "two">>  ''B.'' Somatic reflex </label> <label><<radiobutton "$choice9" "three">>  ''C.'' Pain reflex </label> <label><<radiobutton "$choice9" "four">>  ''D.'' Visceral reflex </label> <label><<radiobutton "$choice9" "five">>  ''E.'' Oculocardiac reflex </label> @@ <br> <<button [[Next Question->Q10post]]>> <</button>>

@@.whitetext;<<if $choice9 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q10 Preganglionic parasympathetic fibres travel in which of the following cranial nerves?''</p> <label><<radiobutton "$choice10" "one">>  ''A.'' Trochlear (CN 4) </label> <label><<radiobutton "$choice10" "two">>  ''B.'' Trigeminal (CN 5) </label> <label><<radiobutton "$choice10" "three">>  ''C.'' Abducens (CN VI) </label> <label><<radiobutton "$choice10" "four">>  ''D.'' Facial nerve (CN VII) </label> <label><<radiobutton "$choice10" "five">>  ''E.'' Vestibulocochlear (CN VIII) </label> @@ <br> <<button [[Submit->results2]]>> <</button>>

<<if $choice10 eq "four">><<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 CRPS more commonly presents in the:''</p> <label><<radiobutton "$choice2" "one" `$choice2 is "one" ? 'checked' : ''`>>  ''A.'' Upper limb </label> <label><<radiobutton "$choice2" "two" `$choice2 is "two" ? 'checked' : ''`>>  ''B.'' Lower limb </label> <label><<radiobutton "$choice2" "three" `$choice2 is "three" ? 'checked' : ''`>>  ''C.'' Either upper or lower limb </label> <br> <<if $choice2 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify"> CRPS more commonly occurs in the upper limb within four to six weeks of the precipitating event. Infrequently CRPS can occur in both the upper and lower limbs or spread to adjacent areas or the contralateral limb.</p> @@ <<button [[Next question->answerQ3post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q3 The differential diagnosis for CRPS is extensive and includes:''</p> <label><<radiobutton "$choice3" "one" `$choice3 is "one" ? 'checked' : ''`>>  ''A.'' Post-herpetic neuralgia </label> <label><<radiobutton "$choice3" "two" `$choice3 is "two" ? 'checked' : ''`>>  ''B.'' Compartment syndrome </label> <label><<radiobutton "$choic e3" "three" `$choice3 is "three" ? 'checked' : ''`>>  ''C.'' Venous thromboembolism </label> <label><<radiobutton "$choice3" "four" `$choice3 is "four" ? 'checked' : ''`>>  ''D.'' Rheumatoid arthritis </label> <label><<radiobutton "$choice3" "five" `$choice3 is "five" ? 'checked' : ''`>>  ''E.'' All of the above </label> <br> <<if $choice3 is "five">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: E'' <p style="text-align:justify"> There is no definitive diagnostic test for CRPS and this is therefore a diagnosis of exclusion. The differential for the condition includes a number of inflammatory, vascular, myofascial and rheumatological diseases: * Inflammatory: infection of the skin, muscle, joint or bone; rheumatological diseases; erysipelas; bursitis * Vascular: venous thromboembolism; atherosclerosis; compartment syndrome; Raynaud’s; thoracic outlet syndrome * Neuropathic: post-herpetic neuralgia; peripheral neuropathy; radiculopathy * Myofascial pain syndromes: overuse; disuse; repetitive strain injury * Psychological disorders: somatoform pain disorders This list is not exhaustive and careful history and targeted investigation should be used to exclude these and other serious conditions. </p> @@ <<button [[Next question->answerQ4post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q4 The International Association for the Study of Pain (IASP) clinical diagnostic criteria for CRPS include:''</p> <label><<radiobutton "$choice4" "one" `$choice4 is "one" ? 'checked' : ''`>>  ''A.'' Early onset progressive pain out of proportion to injury in a limb which is tense to palpation </label> <label><<radiobutton "$choice4" "two" `$choice4 is "two" ? 'checked' : ''`>>  ''B.'' Continuing pain, which is disproportionate to any inciting event </label> <label><<radiobutton "$choice4" "three" `$choice4 is "three" ? 'checked' : ''`>>  ''C.'' Limb pain that is worse with activity and improves with rest </label> <label><<radiobutton "$choice4" "four" `$choice4 is "four" ? 'checked' : ''`>>  ''D.'' Pain in a dermatomal distribution of the affected limb </label> <label><<radiobutton "$choice4" "five" `$choice4 is "five" ? 'checked' : ''`>>  ''E.'' Symmetrical hypersensitivity and dystrophic change in the extremities </label> <br> <<if $choice4 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' Various criteria exist for the diagnosis of CRPS including the ''International Association for the Study of Pain (IASP) clinical diagnostic criteria:'' ''Continuing pain, which is disproportionate to any inciting event'' @@ @@.lightbluetext; ''and'' @@ @@.whitetext;Must report at least one symptom in three of the four of the following categories: * ''Sensory'' - reports of hyperaesthesia and/or allodynia * ''Vasomotor'' - reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry * ''Sudomotor/oedema'' - reports of oedema and/or sweating changes and/or sweating asymmetry * ''Motor/trophic'' - reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) @@ @@.lightbluetext; ''and'' @@ @@.whitetext;Must display at least one sign at time of evaluation in two or more of the following categories: * ''Sensory'' - evidence of hyperalgesia (to pinprick) and or allodynia (to light touch and/or deep somatic pressure and/or joint movement) * ''Vasomotor'' - evidence of temperature asymmetry and/or skin colour changes and/or asymmetry * ''Sudomotor/oedema'' - evidence of oedema and/or sweating changes and/or sweating asymmetry * ''Motor/trophic'' - evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail skin) @@ @@.lightbluetext; ''and'' @@ @@.whitetext;''There is no other diagnosis that better explains the signs and symptoms'' Early onset progressive pain out of proportion to apparent injury in a limb which is tense to palpation is seen in compartment syndrome. Limb pain that is worse with activity and improves with rest is associated with peripheral vascular disease. Pain in a dermatomal distribution of the affected limb suggests a nerve entrapment or radiculopathy. Symmetrical hypersensitivity and dystrophic change in the extremities is sometimes seen with a peripheral neuropathy including that observed in diabetics.@@ <<button [[Next question->answerQ5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q5 Several subtypes of CRPS exist including types I and II. Regarding CRPS type I:''</p> <label><<radiobutton "$choice5" "one" `$choice5 is "one" ? 'checked' : ''`>>  ''A.'' There is an identified nerve lesion and it is the less common subtype </label> <label><<radiobutton "$choice5" "two" `$choice5 is "two" ? 'checked' : ''`>>  ''B.'' There is no identified nerve lesion and it is the less common subtype </label> <label><<radiobutton "$choice5" "three" `$choice5 is "three" ? 'checked' : ''`>>  ''C.'' There is an identified nerve lesion and it is the more common subtype </label> <label><<radiobutton "$choice5" "four" `$choice5 is "four" ? 'checked' : ''`>>  ''D.'' There is no identified nerve lesion and it is the more common subtype </label> <br> <<if $choice5 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify"> CRPS can be classified into type I or II depending on the absence (type I) or presence (type II) of an identified nerve lesion. Type I is the more common subtype and represents about 90% of clinical presentations. It can also be classified as ‘warm’ or ‘cold’ depending on the skin temperature of the limb involved on presentation.</p> @@ <<button [[Next question->answerQ6post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q6 Treatment for CRPS may include all the following except:''</p> <label><<radiobutton "$choice6" "one" `$choice6 is "one" ? 'checked' : ''`>>  ''A.'' Vasodilators </label> <label><<radiobutton "$choice6" "two" `$choice6 is "two" ? 'checked' : ''`>>  ''B.'' Gabapentin </label> <label><<radiobutton "$choice6" "three" `$choice6 is "three" ? 'checked' : ''`>>  ''C.'' Short-term bisphosphonates </label> <label><<radiobutton "$choice6" "four" `$choice6 is "four" ? 'checked' : ''`>>  ''D.'' Ketamine infusions </label> <label><<radiobutton "$choice6" "five" `$choice6 is "five" ? 'checked' : ''`>>  ''E.'' Long term steroids </label> <br> <<if $choice6 is "five">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: E'' <p style="text-align:justify">CRPS treatment should be tailored to the most prominent and troubling features that the individual presents with. This may include: * A calcium channel blocker, an alpha-sympathetic blocker, or phosphodiesterase-5 inhibitor for vasomotor disturbance (‘cold’ CRPS) * Short term bisphosphonates when there is evidence of increased bone uptake * Non-opioid analgesics * Adjuncts for neuropathic pain. The evidence on the use of agents for neuropathic pain such as gabapentin or a TCA in CRPS is limited. These should only be considered or continued where there is evidence of benefit to the individual * Antispasmodic drugs where there is evidence of dystonia including intrathecal baclofen * Sub anaesthetic dose IV Ketamine infusions * IV Lidocaine infusions * Spinal cord stimulators Sympathetic nerve blocks have limited, and conflicting evidence supporting their use however may be of benefit in selected patients </p> @@ <<button [[Next question->answerQ7post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q7 While you are on a team-building exercise at the local safari park one of the tigers escapes. Which of the following adrenoreceptors is predominantly responsible for the increase inotropy and chronotropy you experience:''</p> <label><<radiobutton "$choice7" "one" `$choice7 is "one" ? 'checked' : ''`>>  ''A.'' α~~1~~</label> <label><<radiobutton "$choice7" "two" `$choice7 is "two" ? 'checked' : ''`>>  ''B.'' α~~2~~ </label> <label><<radiobutton "$choice7" "three" `$choice7 is "three" ? 'checked' : ''`>>  ''C.'' β~~1~~ </label> <label><<radiobutton "$choice7" "four" `$choice7 is "four" ? 'checked' : ''`>>  ''D.'' β~~2~~ </label> <label><<radiobutton "$choice7" "five" `$choice7 is "five" ? 'checked' : ''`>>  ''E.'' β~~3~~ </label> <br> <<if $choice7 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify"> β adrenoceptors operate mainly via G~~s~~-protein mechanisms which increase adenylyl cyclase activity and cyclic-AMP concentrations within cells. This results in activation of PKA and protein phosphorylation with a range of cellular effects. ''β~~1~~'' adrenoceptors are the predominant adrenoreceptor in the heart and increase sinoatrial and atrioventricular node firing, and ventricular muscle contractility. The net effect is a greater cardiac output, a key element of the ‘fight or flight’ response. They also cause release of renin from the kidney. ''β~~2~~'' adrenoceptors are mainly located on the smooth muscle but are also found on cardiomyocytes to a lesser extent than β~~1~~ where they act in a similar fashion. β~~2~~ receptors are responsible for bronchodilation, and vasodilation, especially in skeletal muscle to improve blood flow in preparation for fleeing from wild animals or other exercise. ''β~~3~~'' adrenoceptors are predominantly located on adipose tissue, especially brown fat, and liver cells but can also be found on cardiomyocytes where they act in a similar fashion to β~~1~~ adrenoceptors. They play a role in thermogenesis and lipolysis, as well as coronary artery vasodilation and bladder relaxation. ''α~~1~~'' adrenoceptors operate via G~~q~~-protein mechanisms which increases activation of phospholipase C and elevation of IP3 and DAG, ultimately increasing intracellular Ca^^2+^^. This causes an increase smooth muscle contrition and peripheral vasoconstriction. In cardiomyocytes,the increases in intracellular Ca^^2+^^ augment contraction and has a cardioprotective role. In smooth muscle, α~~1~~ adrenoceptors cause contraction by upregulation of intracellular Ca^^2+^^ and activation of myosin light chain kinase. ''α~~2~~'' adrenoceptors operate via G~~i~~-protein mechanisms which essentially does the opposite of β adrenoceptors.They are located: * Prejunctionally where they act to inhibit noradrenaline release * Smooth muscle cells where they cause contraction * Central nervous system where they decrease sympathetic outflow and increase descending modulation of pain sensation </p> @@ <<button [[Next question->answerQ8post]]>> <</button>>

@@.whitetext; <p style="text-align:justify">''Q8 In the autonomic nervous system myelinated preganglionic fibres leave the brainstem or spinal cord and synapse with postganglionic neurones within autonomic ganglia. Which is the postganglionic receptor in these ganglia?''</p> <label><<radiobutton "$choice8" "one" `$choice8 is "one" ? 'checked' : ''`>>  ''A.'' Muscarinic </label> <label><<radiobutton "$choice8" "two" `$choice8 is "two" ? 'checked' : ''`>>  ''B.'' α-adrenergic </label> <label><<radiobutton "$choice8" "three" `$choice8 is "three" ? 'checked' : ''`>>  ''C.'' β-adrenergic </label> <label><<radiobutton "$choice8" "four" `$choice8 is "four" ? 'checked' : ''`>>  ''D.'' Nicotinic </label> <label><<radiobutton "$choice8" "five" `$choice8 is "five" ? 'checked' : ''`>>  ''E.'' Dopaminergic </label> <br> <<if $choice8 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">Preganglionic fibres synapse in autonomic ganglia and release ACh onto nicotinic receptors. These ligand gated ion channels allow cations into the cell and membrane depolarization to occur in the postsynaptic neurone. Muscarinic and adrenergic receptors occur in postsynaptic neurones of the ANS. Dopaminergic receptors are a group of G-protein coupled receptors that mediate the central and peripheral actions of the hormone dopamine. They are most abundant in the brain and pituitary but are also found in the peripheral organs such as the kidney. </p> @@ <<button [[Next question->answerQ9post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q9 Which reflex is independent of the central nervous system?''</p> <label><<radiobutton "$choice9" "one" `$choice9 is "one" ? 'checked' : ''`>>  ''A.'' Short reflex </label> <label><<radiobutton "$choice9" "two" `$choice9 is "two" ? 'checked' : ''`>>  ''B.'' Somatic reflex </label> <label><<radiobutton "$choice9" "three" `$choice9 is "three" ? 'checked' : ''`>>  ''C.'' Pain reflex </label> <label><<radiobutton "$choice9" "four" `$choice9 is "four" ? 'checked' : ''`>>  ''D.'' Visceral reflex </label> <label><<radiobutton "$choice9" "five" `$choice9 is "five" ? 'checked' : ''`>>  ''E.'' Oculocardiac reflex </label> <br> <<if $choice9 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify">A short reflex occurs in the enteric nervous system to autonomously control peristalsis independent of the CNS. All other relaxes pass to the CNS. Somatic reflexes relate to skeletal muscles while visceral reflexes involve glandular and non-skeletal muscle responses. The oculocardiac (or Ashner) reflex is a PNS mediated bradycardia that occurs with traction of the extraocular muscles or compression of the eyeball. The reflex includes central component in the brainstem. </p> @@ <<button [[Next question->answerQ10post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q10 Preganglionic parasympathetic fibres travel in which of the following cranial nerves?''</p> <label><<radiobutton "$choice10" "one" `$choice10 is "one" ? 'checked' : ''`>>  ''A.'' Trochlear (CN 4) </label> <label><<radiobutton "$choice10" "two" `$choice10 is "two" ? 'checked' : ''`>>  ''B.'' Trigeminal (CN 5) </label> <label><<radiobutton "$choice10" "three" `$choice10 is "three" ? 'checked' : ''`>>  ''C.'' Abducens (CN VI) </label> <label><<radiobutton "$choice10" "four" `$choice10 is "four" ? 'checked' : ''`>>  ''D.'' Facial nerve (CN VII) </label> <label><<radiobutton "$choice10" "five" `$choice10 is "five" ? 'checked' : ''`>>  ''E.'' Vestibulocochlear (CN VIII) </label> <br> <<if $choice10 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify"> The oculomotor (CN III), facial (CN VII), oesophageal (CN IX) and vagus (CN X) all have a parasympathetic contribution. They have the following autonomic innervation: * ''Oculomotor III'' pupillary constriction * ''Facial VII'' lacrimal, submaxillary & sublingual glands * ''Glossopharyngeal IX'' Mucus membranes mouth, parotid gland * ''Vagus X'' Thoracic and abdominal viscera to the transverse colon </p> @@ <<button [[Done!->End]]>> <</button>>

"Morning $firstname" Dr Jones greets you as you arrive in the office next day. "How about you sit in on our complex referrals meeting this morning? Melanie triaged this one but she’s just messaged something about water coming through the kitchen ceiling and she’s going to be a bit late. If you read the referral and present it at the meeting that would be helpful. Looks complicated. CRPS." He hands you a sheaf of paper. <<if $crps2 is true>> Thank goodness you read the CRPS stuff Matt sent last night. <<else>> Now you wish you'd read the CRPS stuff Matt sent last night. <</if>> You take a seat and start reading the first page. [[Notes]]

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio team play>> [[Transcript->transcript1]]   [[Next->audiopost1]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%203/audio/team.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/meeting.jpg" style="max-width: 100%;"/> </center> <<set $team to true>>

<<audio team pause>> <<if $lumbar is true & $ketamine is true & $stimulator is true & $amputation is true>> "Now you’ve had a brief summary of the more interventional management of these patients what do you think we should do next for Miss Lewis?" "I think we should... [[bring her in for an MDT assessment]] [[offer a lumbar block and physiotherapy]] [[offer ketamine infusions and physiotherapy]] [[offer lidocaine infusions and physiotherapy]] [[refer her for a spinal cord stimulator]] [[offer the amputation]] <<else>>You consider for a moment. "Could you tell me more about… <<if $lumbar is true>> <<else>>[[lumbar sympathetic blocks]] <</if>> <<if $ketamine is true>> <<else>>[[ketamine infusions]] <</if>> <<if $lidocaine is true>> <<else>>[[lidocaine infusions]] <</if>> <<if $stimulator is true>> <<else>>[[spinal cord stimulators]] <</if>> <<if $amputation is true>> <<else>>[[amputation for CRPS]] <</if>> <</if>>

<p style="text-align:justify">Notes from: Bharwani K, Dirckx M, Huygen F. ''Complex regional pain syndrome: diagnosis and treatment''. //BJA Ed//, 20017; 17:262–268</p><center> !!Complex regional pain syndrome </center> <div class="notes">''Causes of CRPS:''</div> * Trauma (mostly fractures) * Surgery including arthroscopy * Sprains * Burns * Insect bites * Spontaneous <p style="text-align:justify">CRPS occurs in the upper limbs more than lower limbs with an incidence of 5.5 to 26.2 per 100 000 person-years and 4:1 Female:Male ratio.</p> <div class="notes">''Subclassifications:''</div> * CRPS type I = no demonstrable nerve lesion * CRPS type II = demonstrable nerve lesion Or * ‘Warm’ CRPS with a warm limb at onset * ‘Cold’ CRPS with a cold limb at onset <div class="notes">''Diagnosis:''</div> Various criteria exist for the diagnosis of CRPS including the ''International Association for the Study of Pain (IASP) clinical diagnostic criteria'': <center> @@.greentext; ''Continuing pain, which is disproportionate to any inciting event''@@ </center> Must report at least one symptom in at least three of the four of the following categories: * ''Sensory:'' hyperaesthesia and/or allodynia * ''Vasomotor:'' temperature asymmetry and/or skin colour changes and/or skin colour asymmetry * ''Sudomotor/oedema:'' oedema and/or sweating changes and/or sweating asymmetry * ''Motor/trophic:'' decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) Must display at least one sign at time of evaluation in two or more of the following categories: * ''Sensory:'' hyperalgesia (to pinprick) and or allodynia (to light touch and/or deep somatic pressure and/or joint movement) * ''Vasomotor:'' temperature asymmetry and/or skin colour changes and/or asymmetry * ''Sudomotor/oedema:'' oedema and/or sweating changes and/or sweating asymmetry * ''Motor/trophic:'' decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail skin) <center> @@.greentext; ''There is no other diagnosis that better explains the signs and symptoms''@@ </center> <div class="notes">''Phenotypes:''</div> Different pathophysiological phenotypes based on most prominent signs and symptoms can be used to help target appropriate therapies: * Inflammation * Pain/sensory disturbances * Vasomotor disturbances * Motor/dystonic disturbances * Psychological disturbances <div class="notes">''Differential:''</div> * ''Neuropathic pain-like syndromes'' (eg nerve entrapment, radiculopathy, post-herpetic neuralgia) * ''Myofascial pain syndromes'' (eg overuse, disuse, repetitive strain injury) * ''Inflammation'' (eg erysipelas, bursitis, rheumatic diseases, osteomyelitis) * ''Vascular diseases'' (eg Raynaud’s, thrombosis, atherosclerosis) * ''Psychological disorders'' (eg somatoform pain disorders) <p style="text-align:justify">There is no definitive diagnostic test and investigations should be targeted to exclude other disorders or to monitor the signs and symptoms of CRPS.</p> <div class="notes">''Pathophysiology of CRPS:''</div> <p style="text-align:justify"> @@.greentext; ''Both peripheral and central mechanisms are thought to play a role in the initiation and maintenance of CRPS.''@@ In the ‘acute’ phase of CRPS the classic signs of an inflammatory response may occur with pain, swelling, heat and loss of function in the affected limb. However inflammatory markers (CRP, WCC, ESR) are frequently normal. ''Local pro-inflammatory cytokines'' (IL-6 and TNF-alpha) are implicated and may be involved in peripheral nociceptor activation and sensitization. Studies have found increased levels of the neuropeptides Substance-P and calcitonin gene-related peptide (CGrP) which have been shown to cause plasma protein extravasation and neurogenic dilatation of arterioles respectively leading to the concept of a ''neurogenically-mediated inflammation'' in CRPS. There is some evidence from animals that CRPS is an ''auto-inflammatory disease'', while also in animal models, deep-tissue microvascular ischaemia–reperfusion injury is implicated in CRPS. ''Genetics'' may predispose to CRPS, with the frequency of certain human leucocyte antigen loci significantly higher in CRPS patients than in the controls. ''Cortical reorganization and changes in pain processing'', may also occur in CRPS explaining some of the sensory features of the disorder such as the more glove- or stocking-like distribution. Studies have found a decrease in epidermal nerve fibres and a decrease in sweat gland and vascular innervation in patients with CRPS. It is not completely understood whether this ''small-fibre neuropathy'' is a result of CRPS rather than a cause of this disease. Most studies show no association between the onset of CRPS and psychological factors, such as depression, anxiety, paranoia, and hostility/anger.</p> <div class="notes">''Treatment:''</div> <p style="text-align:justify"> @@.greentext; ''Initial management should include patient education, physiotherapy, symptomatic pain management with low risk agents and psychological assessment focusing on psychological and behavioural coping strategies.''@@ </p> Other treatments should be tailored to the CRPS phenotype and may include: * Calcium channel blockers, alpha-sympathetic blockers, or phosphodiesterase-5 inhibitors for vasomotor disturbance (‘cold’ CRPS) * Short-term bisphosphonates when there is evidence of increased bone uptake * Antispasmodic drugs where there is evidence of dystonia * Non-opioid analgesics * Agents for neuropathic pain <p style="text-align:justify">The evidence on the use of agents for neuropathic pain such as gabapentin or a TCA in CRPS is limited. These should only be considered or continued where there is evidence of benefit to the individual. There is insufficient evidence to support the use of glucocorticoids, TNF-α antagonists, thalidomide, or immunoglobulins.</p> Treatment in refractory CRPS: * Low dose IV ketamine (monitor LFTs) * Intrathecal baclofen if dystonia is a significant problem * Sympathetic nerve blocks are generally not recommended including stellate ganglion blocks, thoracic sympathetic nerve blocks, and lumbar sympathetic nerve blocks * Spinal cord stimulation (SCS) may be considered <div class="notes">''Prevention:''</div> Vitamin C immediately after injury or surgery continued for 45–50 days, reduces the risk of developing CRPS. <div class="notes">''Prognosis:''</div> <p style="text-align:justify">The rates of resolution vary widely across studies, however a third of patients remain out of work because of CRPS. This is more likely if the upper limb is involved. Further reading: Royal College of Physicians. [[Complex regional pain syndrome in adults->https://www.rcplondon.ac.uk/guidelines-policy/complex-regional-pain-syndrome-adults]] (2nd edition). July 2018 </p> !!!<p style="text-align:justify">@@.typing;The bottom line: CRPS is a post-traumatic disorder characterized by a non-dermatomal, severe, continuous pain and associated sensory, vasomotor, sudomotor/oedema and/or motor/trophic disturbance. A multidisciplinary team should provide an individualized management strategy with a combination of physiotherapy, psychological therapies, pharmacologic and invasive procedures as indicated.@@ </p> [[CRPS_MCQ.doc->Q1]] [[I'll skip those thanks->patient1]] <A HREF="javascript:window.print()">Click to Print This Page</A> <<set $crps2 to true>>

<p style="text-align:justify"> @@.typing;''Melanie (Psychologist):'' Thanks for standing in for me and presenting Abby to the meeting. Sorry I’m late everyone. This is Morgan our new psychology student who’s with the department for four months, shall we just go round the room quickly and introduce ourselves? ''James Jones (Consultant):'' I’m James Jones, the consultant and this is my colleague another trainee. Welcome to the pain service. ''Graham (Physiotherapy):'' I’m Graham one of the physios and this is Diane and Ruth our fantastic OT and specialist nurse. ''James Jones:'' So, what does everyone think of Miss Lewis? ''Melanie:'' I get the impression from the referral that she’s at the end of her tether and believes that her only way out of the current situation is to get rid of her leg. ''Graham:'' [sucks air through his teeth] That’s a bit extreme though. We can’t promise her that it will solve the situation. I’ve read about a couple of cases where the patient gets CRPS in their stump and can’t wear a prosthesis. That’s extremely debilitating. ''James Jones:'' Well I agree that it should be a last resort. It’s certainly too soon to be seriously considering it. ''Melanie:'' But we need to engage with her, I think it would be really useful if she felt that it wasn’t off the table as an option. I think that would help motivate her to try some other things. ''Graham:'' Why didn’t she carry on with the mirror therapy? ''Melanie:'' It’s not clear from the referral. ''Graham:'' Well why don’t we try and get her pain under better control to facilitate physiotherapy and I can suggest we reintroduce that? I really don’t think we should be considering offering to amputate in such a young patient when she hasn’t exhausted all other alternatives. If she ran races before she’ll have experience of setting goals and working towards them. We need to be able to tap into that. ''James Jones:'' Well there are a few options she hasn’t tried yet that we can trial for improving her pain control. I’ve done a course of low-dose ketamine infusions for this kind of patient before. Either that or lidocaine infusions. But they’re not a good long-term solution. The same regarding sympathetic lumbar blocks. But in the short-term it may be what she needs to facilitate physiotherapy. ''Melanie:'' I think it would be a good idea if I assessed her. I wouldn’t be surprised if she’s struggling to cope given her lack of motivation and interest in things. I could work with her using acceptance and commitment therapy to help her come to terms with her situation and engage with us. We can try and unpick this compulsion to be rid of her limb so early in the disease course because it could be part of a CRPS related body-dysmorphia rather than a considered objective decision. ''Graham:'' What about a spinal cord stimulator? Could we refer her for assessment? ''James Jones:'' Well it is an option and I’d rather we considered everything else before we even think about amputation. But we don’t do it here, so I’d have to refer her one of the regional centres and then she'd have to be assessed, have a successful trial, and then get the device. And the results are variable. I’ve seen people who benefit greatly from the devices, but others feel like they’ve been through the process for nothing. That’s why the assessment for these things is so rigorous. It isn’t an easy or rapid solution to the problem. ''Melanie:'' There isn’t an easy or rapid solution. ''James Jones:'' Granted, there isn’t. We all know from experience that an integrated multidisciplinary approach with patient education, physio and OT, psychological interventions and pain relief are the pillars of treatment for these patients. ''Melanie:'' But we have to navigate managing a patient who is disengaged with the idea that these other things offer any benefit and is fixated on the idea that an amputation is the answer. ''Dr Jones'': What do you think?@@ </p> <center> [[Play audio->crps1]]    [[Next->audiopost1]] </center> <<audio team pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Amanda Congrev, Seb Holborow and Ian Price Our photographer: Tim Green Our scenario 3 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_3 <<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>

<p style="text-align:left"><img src="images/gplogo.jpg" style="max-width: 20%;"/></p> <p style="text-align:right"> Valley Medical Practice Valley road St Elsewhere LL12 6LL</p> Dear Dr Jones ''RE: Miss Abby Lewis, DOB: 04/05/1988, NHS No: 0000 555 6666'' Diagnosis: Complex regional pain syndrome of the right lower limb Medication: diclofenac 50 mg TDS; Butrans 10 mcg/hr patch, gabapentin 400 mg TDS, zopiclone 7.5 mg nocte <p style="text-align:justify"> Miss Lewis has recently joined the practice after moving into the area. She was under the care of the pain service local to her previous residence and I am waiting for correspondence from them. Miss Lewis attended the practice this week in some distress complaining of severe burning pain in the limb and requesting to be seen as soon as possible by the pain service here. The original injury occurred nine months ago while on a trail run and included an avulsion of the medial and posterior tibial malleoli, and a comminuted fracture of the fibula. These were surgically fixed at the time of the injury and the issues with pain began within days of the ORIF. Miss Lewis had extensive investigation in the postoperative period including an MRI, CT and several doppler US to rule out infective or thrombotic causes for her ongoing pain. She has also had multiple blood tests and has had unremarkable inflammatory markers throughout. Miss Lewis has returned to the parental home so that her parents can provide practical support. She is unable to continue to work in her role as a freelance digital marketing consultant and her condition has deteriorated to the point that she is unable to weight bear on her right foot and is not really leaving the house. On examination Miss Lewis is systemically well and apyrexial. Her right lower leg is somewhat swollen compared to the left. There is some reddening and dryness of the skin of the limb and some trophic changes of the right toe nails. The leg is hypersensitive to touch to just below the knee and warmer than the other leg. Pulses are normal in both legs. I was unable to examine the motor function due to discomfort. She reports that under the previous pain service she has had several sessions with the psychologist and their physiotherapist including a period of mirror therapy. She felt that this did not help. She has been researching her condition and is adamant that amputating her limb is the only way to improve her current situation. Unfortunately, I did not have time to explore this belief with her in the surgery.</p> I would appreciate you seeing this lady as a matter of urgency. Yours sincerely !!!@@.writing; //D Ried//@@ Dr Ried MBBS MRCGP Dip Av Med [[Next->complexMDT]]

<p style="text-align:justify">@@.console;Abby sits across from the orthopaedic consultant. Her grey hospital issue crutches lean against edge of the desk. It’s eight weeks since her accident. “We have the report from the MRI and CT you had the week before last and there isn’t any infection in the bones or tissues. The blood test results don't indicate any signs of infection or inflammation and we've ruled out a blood clot in your calf with the ultrasound. So that’s all good news.” Abby’s expression tells him she doesn’t feel like this is good news. “Then what’s going on? Why is my foot so painful? I can’t put any weight on it. It burns all the time, especially at night. I take all the pain killers. They do nothing. I haven’t slept. If there isn’t an infection why is my leg so red and hot?” “Have you ever heard of something called complex regional pain syndrome? It used to be called reflex sympathetic dystrophy.” “I’ve never heard of it. Is it bad? Can you do something to cure it?” “I have some colleagues in the pain service who are very good at managing the condition. I’ll ask them to see you.”@@</p> [[Next->patient3]]

The rest of the MDT are already settled in for the meeting to discuss the complex referrals when you join them. You listen to the discussions around each case before it’s your turn to give a summary of what you’ve read in Abby Lewis’s notes. Melanie the psychologist arrives just as you're finishing with a new face in tow. [[Listen to what the MDT have to say->crps1]] [[Transcript->transcript1]] <<audio team pause>>

“I think we should offer her a course of ketamine infusions and intensive physiotherapy.” Dr Jones nods "I think that may be how we end up managing this lady but first she needs a proper assessment with the MDT." [[Next->clinic1]]

"I think we should refer her for a spinal cord stimulator." Dr Jones shakes his head "I don't think that should be our first step. Are you aware of the process? No, I think we should bring her in for an MDT assessment and then consider our options." [[Next->clinic1]]

"I think we should bring her in for an MDT assessment." Dr Jones nods his head "I think that's an excellent idea. Lets send her an urgent appointment for the MDT assessment clinic." [[Next->clinic1]]

<p style="text-align:justify">@@.console;It’s three am. A random cookery show is playing on the TV. Abby’s not watching it. She never does, it’s a bit of company in the night when the pain is at its worst and she feels most alone with it. She shifts stiffly on the sofa but can’t find a more comfortable position. It’s stuffy in the room but she doesn’t open the window because the breeze on her leg would be unbearable. Or rather more unbearable because right now the burning pain is already unbearable. How has it come to this? She can't believe it's almost nine months since her injury. After all the misery it’s brought into her life, she struggles to even look at her leg now. She gets this intense sense of detachment which doesn’t even make sense to her; how can you hate your own leg? She brings Google up on her tablet and starts to type into the search bar...@@ </p> [[Next->typing]]

<center> !@@.typing2; amputation for CRPS@@ </center> <<timed 6s>> <<goto patient5>> <</timed>>

@@.console;Abby’s crying so hard she can’t read the page of links when it appears on the screen.@@ [[Next->complex]]

<center> !! @@.greentext; The Autonomic Nervous System (ANS)@@ </center> The ANS is the division of the peripheral nervous system that is involved in homeostasis and consists of three parts: * ''Sympathetic'' (SNS) - fight or flight * ''Parasympathetic'' (PNS) - rest and digest * ''Enteric'' (ENS) - gastrointestinal tract function <p style="text-align:justify">The hypothalamus acts as a bridge and integrator between the central nervous system (CNS) and ANS. Except for the adrenal gland, where myelinated preganglionic neurons synapse directly with adrenaline-secreting chromaffin cells, the ANS is made up of two-neurone effector pathways. Myelinated preganglionic fibres (from the CNS) synapse with unmyelinated postganglionic neurone in a peripheral ganglion. Here ''acetylcholine'' (ACh) is released and acts on ''nicotinic'' receptors (ligand-gated ion channels).</p> <div class="notes">''ANS Anatomy''</div> <p style="text-align:justify">In the SNS this synapse is adjacent to the spine in a chain of ganglia with ''thoracolumbar input'', the ''sympathetic chain'', and several prevertebral ganglia (coeliac and superior/inferior mesenteric). Therefore in the SNS the preganglionic is relatively short and postganglionic fibre is relatively long. The postganglionic neurotransmitters are ''ATP'' and ''noradrenaline'' (NA) acting on P2X and P2Y and G-protein-coupled ''α and β receptors'' respectively. The PNS is a ''craniosacral'' system with preganglionic neurones located in the brain stem and sacral spinal cord. Preganglionic fibres travel in the cranial nerves (III, VII, IX, X) and sacral spinal nerves to ganglia close to, or within, the target effector. Therefore, these fibres are longer with comparatively short postganglionic neurones. The postganglionic neurotransmitters are ''ATP'' which activates P2X and P2Y receptors and ''ACh'' acting on G-protein coupled ''muscarinic'' receptors.</p> <center> <img src="images/ans.jpg" style="max-width: 100%;"/> Figure 1: Schematic diagram of the anatomy and function PNS (left) & SNS (right). ^^ Access figure for free at https://openstax.org/books/anatomy-and-physiology/pages/15-1-divisions-of-the-autonomic-nervous-system ^^ </center> <div class="notes">''Enteric nervous system''</div> <p style="text-align:justify">The ENS has five times the number of neurons as the spinal cord and is composed of the ''myenteric plexus'' (Auerbach’s) and the ''submucosal plexus'' (Meissner’s). These communicate with the CNS via CN X and coordinate peristalsis and regulate secretion and absorption and can act independently of the CNS with local ''short reflexes'' occurring autonomously to control peristalsis. Hirschsprung’s disease occurs when this plexuses fail to form, whilst achalasia, megacolon and megaureter can be caused by plexus destruction.</p> <div class="notes">''Function of the ANS''</div> <center> |@@.greentext;''SNS''@@|@@.greentext;''PNS''@@| |alarm fight or flight|homeostasis-rest-digest| |thoracolumbar|craniosacral| |preganglionic fibre ACh on nicotinic R|preganglionic fibre ACh on nicotinic R| |postganglionic NA on adrenoceptors|postganglionic ACh on muscarinic R| |increased cardiac output (β~~1~~)|slowing & reduced conduction contraction of heart (M~~2~~)| |skin & splanchnic vasoconstriction (α~~1~~, P2X, P2Y)|vasodilation (M~~3~~ on endothelium >NO)| |skeletal and coronary vasodilation (β~~2~~)|| |bronchodilation (β~~2~~)|bronchoconstriction (M~~3~~)| |sweating (M~~2~~)|salivation (M~~3~~)| |dilation of pupils (β~~2~~)|constriction of pupils (M~~3~~)| |inhibition GI peristalsis (β~~2~~)|GI absorption & motility (M~~3~~)| |decreased insulin (α~~2~~)|secretion of enzymes/hormones (inc insulin) (M~~3~~)| |gluconeogenesis (>glucose) (β~~2~~)|glycogenesis (>glycogen) (M~~3~~)| |lipolysis (β~~2~~ & β~~3~~)& fatty acid release|| |glycogenolysis (glycogen to glucose) (β~~2~~)|| |>renin-angiotensin-aldosterone axis (β~~1~~)|| |bladder (β~~3~~)|micturition (M~~3~~)| ||chemosensation via carotid and aortic bodies| ||BP sensation via the carotid bifurcations and aortic arch| </center> <div class="notes">''Pharmacology of the ANS''</div> <center> |@@.greentext;''Receptor''@@|@@.greentext;''Agonist''@@|@@.greentext;''Antagonist''@@| |α~~1~~ |phenylephrine|doxazosin, phentolamine| |α~~2~~ |clonidine|not in use| |β~~1~~ |dobutamine (lesser α~~1~~ β~~2~~ ) |esmolol| |β~~2~~ |salbutamol |propranolol (also β~~1~~ )| |β~~3~~ |trial drugs for obesity|low affinity to current β-blockers| |M~~3~~ |pilocarpine (miotic) |atropine| |Nicotinic|nicotine (initial stimulation)|nicotine (subsequent block)| </center> <div class="notes">''Blockade of the ANS''</div> * ''Sphenopalatine block'' for post-dural puncture headaches and facial pain * ''Stellate ganglion block'' for upper limb CRPS and intra-arterial thiopentone * ''Coeliac plexus block'' for pancreatic pain * ''Lumbar sympathectomy'' for ischaemic pain from PVD and lower limb CRPS * ''Ganglion Impar block'' for pelvic pain !!!<p style="text-align:justify">@@.typing;The bottom line: The ANS is made up of sympathetic, parasympathetic and enteric divisions and is engaged with unconscious control of systems. Myelinated preganglionic fibres leave the CNS and synapse with postganglionic neurones in ganglia releasing ACh onto nicotinic receptors. Postganglionic neurones terminate on effector systems releasing NA on α and β adrenoceptors in the SNS and ACh on muscarinic receptors in the PNS.@@ </p> [[Back->clinic1]] [[Show me the evidence->ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

Books: # Betts G, Young K, Wise J, //et al.// Anatomy and Physiology. //OpenStax// 2013. # Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition 2017. Chapters 8-12. # Rang and Dale’s Pharmacology 9th edition 2019. Chapters 13-15. # Wassall R, Teramoto N, Cunnane T. Noradrenaline. Encyclopaedia of Neuroscience. 2009; 1221-1230 Papers: # Knudsen L, Terkelsen A, Drummond P, Birklein F. Complex regional pain syndrome: a focus on the autonomic nervous system. //Clin Auton Res//. 2019; 29(4):457-467. # Menon R, Swanepoel A. Sympathetic Blocks. //CEACCP//. 2010; 10(3): 88–92 # Wehrwein E, Orer H, Barman S. Overview of the anatomy, physiology, and pharmacology of the autonomic nervous system. // Compr Physiol // 2016; 13;6(3):1239-78. [[Back->print out on the ANS]]

<p style="text-align:justify">@@.console;Dan the physiotherapist from the pain service has been working with Abby for three sessions now. The first session was entirely made up of assessing what Abby’s baseline ability was. She’d left the appointment disheartened; after being so fit and active it was dreadful objectively recording how limited she is by her leg. They’d worked out some goals between them and she’d left the next session with exercises to do at home. Just three repetitions of each but trying to do one more every other day. In the third session Dan brought in a big mirror box and put it over her bad leg. She then watched her reflected left leg in the mirror where her bad leg would be while she did some exercises. He told her that her brain would believe the visual input it saw in the mirror over the somatosensory/proprioceptive feedback from her leg and it would help retrain the faulty processing that was causing her pain. He told her to try and do four sessions of five minutes every day at home with a mirror ‘little and often’. But Abby is so tired from not sleeping she just can’t find the motivation to do it at home, and because she can't face telling Dan she’s not done her homework, she cancels her next appointment. She doesn’t leave the house for a week.@@</p> [[Next->patient4]]

Two weeks later and you are sitting in the clinic room with Dr Jones. The first person on the list has DNA'd their appointment. You try and look busy reading the next person's notes. They belong to Miss Lewis. "So $firstname, autonomic dysfunction is a feature of CRPS. Why don't you tell me what you know about the autonomic nervous system?" You sigh with relief "I'm glad you asked me that. I’ve just written some notes on the autonomic nervous system for a tutorial next week.” You rifle around in your bag for a moment and offer him a [[print out on the ANS]]. He glances at the page “Excellent work. This always comes up in the exams so it’s worth knowing. Ah, it looks like our patient is here.” [[Next->clinic2]]

"I think we should offer her the amputation. It's what she wants and she has the capacity to make that decision." Dr Jones shakes his head "That's unfortunate. Amputation is obviously not our first step. Are you aware of the evidence on amputation? No, I think we should bring her in for an MDT assessment and then consider our options." [[Next->clinic1]]

"Now you’ve had a brief summary of the more interventional management of these patients what do you think we should do next for Miss Lewis?" "I think we should... [[bring her in for an MDT assessment]] [[offer a lumbar block and physiotherapy]] [[offer ketamine infusions and physiotherapy]] [[offer lidocaine infusions and physiotherapy]] [[refer her for a spinal cord stimulator]] [[offer the amputation]]

“I think we should offer her a course of lumbar blocks and intensive physiotherapy.” Dr Jones nods "I think that may be how we end up managing this lady but first she needs a proper assessment with the MDT." [[Next->clinic1]]

<center>@@.whitetext; !!!Lumbar sympathetic blocks <p style="text-align:justify">More invasive interventions are generally reserved for patients who are not responding or continue to worsen despite a combination of physiotherapy, psychological therapies, and drugs. ''Uses include:'' CRPS, phantom limb pain, lower limb ischaemia not amenable to other interventions, intractable diabetic neuropathy, cancer pain ''Anatomy:'' The densest portion of lumbar sympathetic ganglia is located on the anterolateral aspect of L2-L3 so the block is most commonly performed here. ''Equipment:'' The block is generally performed using a fluoroscopic C-arm X-ray, however ultrasound guided techniques have been described. Full asepsis and monitoring as per AAGBI guidelines are necessary. ''Procedure:'' The inferior and superior spread of contrast on the anterior aspect of L1-L3 is used to confirm the correct location on imaging before 10-20ml of 0.5% bupivacaine is injected. Other neuroablative techniques using radiofrequency lesions or neurolytic solutions may be used in cancer or for intractable limb PVD. A 2-3^^o^^C rise in temperature of the affected limb is a good indicator of a successful block. The limb may also become visibly flushed due to vasodilation. Relief can last from hours to indefinitley. Blocks are generally repeated no more frequently than every 3-6 months. ''Evidence:'' In 2016 Cochrane updated their previous systematic review on the use of sympathetic blockade in CRPS and concluded: ‘There remains a scarcity of published evidence and a lack of high quality evidence to support or refute the use of local anaesthetic sympathetic blockade for CRPS’. However many interventional pain clinicians use sympathetic blocks in selected individuals who have exhausted other treatment modalities with some benefit.</p> @@ [[I want to know about the other treatments->audiopost2]] [[I want to make some treatment decisions->what treatment?]] [[Show me the evidence->ref4]] </center> <<set $lumbar to true>>

<center> @@.whitetext; !!!Ketamine infusions <img src="images/ketamine.jpg" style="max-width: 100%;"/> <p style="text-align:justify">Ketamine is an enantiomeric mixture of (R)-ketamine and (S)-ketamine used as an intravenous infusion for CRPS, neuropathic pain, and other intractable chronic pain states. It acts via non-competitive antagonism of the NMDA receptor and a reduction in the presynaptic release of glutamate. It also has a complex interaction with opioid receptors especially mu and kappa. Its mechanism in chronic pain is suggested to be partly via a reversal of central sensitisation while its anti-depressant actions are possibly beneficial in this patient group. Dosing regimens vary widely but can be broadly categorized into high-dose and low-dose infusions which may be given as a single outpatient infusion over hours or as an inpatient over 2-5 days. A concurrent dose of a benzodiazepine is often given to reduce the unpleasant dissociative effects. Pain relief is temporary and lasts from days to several weeks with limited evidence of a benefit persisting beyond 12 weeks. The issue of dependence occurs with repeated infusions. ''Evidence:'' Systematic reviews have found only low- to moderate-quality evidence supporting the use of subanaesthetic doses of ketamine for CRPS^^1-3^^. </p> @@ [[I want to know about the other treatments->audiopost2]] [[I want to make some treatment decisions->what treatment?]] [[Show me the evidence->ref5]] </center> <<set $ketamine to true>>

<center> @@.whitetext; !!!Spinal cord stimulators <p style="text-align:justify"> <img src="images/scs.jpg" style="max-width: 100%;"/> ^^Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 52468^^ There is evidence from RCT supporting the use of SCS for CRPS, neuropathic pain, ischaemic pain and failed back surgical syndrome. In 2008 NICE recommended the use of the devices in severe, prolonged, CRPS following a successful trial of stimulation. SCS are helpful in selected patients as part of an overall rehabilitation strategy for managing chronic pain. Its mechanism of action includes inhibition of pain transmission in the dorsal horn, supra-spinal activity via the posterior columns and pronounced autonomic effects. GABA, adenosine, substance P, serotonin, and NO play a role in its analgesic and anti-ischaemic effects. Stimulation of the spinal cord is via spinal cord electrodes placed in the dorsal epidural space and powered by an implanted pulse generator (similar to a cardiac pacemaker) that depolarizes the target nerves. Electrodes may be placed percutaneously under local anaesthesia or surgically under GA. The patient has a remote control for the device and can vary the voltage and frequency according to pre-set limits. The electrical field generated by the SCS creates an area of paraesthesia where the patient had previously experienced pain. Anaesthetists commonly encounter patients with implanted devices including spinal cord stimulators and the following special precautions should be considered: * Unipolar diathermy should be avoided. If its use is essential, the reference plate should be placed away from the SCS and so that all components lie outside the electrical field of the diathermy * MRI in the context of SCS is complex. The magnetic field can cause lead movement, neural damage and heating of the device components causing tissue damage. The location of the device may cause artefact and corrupt images. Early discussion with an experienced radiologist and knowledge of the specific device and its serial number is key for safe imaging * Shortwave diathermy, microwave diathermy and therapeutic US are hazardous in patients with SCS * There is the serious risk of damaging the device leads or introducing infection with neuraxial blockade </p> @@ [[I want to know about the other treatments->audiopost2]] [[I want to make some treatment decisions->what treatment?]] [[Show me the evidence->ref6]] </center> <<set $stimulator to true>>

<center>@@.whitetext; !!!Amputation <p style="text-align:justify">A strong wish to have a CRPS limb amputated can occur from early in the disease course and may sometimes be part of the CRPS-related regional body-dysmorphia, which may be caused by a CRPS-associated shift in cortical limb-representation. Patients with CRPS may approach their clinical teams requesting this; however there is insufficient robust evidence to predict the outcome from amputation. In their frequently quoted 1995 case series, Dielissen //et al.//^^1^^ reported the outcome of 28 patients undergoing a total of 34 amputations for CRPS. It should be noted that 12 of these amputations were a digit, 18 lower limb, and only three upper limb. Almost all these patients had recurrence of symptoms in their stump. 71% had onset of phantom limb pain and only two were able to tolerate wearing a prosthesis. Despite these outcomes 24/28 reported overall satisfaction with the amputation. A more recent small retrospective case series from the Netherlands^^2, 3^^ showed a similar incidence of phantom limb pain, a recurrence of CRPS in the residual limb in 3/21 patients and a different limb in 2/21. Half were able to wear a prosthesis and 20/21 reported an improvement in their lives following the amputation. In their comparative study of amputees and non-amputees with intractable CRPS, Midbari //et al.//^^4^^, found the 19 patients who had an amputation had statistically significant reductions in pain and disability scores. In their 2018 guidance^^5^^ on the management of CRPS the Royal College of Physicians mandate the involvement of an MDT experienced in chronic pain management and CRPS before such referral is considered. They recommend the factors to be considered include: * Unrealistic expectations * Psychological disorders * Negative coping mechanisms * Amputation is unlikely to resolve pain * Wearing a prosthesis may not be possible * Natural recovery frequently occurs within 18-24 months of onset </p> @@ [[I want to know about the other treatments->audiopost2]] [[I want to make some treatment decisions->what treatment?]] [[Show me the evidence->ref2]] </center> <<set $amputation to true>>

“I think we should offer her a course of lidocaine infusions and intensive physiotherapy.” Dr Jones nods "I think that may be how we end up managing this lady but first she needs a proper assessment with the MDT." [[Next->clinic1]]

<center>@@.whitetext; !!!Lidocaine infusions <img src="images/lidocaine.jpg" style="max-width: 100%;"/> <p style="text-align:justify">The amide local anaesthetic, lidocaine, has been used in the treatment of several chronic pain conditions including CRPS. Infusions are generally reserved for use in refractory cases or during a significant flare that is not responsive to standard treatment. It is thought that lidocaine attenuates peripheral nociceptor sensitization and central hyperexcitability through its sodium channel blocking action. Lidocaine also decreases circulating proinflammatory cytokines which are recognised to play a role in hyperalgesia and central sensitization. Optimal doses and administration regimens have not been determined however a regimen of 1-5 mg.kg^^-1^^ over 30-60 minutes is frequently used. The plasma clearance of Lidocaine is 10 mg.kg^^-1^^.min^^-1^^ in patients with normal hepatic function and blood flow. During the infusion patients need monitoring as per the AAGBI guidelines and the availability of intralipid in the event of inadvertent toxicity. Evidence: Lidocaine for neuropathic pain is considered safe, better than placebo, and as effective as other analgesics^^1^^. In a recent^^2^^ retrospective chart review on the use of lidocaine infusions in chronic long-term pain, relief was seen in 15 of the 38 CRPS patients included in the study.</p> @@ [[I want to know about the other treatments->audiopost2]] [[I want to make some treatment decisions->what treatment?]] [[Show me the evidence->ref3]] </center> <<set $lidocaine to true>>

Dr Jones is looking at you with his last sentence, “What do you think we should do $firstname?” [[Next->audiopost2]] <<audio team pause>>

Dr Jones invites Abby into the room. She’s using crutches to walk and not putting any weight on her right foot which she holds in what looks a horribly uncomfortable position. “Hello Miss Lewis, I’m Dr Jones one of the pain consultants and this is Dr $surname one of my colleagues who’s with me today. We had your referral from your GP but want to hear from you about what’s been happening?” Abby looks at the floor as she starts to [[talk->crps3]] [[Transcript->transcript2]] <<audio abby pause>>

# Dielissen PW , Claassen AT , Veldman PH , Goris RJ. Amputation for reflex sympathetic dystrophy. //J Bone Joint Surg Br// 1995;77:270–273. # Krans-Schreuder HK, Bodde MI, Schrier E //et al.// Amputation for long-standing, therapy-resistant type-I complex regional pain syndrome. //J Bone Joint Surg Am// 2012;94(24):2263–8. # Bodde MI, Dijkstra PU, Schrier E //et al.// Informed decision-making regarding amputation for complex regional pain syndrome type I. //J Bone Joint Surg Am// 2014;96(11):930–4. # Midbari A, Suzan E, Adler T //et al.// Amputation in patients with complex regional pain syndrome: a comparative study between amputees and non-amputees with intractable disease. //Bone Joint J// 2016;98-B(4):548–54. # Royal College of Physicians. Complex regional pain syndrome in adults (2nd edition). July 2018. [[Back->amputation for CRPS]]

Did you pick up on these features from Abby's history? *Pain associated with sensory, vasomotor, sudomotor and motor/tropic symptoms and signs *Neglect-like sensory symptoms: “it doesn’t even feel like it belongs to me” *Neglect-like motor symptoms: “I can’t move it the way I want to” *The presence of a number of [[yellow flags]] *Significant side effects from her current analgesic regimen *Lack of targeted patient education on her condition and it’s treatment *Unrealistic expectations and fixation on a specific treatment If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? [[Next->plan1]] <<audio abby pause>>

!!!Yellow flags These are psychological indicators that an individual is at risk of long-term disability and chronicity due to their pain: *Belief that pain and activity are harmful *Sickness behaviours, such as extended rest *Social withdrawal *Emotional problems such as low or negative mood, depression, anxiety and stress *Problems and/or dissatisfaction at work *Problems with claims or compensation, or time off work *Overprotective family; lack of support *Inappropriate expectations of treatment, including low expectations of active participation in treatment *Catastrophising, avoidance and misinterpreting bodily symptoms *History of depression or anxiety *Drug or alcohol use ~~Adapted from Nicholas MK, Linton SJ, Watson PJ, //et al.// Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal. //Phys Ther.// 2011 May91(5):737-53.~~ [[Back->case points]]

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio abby play>> [[sources of support]]    [[Transcript->transcript2]]    [[Next->case points]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%203/audio/abby.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/tissue.jpg" style="max-width: 100%;"/> </center> <<set $abby to true>>

<p style="text-align:justify"> @@.typing;This all feels quite shocking still to be honest. It’s been nine months since my accident and I really struggle with this being me. I was so different before. I knew something wasn’t right within a couple of days of having my ankle fixed. It felt like my skin was on fire and the burning pain was through the roof. It felt like my skin was too tight. The orthopaedic doctors said I might have compartment syndrome and took my plaster off but it wasn’t that. Then they said it was a clot and sent me for an ultrasound. But there was no clot so they started me on antibiotics because they thought I had an infection. I had more scans and they’re telling me it's not an infection and I could stop the antibiotics. Then the orthopaedic consultant is telling me that we’ve ruled out all these things like it’s good news. But I could hardly walk by then and wasn’t sleeping, so for me not getting an answer, something they could fix, that was about as far from good news as I could get. He asked me if I’d heard of CRPS and said he was sending me to some pain service people who could ‘manage’ it. The pain service before were all nice people, I think it could have helped, but I was struggling to function because of my leg and I just couldn’t see how anything they were suggesting was going to help. I work freelance and none of my contracts were renewed, I can’t put weight on my foot so I can’t drive, I wasn’t even able to get round the supermarket. My parents offered for me to go back to them because I wasn’t coping. It feels bad to be sleeping in the room you had as a kid with the same My Little Pony wallpaper. I took everything the GP and the pain people told me to take, they even gave me some patches that are meant to be good and I just spent the whole time feeling half asleep. But the pain is still there, a constant burning pain that takes up all the space in my life. I have to drag this swollen, stiff, leg round that doesn’t even feel like it belongs to me and I can’t move it the way I want to, it’s not the pain, it just feels like I’m not in control of it. When I’m boiling, it might be freezing and blue, if I’m cold, it can be red and hot. Even the toenails have gone all brittle and the skin is shiny and thin. I can’t even put moisturiser on it because I can’t bear to touch it. Even the lightest touch hurts. And I don’t use it, so all the muscle I had in my legs from running is just gone. I’m sick of it ruining my life. I want to be rid of it. I know that you can do that for this CRPS thing. I looked it up online and there are lots of people who have got rid of their leg and are much better after. That guy in that Paralympics a couple of years ago had CRPS before and now he’s got blades and wins medals. I’m stuck at my parents’ house with no job, no life, and My Little Pony wallpaper to stare at, so you’ve got to help me do this.@@ </p> <center> [[Play audio->crps3]]    [[Next->case points]] </center> <<audio abby pause>>

It’s late and you’re thinking of going to bed when you get a text alert. [[better check]] <<audio text play>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 22:38@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Sorry I know I'm always asking favours</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; You still owe me from last time! @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> I'm reusing those questions on CRPS I did ages ago with answers. Would you do them and see how you get on? Please?? [[CRPS_MCQ.doc->Q1post]] </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; You're lucky I'm such a great friend @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p><img src="images/emoji.jpg" style="max-width: 25%;"/> You know it</p> </div> </div> </p> <<audio text pause>>

<center><img src="images/clock.jpg" style="max-width: 100%;"/> </center> <p style="text-align:justify">@@.console; It’s 7:10am. The first thing Abby does when she opens her eyes is snooze the alarm. The second is adjusting the settings on the remote for her spinal cord stimulator. Before she got the device, the nice consultant Dr Jones did some blocks that gave her some temporary relief but never lasted more than a week or so. It had let her progress with the physio a bit. She’d also attended a PMP and that had really helped her with her expectations about managing the pain but not necessarily being rid of it. The spinal cord stimulator hasn’t been a magic bullet. They’d made it clear to her it wasn’t going to be during the assessment process for the device. Once she’d worked out how to use it best, with support, she’d been able to come off the Butrans patches completely. She doesn’t even know where her crutches are, maybe she left them at her parents when she moved back to her flat? She's doing some freelance consultancy again and if she doesn't get up soon she's going to be late for work. @@ [[Next->outcome2]] </p>

<center><img src="images/clock.jpg" style="max-width: 100%;"/> </center> <p style="text-align:justify">@@.console;It’s 7:10am. The alarm is going off. Abby rolls over and presses snooze. The persistent pain service suggested she try their PMP alongside some changes to the drugs she took. They started her on Duloxetine and after a while she stopped using the Butrans patches because they were making her so sleepy and sick. The PMP helped her find ways to cope with things better and pace herself but she still struggled doing the physio because of intractable pain and then she started to develop skin ulcers on the top of her foot. The consultant offered to do a ketamine infusion to see if that would let her progress with rehab but her liver function had gone off and she’d had to stop them. She’d had several lumbar sympathetic blocks with only a very temporary benefit, so they’d referred her to be assessed for a spinal cord stimulator. She’d got as far as a trial with temporary electrodes but hadn’t got the improvement they’d all hoped for and that wasn’t progressed further. All the time she kept on getting recurrent skin infections in the now chronic ulcers and spent the next 18 months on and off antibiotics and in and out of hospital. After one admission where she’d been seriously unwell, she asked about the possibility of an amputation again. They had involved lots of services in the decision. She’d seen the psychologist several times, a specialised physiotherapist and occupational therapist and the pain team had been extensively involved. By the time the decision was made Abby was under no illusions that this was going to solve all her problems. She understood there was a risk of phantom limb pain or CRPS in her remaining leg. She knew there was a chance she’d never be able to wear a prosthesis. And if you asked her now would she do it again, like most people with CRPS who undergo amputation, she’d say yes. She does get some phantom limb pain and can’t wear her false leg for long before it gets too uncomfortable and her life is very different to the one she had before. She's doing some freelance consultancy again and if she doesn't get up soon, she's going to be late for work. @@ [[Next->outcome2]] </p>

<p style="text-align:justify">There is an empathetic pause. Dr Jones holds out a box of tissues to Abby who takes a couple. “So are you going to help me?” She asks. “We have a whole team of people here who want to work with you to make this situation better. It probably doesn’t feel like it but you are still early in the course of your condition, and there is a lot we can try, but you need to give these things a chance, and I understand why that might be difficult." "Firstly, we are going to give you reliable information about your condition and advice to help put you in control of self-managing it. Alongside that, the physiotherapists are going to work with you to gradually increase your activities and function. Our psychologist is going to help you manage the emotional impact of this and find better ways of coping with things. And importantly, we are going to work out a treatment plan for managing your pain and that might be trying different medicines or interventions to find what works for you. It’s not quick, or easy, but we can improve on how you feel now.” Dr Jones is watching Abby intently as he lets her take in what he's said. Abby looks a bit dubious but nods "Ok what next then?" "I'd like you to meet some of the other members of the team and we can make a solid plan together with you." </p> [[Next->plan2]]

Abby goes in with Melanie the psychologist leaving you and Dr Jones to see the next patient. [[Next->plan3]]

“What do you think is going to be the outcome for Abby?” You ask him. “I was going to ask you the same question. Given what you’ve learned about persistent pain and CRPS, what do ''you'' think will happen?” You think for a moment, “It’s difficult to know what will help but I think it will be… [[attending a pain management programme]] [[lumbar blocks and physiotherapy]] [[ketamine infusions and physiotherapy]] [[Lidocaine infusions and physiotherapy]] [[a spinal cord stimulator]] [[she ends up having the amputation->plan6]]

A few hours later and you are alone in the office finishing up with writing notes and actioning parts of plans generated from the morning’s clinic. Dr Jones comes in with two mugs and puts one down in front of you. It’s the first time on the placement he’s made you tea, so you are alerted to the fact this is going to be either something really good, or really bad. He sits down at the next desk and there is a long pause… [[Next->plan4]]

“I’ve always admired how the psychologists as a profession, they have such robust clinical supervision processes. I’m very lucky here that we are a cohesive team so if I have a difficult encounter, I have colleagues I trust who will listen. I suspect it isn’t so easy when you are a trainee who isn’t necessarily in the department very long?” He pauses again. “I’ve also been doing this long enough to know that we aren’t going to fix everyone and if we can help them manage their condition then we are giving them something they haven’t found anywhere else.” Another pause. “I wanted you to know that if you found anything in this morning’s clinic difficult then any of us in the department would be happy to talk it over with you and that’s a healthy way to respond to things that challenge us. I’ve also emailed you a [[list of sources of support]] because there are lots of options.” You nod “Thank you, I appreciate it.” Dr Jones smiles “And next time you can make the tea.” [[Next->plan5]]

@@.typing;''From:'' James Jones (Consultant Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Sources of support Hi $firstname I know today's clinic was a bit emotive and I just wanted you to be aware of the sources of support available to you: * Your educational supervisor or clinical supervisor * Your deanery professional support unit ''Academy of Medical Royal Colleges Support for Doctors:'' https://www.aomrc.org.uk/supportfordoctors/ ''Association of Anaesthetists of Great Britain and Ireland@'' Wellbeing and support pages offering a wide range of services: https://anaesthetists.org/Home/Wellbeing-support ''#OurNHSPeople'' A package of practical and psychological support resources including a 24/7 wellbeing support line, peer to peer, team and personal resilience support and free mindfulness apps: https://www.people.nhs.uk ''The British Medical Association'' Confidential 24/7 counselling service is available to all doctors and medical students including non-members: 0330 123 1245 https://www.bma.org.uk/advice-and-support/your-wellbeing And don't forget your own GP and if you need them the The Samaritans number is ''116 123'' Best wishes James@@ [[Back->plan4]]

Dr Jones looks at you for a long time "The problem is the media make it seem like this is a common occurrence for CRPS when it isn’t. That’s why someone crowd funding their amputation privately, or in the extreme doing it themselves, is newsworthy. The most likely outcome, fortunately, for any patient with CRPS is a degree of remission. But let’s consider what would bring Abby to the point where an amputation is being seriously considered…" [[Next->she ends up having the amputation]]

# Challapalli V, Tremont-Lukats IW, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev. 2005 # Iacob E, Hagn EE, Sindt J, Brogan S, //et al.// Tertiary Care Clinical Experience with Intravenous Lidocaine Infusions for the Treatment of Chronic Pain. //Pain Med// 2018;19(6):1245. [[Back->lidocaine infusions]]

# O'Connell NE, Wand BM, Gibson W, Carr DB, //et al.// Local anaesthetic sympathetic blockade for complex regional pain syndrome. //Cochrane Database Syst Rev//. 2016;7:CD004598. [[Back->lumbar sympathetic blocks]]

# O'Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. //Cochrane Database Syst Rev//. 2013 # Connolly SB, Prager JP, Harden RN. A systematic review of ketamine for complex regional pain syndrome. //Pain Med//. 2015;16(5):943. # Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, //et al.// Consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. //Reg Anesth Pain Med//. 2018;43(5):521. [[Back->ketamine infusions]]

# British Pain Society guideline on spinal cord stimulation for the management of pain: recommendations for best clinical practice April 2009 # Moore D, McCrory C. Spinal cord stimulation. //BJA Ed// 2016 16(8);258-263. [[Back->spinal cord stimulators]]

@@.typing2; <center> !!HEADS UP ''Module 3 includes some content of an upsetting nature. We understand that not everyone is coming to this after a good day We wanted to let you know about some [[sources of support]]'' !!Because you are incredibly important ''Take care'' !!Virtual Anaesthetics ''[[Next->It's late]]'' </center> <<audio text pause>>

@@.typing; !!!Sources of support Hi $firstname We wanted you to be aware of some of the sources of support available to you: * Think about reaching out to a trusted colleague, friend, or family member * Contact your family doctor or healthcare provider * If you are in education find out about support services they provide ''The Samaritans:'' Provides confidential support for people feeling distress or despair on a free 24-hour helpline, by email, or via a self-help app: https://www.samaritans.org Phone: ''116 123'' Email: ''jo@samaritans.org'' ''#OurNHSPeople'' A package of practical and psychological support resources including a 24/7 wellbeing support line, peer to peer, team and personal resilience support and free mindfulness apps: https://www.people.nhs.uk ''For UK medics:'' * Your educational supervisor or clinical supervisor * Your deanery professional support unit ''Academy of Medical Royal Colleges Support for Doctors:'' https://www.aomrc.org.uk/supportfordoctors/ ''Association of Anaesthetists of Great Britain and Ireland@'' Wellbeing and support pages offering a wide range of services: https://anaesthetists.org/Home/Wellbeing-support ''The British Medical Association'' Confidential 24/7 counselling service is available to all doctors and medical students including non-members: ''0330 123 1245'' https://www.bma.org.uk/advice-and-support/your-wellbeing <<if $abby is true>> [[Back->crps3]] <<elseif $abby is false>> [[Back->heads up]] <</if>> <<audio abby pause>>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_3@@

<center> !!!BETA Virtual Anaesthetics_Pain training_3 <<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>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module3.pdf]]'' [[Back|Introduction]]

''>'' 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>>