NURS 6521 Assignment: Decision Tree for Neurological and Musculoskeletal

NURS 6521 Assignment: Decision Tree for Neurological and Musculoskeletal

Introduction

Complex regional pain syndrome, CRPS presents with dysfunction of extremities, severe pain, contractions, and swelling (Shim, et al., 2019). The cause of the syndrome is either trauma or surgical procedures. CRPS has three clinical stages, the acute, sub-acute, and chronic phases. The acute phase lasts for approximately three months. The sub-acute phase involves symptoms progression up to nine months, and the chronic phase is over one year. CRPS clinical signs and symptoms are severe pain, usually burning in nature, with vasomotor redness that worsens dependency, hyperhidrosis, and coolness to touch. CRPS is a result of central dysregulation of the nociceptive impulses that cause vasoconstriction. The vasoconstriction causes prolonged ischemia that produces more pain. It also builds a reflex arch that promotes further sympathetic firing and vasospasm. The result is a painful, swollen, and non-functional extremity.

Chronic CRPS is the accurate diagnosis for this patient because he presents with severe cramping of the toes, cooling of extremities, and inability to use the limbs. The patient has suffered pain for seven years. He has a positive history of trauma on his right hip where he sustained a 75% cartilage tear. The patient also has mild depressive mood disorder because he has been presenting with low mood since the onset of the disease, loss of his source of income, and separation from his fiancée. He has been on hydrocodone, which he takes sparingly due to the side effects. Hydrocodone is an opioid used in the treatment of pain. It is also an antitussive used to treat cough in adults. However, the patient does not fully comply with treatment due to its adverse effects such as anxiety, drowsiness, fatigue, and shortness of breath.

The three decisions made in the treatment for this include; Savella, Amitriptyline, and Neurontin. Savella treats depression and complex regional pain syndromes. It is a serotonin and norepinephrine reuptake inhibitor whose effects on regulates dysfunctional noradrenergic and serotonin pathways thus reducing the vasoconstriction that contributes to pain (Zou, et al., 2018). Savella is well tolerated compared to amitriptyline and hydrocodone. In addition to that, it has no side effects compared to the other two drugs.

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Amitriptyline is a tricyclic antidepressant that blocks both serotonin and norepinephrine neurotransmitters. It is FDA approved for a major depressive mood disorder. In addition, it is an off-label drug for post-traumatic stress disorder and CRPS. Amitriptyline achieves its therapeutic effects four to six after the initial drug administration. Amitriptyline is not the drug of choice for this patient because of its adverse effects such as hypotension, dizziness, weight gain, and increased risk for bone fractures (Meshalkina, et al., 2018). Neurontin is a GABA mimetic agent that binds to the subunit of voltage-gated calcium channels (Moore, et al., 2018). It is FDA approved for the treatment of convulsive disorders. It is an off-label opioid therapy for neuropathic pain. It is effective in the treatment of CPRS. It has beneficial effects on insomnia, fatigue, depression, and quality of life. However, it relieves 50 % of the pain and has a high chance of addition. Therefore, it is not the drug of choice for this patient because he will not experience worthwhile pain relief. Savella is the drug of choice. The desired effects are to relieve pain and improve the depressive mood.

References

Meshalkina, D. A., Kysil, E. V., Antonova, K. A., Demin, K. A., Kolesnikova, T. O., Khatsko, S. L., … & Kalueff, A. V. (2018). The effects of chronic amitriptyline on zebrafish behavior and monoamine neurochemistry. Neurochemical research, 43(6), 1191-1199.

Moore, A., Derry, S., & Wiffen, P. (2018). Gabapentin for chronic neuropathic pain. Jama, 319(8), 818-819.

Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practising clinician. British journal of anaesthesia, 123(2), e424-e433.

Zou, C. X., Becker, J. E., Phillips, A. T., Garritano, J. M., Krumholz, H. M., Miller, J. E., & Ross, J. S. (2018). Registration, results reporting, and publication bias of clinical trials supporting FDA approval of neuropsychiatric drugs before and after FDAAA: a retrospective cohort study. Trials, 19(1), 1-11.