Headache, Fever, & Musculoskeletal Injuries PDF

Headache, Fever, & Musculoskeletal Injuries Page 8: Headache Types Tension-Type, Migraine, Sinus Details on location, nature, onset, duration, and non-headache symptoms for each type Tension-Type : Bilateral, over top of the head, extending to base of skull Nature: Varies: diffuse ache to tight, pre...

Headache, Fever, & Musculoskeletal Injuries Page 8: Headache Types Tension-Type, Migraine, Sinus Details on location, nature, onset, duration, and non-headache symptoms for each type Tension-Type : Bilateral, over top of the head, extending to base of skull Nature: Varies: diffuse ache to tight, pressing, constricting pain Onset: Gradual Duration: Minutes to days Non-headache symptoms: Scalp tenderness, neck or muscle pain Migraine: Usually unilateral Throbbing, sometimes preceded by aura Onset: Sudden Duration: Hours to days Non-headache symptoms: Nausea Sinus: Face, forehead, periorbital area Nature: Pressure behind eyes or face; dull; bilateral; worse in morning Onset: Simultaneous with sinus symptoms Duration: Days Non-headache symptoms: Nasal Congestion Page 9: Exclusions to Self Care Severe head pain Rapid onset of maximum pain Concerning change in headache pattern (first or worst, gradual escalation over months) Persisting for 10 days +/- treatment Occur > 15 days per month for 6 months Third trimester of pregnancy New headache during pregnancy Age < 8 years High fever or signs of serious infection Neck stiffness History of liver disease or ≥ 3 alcoholic drinks/day Association with underlying pathology Migraine symptoms with no previous migraine diagnosis Neurologic changes (seizures, vision changes, altered mental status) High risk comorbid conditions (cancer, HIV Page 10: Non-Pharmacologic Therapies Tension: Relaxation exercises Physical therapy – stretching and strengthening head and neck muscles Chronic headaches – headache log to document triggers, frequency, intensity, duration, response to treatment Headache diary: > 8 weeks; frequency, duration, related symptoms, precipitating factors, medications used for relief, menstruation schedule Migraine: Maintaining regular schedule: sleeping, eating, exercise Stress management Ice or cold packs applied with pressure to forehead or temple areas Avoiding light, noise, and other triggers Avoiding trigger foods, hunger/low blood sugar Page 12: General Treatment Approach Headaches Limit OTC analgesic use to < 3 days per week OR < 14 days per month (prevent medication overuse headache) For migraines, medication work best when taken during aura (as applicable) or at the onset of symptoms Sinus headaches respond well also to decongestants Concomitant use of a decongestant + nonprescription analgesic can help to relieve sinus headache pain When to follow up: Headache persists > 10 days Headache worsens despite self-treatment After HCP diagnosis/follow-up: Chronic headaches – after 4-6 weeks of management Episodic headaches – after 6-12 weeks of management Page 15: Fever Pathophysiology Average body temperature: 97.5-98.9°F (36.4-37.2°C) Common core body temp = 98.6°F (37°C) Body temperature is regulated by the hypothalamus and neurons in skin and CNS Pyrogens – fever producing substances Exogenous: toxins, microbes; Endogenous: immune cytokines Prostaglandins – produced and released in response to pyrogens and elevate body temperature set in the hypothalamus Page 17: Measuring/Detection of Fever Different methods of measuring fever and their definitions Explanations on oral, rectal, axillary, tympanic, and temporal measurements Oral: greater than 99.5F , 20-30 min to use after eating/drinking Rectum: more than 100.4 degrees F, Preferred in children Most reliable Ear: more than 100 degrees F, Ensure proper technique for best measurement Armpit: Least reilable, more than 99.3 degrees Forehead: “No touch” , Varies with age, Convienient Page 18: Exclusions to Self Care Patients > 3 months old with rectal temp ≥ 104 °F Patients < 3 months old with rectal temp ≥ 100.1 °F Severe symptoms of infection Risk for hyperthermia Impaired oxygen utilization (cardiovascular or pulmonary disease) Impaired immune function (cancer, HIV) CNS damage (head trauma, stroke) Children with a history of febrile seizures or seizures Patients > 2 years old with fevers that last > 3 days without treatment Patients < 2 years old with fevers that last > 24 hours Children with any of the following: Development of spots or rash Refuse fluids Very sleepy irritable, or difficult to wake Vomiting, cannot keep fluids down Repeated diarrhea Stiff neck Page 19 Non-Pharmacologic Therapies o Fluid replacement: § Children: increase by 30-60mL per hour § Adults: increase by 60-120mL per hour o Other measures: § Wearing lightweight clothing § Maintaining a comfortable room temperature § Body sponging/bathing (limited effectiveness) § Avoiding ice baths or alcohol solutions Page 20 Goal of Therapy o Alleviate discomfort of fever, not targeting a specific body temperature Page 21 Approach to Treatment - Fever o Accurate measurement of body temperature o Use the same thermometer consistently o Treatment may include OTC antipyretics and non-pharm measures o Follow-up with a healthcare provider if fever persists > 72 hours or new symptoms develop Page 25 Musculoskeletal Pain o Pathophysiology of musculoskeletal system o Common disorders: myalgia, tendonitis, bursitis, sprain, strain, osteoarthritis Page 26 Exclusions to Self-Care o Severe pain (pain score > 6) o Pain lasting > 10 days o Pain persisting > 7 days after treatment with a topical analgesic o Increase in intensity or change in character of pain o Pelvic or abdominal pain (excluding menstrual pain) o Accompanying signs of infection, nausea, or vomiting o Visually deformed joint, abnormal movement, weakness /numbness in limb(s), suspected fracture o Pregnancy o o < 2 years of age Back pain, associated with loss of bowel and/or bladder control Page 27 Non-Pharmacologic Therapies - RICE Rest: o Rest injured area until pain is reduced, generally 1-2 days Use slings, splints, crutches as necessary Ice: o Apply ice as soon as possible after injury 15-20 min increments At least 3-4 times daily Continue until swelling subsides (usually 1-3 days) Compression: o o o Apply compression to the injured area with elastic support bandage Elevation for musculoskeletal injuries: Elevate the injured area at or above level of heart 2-3 hours a day (if possible) Page 28 Non-Pharmacologic Therapies - Heat o Recommended for non-inflammatory cases only: Not to be used on injured or inflamed areas o Do not use with topical agents (analgesic or other) Do not use on broken skin Do not use on areas of skin with decreased sensation o Recommended as adjunct non-pharm therapy for osteoarthritis Increase blood flow, reduce muscle spasm, alleviate stiffness o Apply in 15-20 min increments, 3-4 times daily Page 29 Non-Pharmacologic Therapies - Other o Stretching, massaging, hydration, TENS(transcutaneous electrical nerve stimulation), chiropractor, physical therapy, acupuncture, Epsom salt baths Treatment Goals: Decrease intensity of pain Decrease duration of pain Restore function of the affected area Prevent re- injury and disability Prevent acute pain from becoming chronic persistent pain Page 31 Approach to Treatment - Musculoskeletal Pain Non-drug therapy like RICE or heat OTC oral analgesics for limited self-care use- 10 days: APAP – can be used for inflammatory pain including osteoarthritis NSAIDs – better for inflammatory pain Topical analgesics guidelines: Do not use concurrently with heat Monitor for changes in skin condition Do not apply to wounded, broken, or irritated skin Avoid eyes, inside of nose, mouth, or genital Follow Up: Pain persists > 10 days (excluding osteoarthritis) Symptoms do not improve for ≥ 7 days Page 32 Knowledge Checkpoint o Best approach to treatment for inflammatory wrist pain Page 34 Knowledge Checkpoint o Appropriate non-pharmacologic options for non-inflammatory musculoskeletal pain Page 35 Knowledge Checkpoint o Appropriate non-pharmacologic options for non-inflammatory musculoskeletal pain, emphasizing RICE approach Page 36 Headache Differentiate types for proper treatment o Sinus headaches may respond better to analgesic + decongestant Non-pharm approaches o Avoiding triggers, relaxation techniques, maintaining a headache diary Limit OTC analgesic use o < 3 days per week or < 14 days per month Fever Caused by prostaglandin synthesis in response to pyrogens Drug therapy targets prostaglandins Proper thermometer technique is crucial Non-pharm approaches o Fluids, maintaining comfortable room temperature Treat to alleviate symptoms, not target body temperature Limit OTC antipyretic therapy to ≤ 3 days Musculoskeletal Pain Differentiate between inflammatory and non-inflammatory pain Non-pharm approaches o RICE, heat for non-inflammatory pain, TENS, physical therapy Limit oral OTC therapy to < 10 days without healthcare provider (HCP) supervision Page 39 Acetaminophen (MAPAP, TYLENOL) Mechanism of Action (MoA) o Central inhibition of prostaglandin synthesis Black Box Warning: Hepatotoxicity Counseling patients on adherence to maximum daily dose recommendations Checking for other products containing APAP Acetaminophen Dosing Preparations: Tablet 325mg IR 500mg IR – “Extra Strength” 650mg ER – “Arthritis” Capsules Liquid Packet Adults: (older than 12 years): 325mg - 1000mg every 4-6 hours ER products: 650-1300mg every 8 hours as needed Children (less than 12 years): 10-15mg/kg every 4-6 hours Maximum of 480mg per dose x5 doses (2,400mg) OR 75mg/kg/day Page 43 NSAIDs Mechanism of Action o Reversibly inhibit COX-1 and COX-2 enzymes Risks include increased bleeding, clotting, and GI events Black Box Warnings for stomach bleeding, CV events Caution with concurrent use of IBU and ASA Page 49 Salicylates (Asprin: Bayer, Ecotrin) (Magnesium Salicylate: Doans) Mechanism of Action: Inhibition of COX-1 and COX-2 Antiplatelet effects with inhibition of TXA2(thromboxane) Irreversible platelet inhibition while NSAIDS are reversible Dosage forms and considerations for ASA: Regular IR: absorbed in stomach and small intestine, may irritate stomach Enteric-coated: delay absorption until small intestine, avoid stomach irritation, ulcer risk PPIs or other antacids may negate this effect Buffered: co-formulated with an antacid to reduce stomach upset symptom ASA intolerance: Cutaneous or respiratory Not an immunologically mediated allergy Increased risk in those with chronic urticaria, nasal polyps Salicylate considerations for Reye's Syndrome: Do not give aspirin or products containing aspirin to children and teenagers who have or are recovering from chickenpox or influenza-like symptoms. Recommend avoiding use in children and teenagers ( 18 years): 325-1000mg every 4-6 hours as needed Maximum of 4000mg daily Children (< 18 years) DO NOT USE Page 51: Preparations (OTC): Tablet: IR – 325mg Tablet: ER – 580mg MAGNESIUM SALICYLATE DOSING Adults (> 18 years): 1160mg every 6 hours as needed Maximum of 4640mg daily Children (< 18 years) DO NOT USE Page 52 Salicylate Considerations Reye's Syndrome risk with aspirin use in children Avoid aspirin in children recovering from chickenpox or flu-like symptoms Symptoms and risks of Reye's Syndrome: lethargy, nausea, vomiting, changes in behavior Can lead to neurologic damage, fatty liver, hypoglycemia *AVOID ASA CONTAINING PRODUCTS IN CHILDREN Recommend avoiding use in children and teenagers ( 3% Rubefacient when applied vigorously Ingestion may lead to serious adverse reactions: seizures, delirium, coma, death Avoid use in children Menthol: MoA: Counterirritant at concentrations > 1.25% Activates TRPM8 receptor to trigger a cold sensation, followed by warmth Acts as a permeability enhancer when administered with other topical agents Caution – menthol hypersensitivity Discontinue if irritation, rash, burning, stinging, swelling, or infection occur Page 72: General Counseling for Topical Products Immediately discontinue and seek medical attention if pain, swelling, blistering of the skin occurs after application Do not bandage the area tightly where the product has been applied Do not use heat where the product has been applied Do not apply to wounded, damaged, broken, or irritated skin Do not allow these medications to come in contact with eyes, inside the nose or mouth, or with genitals Page 73 Topical agents for pain management o Application considerations for all agents o Diclofenac: different from oral NSAIDs, patient counseling required; Off-label use of diclofenac o Patient counseling for capsaicin o Some agents available as patches or creams/gels/ointments o Topical NSAID: Diclofenac o Counterirritant: methyl salicylate, camphor, menthol, capsaicin o Topical Anesthetic: lidocaine o trolamine salicylate Page 74 Complementary Therapies for headache o Butterbur, feverfew, riboflavin, coenzyme Q10 for migraine prevention o Limited efficacy of some therapies o Magnesium, omega-3 fatty acids, essential oils for migraine prevention o Acupuncture found to be effective for migraine prevention Page 75 Complementary Therapies for fever o None mentioned Page 76 Complementary Therapies for pain o Glucosamine and chondroitin controversial efficacy o Strongest evidence for hand arthritis o Combination therapy needed, dosing importance emphasized