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Sakit kepala Tegangan (Tension Headaches)


Sakit kepala tegangan secara sederhana digambarkan ketika nyeri atau kegelisahan seperti regu
yang ketat yang sering dihubungkan dengan keketatan di dalam otot-otot leher. Sakit kepala itu bisa di
garis depan, sementara, atau occipital, selagi lebih sering dari dua belah pihak dibanding yang secara
sepihak. Nyeri intensitas pada umumnya membangun secara berangsur-angsur dan berubah-ubah, jam
kekal kepada hari-hari. Mereka bisa dihubungkan dengan tekanan atau tekanan secara emosional.
Perawatan adalah yang merupakan gejala dengan NSAIDs.

Sakit kepala Migren [Rangsangan]


Sakit kepala migren [rangsangan] pada umumnya digambarkan sebagai berdenyut atau
memukulkan dan sering dihubungkan dengan fotofobia, scotomata, kemuakan, memuntahkan, dan
melokalisir kelainan fungsi tubuh penumpang sementara ilmu kegaiban tentang orang mati (perasaan
pribadi mengawali epilepsy). Yang belakangan bisa berhubungan dengan perasaan, motor, visual, atau
pencium. Migren [rangsangan] klasik menurut definisi didahului oleh satu perasaan pribadi mengawali
epilepsy, sedangkan migren [rangsangan] yang umum bukan. Rasa sakit tersebut adalah biasanya
secara sepihak tetapi dapat dari dua belah pihak dengan suatu lokasi frontotemporal dan ukuran berat
4–72 h.Migren [rangsangan] terutama mempengaruhi anak-anak (kedua-duanya seks-seks dengan
sama) dan orang dewasa muda (sebagian besar wanita-wanita). Suatu sejarah keluarga sering
menyajikan. Provokasi oleh bau-bau, makanan-makanan tertentu (misalnya, anggur merah), haid, dan
tidur perampasan adalah umum. Tidur characteristically membebaskan sakit kepala. Mekanisme itu
adalah kompleks dan boleh termasuk vasomotor, autonomic (sistem batang otak serotinergic), dan
trigeminal kelainan fungsi tubuh inti. Perawatan adalah yang abortif maupun ( untuk
berakhir/mengakhiri serangan) dan alat pencegah. Perawatan abortif cepat termasuk oksigen,
sumatriptan (6 mg subcutaneously), dihydroergotamine (1 secara dalam otot mg atau subcutaneously),
lidocaine yang kedalam pembuluh darah (100 mg), butorfanol nasal (1–2 mg), dan sphenopalatine
blok. Opsi yang abortif lain termasuk zolmitriptan percikan nasal, dihydroergotamine percikan nasal,
atau satu serotonin lisan 5-HT1B/1D-receptor agonis (almotriptan, frovatriptan, naratriptan, rizatriptan,
eletriptan, atau sumatriptan). Perawatan alat pencegah boleh termasuk -blockers adrenergik, zat kapur
menggali blockers, cuka valproic, dan amitriptilina.

Nyeri kepala seperti diikat (Cluster Headaches)


Nyeri kepala seperti diikat secara sederhana terjadi di periorbital, terjadi di dalam seikat-seikat
dari nya kepada tiga menyerang satu hari (di) atas suatu 4 sampai dengan 8 minggu. Rasa sakit tersebut
digambarkan sebagai suatu nyala atau mengebor sensasi bahwa Mei membangkitkan pasien dari tidur.
Itu ukuran berat 30–120 min. Pengampunan untuk sekitar satu tahun pada waktu yang sama bersifat
umum. Mata merah, menyobek, kekakuan nasal, dan ptosis (Sindrom terompet/tanduk) bersifat
penemuan klasik. Sakit kepala itu pada umumnya kadang-kadang tetapi dapat menjadi kronis tanpa
pengampunan-pengampunan.Nyeri kepala seperti diikatterutama mempengaruhi [jantan/pria]-
[jantan/pria] (90%). Perawatan abortif termasuk oksigen dan sphenopalatine blok. Perawatan alat
pencegah boleh termasuk litium dan suatu celana pendek sepanjang prednison dan verapamil.

Arteritis Sementara
Arteritis sementara adalah satu kekacauan yang berapi-api/penyebab radang dari nadi/jalan
utama ekstrakranial. Sakit kepala itu dapat secara sepihak atau dari dua belah pihak, membosankan dan
tumpul di dalam mutu, dan menempatkan di dalam bidang yang sementara di dalam sedikitnya 50%
dari pasien-pasien. Rasa sakit tersebut mengembangkan (di) atas beberapa jam dan bisa tajam kadang-
kadang, dan lebih buruk pada malam hari dan di dalam udara dingin. Kelembutan kulit kepala adalah
biasanya menyajikan. Arteritis sementara adalah suatu kekacauan secara relatif umum dari pasien-
pasien yang lebih tua (>55 tahun), dengan satu timbulnya dari sekitar 1 dalam 10,000 per tahun dengan
suatu keunggulan wanita yang sedikit. Polymyalgia rheumatica, demam, dan kehilangan bobot sering
juga menyajikan. Awal hasil diagnosa adalah penting karena tanpa kemajuan perawatan dapat
menjurus kepada kebutaan melalui keterlibatan dari nadi/jalan utama yang berkenaan dengan mata.
Perawatan kortikosteroid adalah sangat efektif. Biopsi nadi/jalan utama sementara mengkonfirmasikan
hasil diagnosa.
Trigeminal Neuralgia
The pain of trigeminal neuralgia (tic douloureux) is classically unilateral, usually located in
the V2 or V3 distribution of the trigeminal nerve. It has an electric shock quality lasting seconds up to
2 min at a time and is often provoked by contact with a discrete trigger area in the affected nerve
branch. Facial muscle spasm may be present. It is a disease of middle-aged and elderly patients with a
2:1 female to male ratio.
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In at least some patients it may be due to irritation from tortuousity of blood vessels in the posterior
fossa. The drug of choice for treatment is carbamazepine. Phenytoin or baclofen may be added,
particularly if patients do not tolerate the required doses of carbamazepine. More invasive treatments
for patients who do not tolerate drug therapy include glycerol injection or radiofrequency ablation of
the gasserian ganglion and microsurgical decompression of the trigeminal nerve (Jannetta procedure).

CASE DISCUSSION: ANALGESIA FOLLOWING THORACOABDOMINAL SURGERY

An obese 21-year-old male is admitted to the recovery room following a right


thoracoabdominal lymph node dissection for a testicular malignant growth. The incision extends from
the eighth rib to the pubis and a right thoracostomy (chest tube) is present. He had consented to an
epidural catheter for managing his pain postoperatively. Unfortunately, placement of the catheter prior
to surgery proved to be very difficult because of his obesity, and could not be accomplished. He is
extubated and awakens from anesthesia in severe pain and is noted to have shallow breathing at a rate
of 35/min ("splinting"). A total of 10 mg of morphine sulfate is given intravenously before he stops
complaining of pain and becomes very drowsy again.
While the patient was receiving 50% oxygen by face mask, an arterial blood reading is as
follows: PaO2, 58 mm Hg; PaCO2, 53 mm Hg; pH, 7.25; and HCO3–, 21 mEq/L. The postoperative
chest film reveals clear lung fields with diminished lung volumes.

Why Is Pain Management Very Important in This Patient?


The patient is at high risk for pulmonary complications because of his obesity and the
extensive thoracoabdominal incision. He is unable to take deep breaths or cough effectively, and
already has hypoxemia and respiratory acidosis. In fact, if his respiratory status cannot be improved
promptly, endotracheal intubation and controlled mechanical ventilation should be considered. The
chest film is very helpful in excluding residual right pneumothorax, significant hemothorax, or lobar
atelectasis that could explain his marginal respiratory status. The most likely explanation of these
findings is inadequate pain relief combined with opioid-induced respiratory depression. The
hypoxemia is most likely due to microatelectasis and a low functional residual capacity (see Chapter
22), whereas the hypoventilation is due to splinting from incisional pain, the residual effects of
intraoperative anesthetics (including opioids), and postoperative morphine. Clearly, satisfactory opioid
analgesia could not be obtained in this patient without significant respiratory depression and
oversedation. Additional, more effective analgesic measures are indicated if postoperative mechanical
ventilation is to be avoided.

What Additional Options Are Available to Manage His Pain More Optimally?
Additional intravenous opioids would likely aggravate the respiratory depression and are to be
avoided (unless the patient is reintubated). Intrathecal opioid administration may provide relatively
rapid analgesia for the abdominal part of the incision but will require several hours for analgesia of its
thoracic extension; the technique also predisposes to delayed respiratory depression. Moreover,
performing a lumbar puncture in this setting is likely to be as difficult or more difficult than placing an
epidural catheter preoperatively.
Intravenous ketorolac can offer additional analgesia without respiratory depression and can
significantly reduce opioid requirements. The use of ketorolac immediately following such extensive
surgical dissections, however, may be hazardous because of its antiplatelet effects and risk of
postoperative hemorrhage.
Ketamine in low doses (10–20 mg/h) is a very potent analgesic and is not a respiratory
depressant. In higher doses, it is more likely to cause excessive sedation and psychotomimetic effects.
Although a ketamine infusion may be a reasonable option, concerns about oversedating this patient are
justified.
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Multiple intercostal blocks (see Chapter 17) can provide excellent analgesia for thoracic
incisions and are indicated in this patient. Splinting can be abolished, and vital capacity and arterial
blood gases often improve. Four to five milliliters of 0.25% bupivacaine can be injected at the
appropriate dermatomal levels where the rib can be palpated. Moreover, because the patient already
has a chest tube, the risk of a significant pneumothorax is minimal. A similarly effective technique that
may be easier to perform in this obese patient is interpleural analgesia.

What Is Interpleural Analgesia?


The technique can provide analgesia over the chest wall and upper abdomen. It involves
placement of a catheter into a tissue plane within the chest wall such that a single injection of local
anesthetic spreads to several intercostal nerves. The terms "intrapleural" and "interpleural" have been
used interchangeably, but the latter is generally preferred.

What Is the Anatomic Basis of Interpleural Analgesia?


The intercostal space posteriorly has three layers: the external intercostal muscle, the posterior
intercostal membrane (which is the aponeurosis of the internal intercostal muscle), and the intercostalis
intimus muscle (part of the transversus thoracis group of muscles, which is a continuation of the
transversus abdominis). Intercostal nerves lie in between the posterior intercostal membrane and the
intercostalis intimus muscle. Whereas the posterior intercostal membrane forms a complete barrier
beneath the external intercostal muscle, the intercostalis intimus muscle is incomplete and freely allows
fluid to pass into the subpleural space. Thus, interpleural analgesia can be accomplished by placing a
catheter either deep to the internal intercostal muscle but superficial to the parietal pleura, or between
the parietal and visceral layers of the pleura. In either case, the local anesthetic injected will diffuse to
adjacent intercostal nerves. The number of nerves affected depends on the level of the catheter, the
volume of anesthetic injected, and the effects of gravity. In some instances the local anesthetic may
reach the paravertebral space.

How Is Interpleural Anesthesia Performed?


A single epidural catheter is most commonly inserted through a Tuohy needle at a level
between T6 and T8. The needle is inserted at a point anywhere between 8 cm lateral to the posterior
midline and the posterior axillary line. It is then "walked off" the inferior edge of the rib (see
intercostal nerve block, Chapter 17) and advanced to a position either just deep to the posterior
intercostal membrane just beneath a rib, or between the parietal and visceral space. In the first instance,
a "pop" may be encountered as the needle pierces the posterior intercostal membrane. In the second
instance, a loss of resistance technique (similar to that for epidural anesthesia) can be used to identify
entry into the pleural cavity. The catheter is then advanced 3–6 cm past the tip of the needle and fixed
in position as the needle is withdrawn. Local anesthetic (20–25 mL; usually 0.25% bupivacaine) is then
injected. The mean duration of analgesia with bupivacaine is about 7 h (range 2–18 h). Peak plasma
concentrations of the local anesthetic occur 15–20 min after injection. Adding epinephrine to the
bupivacaine solution reduces and slightly delays the peak plasma concentration. Continuous infusions
have also been employed at a rate of 0.125 mL/kg/h.

What Are Other Indications for Interpleural Analgesia?


Interpleural analgesia is most effective in providing analgesia to patients with multiple rib
fractures and those who have undergone open cholecystectomy. Postoperative analgesia is inconsistent
following thoracotomy when multiple chest tubes are in place and a significant amount of blood is
likely to be present in the chest; a significant amount of the local anesthetic may be lost through the
chest. The technique can also be used for chest wall pain due to cancer, acute herpes zoster, and
postherpetic neuralgia.
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What Are the Hazards of Interpleural Anesthesia?


Pneumothorax is a significant risk if a chest tube is not already in place. Unilateral sympathetic
block may be observed and can result in a Horner's syndrome. Chest wall hematoma has been reported.
Systemic absorption is significant; high plasma concentrations of local anesthetics can be observed
with continuous infusions, particularly after 2 days. Fortunately, clinical reports of systemic toxicity
(seizures) are rare. Rarely, the local anesthetic can spread to the epidural space.

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