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Hi, Victoria. Sorry. Are you able to um see and hear me? Now, was anyone just able to pop in the chart and let me know if they were able to hear what I was saying earlier or if they were able to hear me at the moment? Ok, great. Sorry. Did you? Um I had started but I think maybe only for my minute. Ok, really? Sorry about that guys. Um It must have been an issue with my connection there. Um So I'll just pop back to the start um and go through that all again. Um So sorry about that. Um So um just to introduce myself quickly. So my name is Saba, I'm currently in F two. and I'm just gonna be talking to you quickly about um pain management and decreased consciousness. Um So sorry for the late start. Um but I'll try to go through things as quickly as possible, so hopefully we don't finish late for you guys. Um So we'll be going through um first the acute and chronic pain um and then we'll be moving on to talk about um decreased consciousness and within that we're gonna cover um areas such as drug overdose poisonings and also airway management. So, these are all areas um on your UK MLA um map that we'll be going through for you. So first we need to start with acute and chronic pain. Um So, um this is the who analgesia ladder. Um And this is basically um sort of, it was first, um, it was first used as sort of a way to manage cancer pain, but it's actually sort of now used in all settings for pain really. Um And it's the basis of what you wanna go off when you're managing any types of pain. Um So firstly, you've got your non opioids at the bottom. Um So these are things such as paracetamol and nsaids and these are really key things that you wanna make sure any patient in pain has been started on. Um As these are really your first step in the rung of that ladder. Um And then if that doesn't work and that doesn't properly control someone's pain, you're gonna move up the rung to your weak opioids. Um So this is codeine, traMADol and dihydrocodeine. Um And if that still isn't working well for your patient, then you move up again to a strong opioid and in this setting, you're gonna stop your weak opioid cos you um don't want to, you wanna make sure a patient isn't getting two types of opioids at once because that can be unsafe. Um So you'd keep your non opioid and you'd add in, um, either morphine or oxyCODONE to treat the pain. Um, so, um, here's just a bit more information on your non opioid medications. Um, so firstly, we'll have paracetamol. So, paracetamol really good medication. Um, there's very few side effects associated with it or, um, even so there are side effects but they're very uncommon to happen. Um, if that makes sense and really the, the most common side effect that you would see would be um an overuse headache. So, if someone's been taking paracetamol consistently, um for sort of three weeks or more, that's when they become at risk of getting less. Um, otherwise, um, very unlikely that anyone's gonna get any um side effects from taking paracetamol. Um and then, um the only real setting where you want to be a bit cautious in prescribing paracetamol is in anyone with liver failure and specifically acute liver failure. Um And the reason for that is obviously paracetamol is broken down by the liver. Um So if you've got acute liver failure, your liver is not working, it's not going to be able to do that side of things. Um And you're gonna get a build up of paracetamol, which is gonna be doubly bad because paracetamol itself is toxic to the liver. So anyone with acute liver failure setting, you want to avoid paracetamol in more of a chronic liver failure, it's still safe to use and you can still prescribe it um Then we've got Ibuprofen. Ibuprofen is sort of a less good um, non opioid option. Um And the reason being is it does have quite a lot more side effects and these side effects can be quite severe. Um So it's definitely important to um have a little bit more of a think before you prescribe someone Ibuprofen and just check that they don't have any risk factors that's gonna put them at risk with these side effects. Um So first we've got AK um, so, um, you just want to be a bit cautious of prescribing um ibuprofen to anyone with a bad renal function. Um just because it can make their renal function a bit worse. Um And um if someone, if you've just started um Ibuprofen in a patient and then, then get an AK I, you wanna consider maybe the Ibuprofen was the cause of that. Um And then secondly, you've got gastric ulcers and bleeds. Um And um this really happens tends to happen if you've been giving someone um Ibuprofen consistently for a few days, it doesn't happen after the first use. Um But because of the risk of this, you definitely want to make sure that you're checking if any patients have had a history of a um gastric bleed or an ulcer, um or any patients who are on blood thinners, um You want to be avoiding prescribing Ibuprofen in these patients. And the reason for that is um because you want to, um, really limit your chance of them having a bleed again. Um, and if they're on a blood thinner, then there are a very high chance of, if they do have a bleed, that bleed being far more catastrophic. So you want to avoid any risk of that happening. Um, and in anyone that you're prescribing ibuprofen for, for, and you're expecting them to take it for a few days or more, then you wanna make sure that you're giving them a PPI at the same time. So something like omeprazole, um just again, um let them know that you're giving that just to protect the stomach and protect any, um from the chance of any side effects of developing. Um And they only need to take that PPI while they're taking the Ibuprofen and they can stop once they've stopped taking it. Um The other reason of people you want to be cautious about prescribing ibuprofen in is asthmatics. Um So some asthmatics will get bronchospasm. So they'll go into an asthma attack after taking nsaids. Um It's sort of impossible to know before they've tried it if they're gonna be the kind of person that that's gonna happen in. Um So really, it's just, they've gotta try it and see what happens. So if you've got someone who's asthmatic, it's really important, you check with them. Have you ever taken an NSAID before? Um And if they have check, if it caused an asthma attack and obviously, if it did avoid it, um, if it didn't, and it's completely safe to use and if they've never taken it before, then it's fine for them to try it, but just warn them of the fact that it could cause them to go into an asthma attack. So, just make sure they've got their inhalers to hand and things like that. Um, and then there's, um, at the bottom there, we've got a few other, um, nsaids that you'll commonly be prescribing. Um, so, um Diclofenac firstly, um, is often prescribed as APR form. Um and this tends to be given um really in a setting of renal colic. Um just because it tends to be really effective at dealing with that specific kind of pain. Um Mefenamic acid you will give um to a patient with dysmenorrhea or sometimes menorrhagia. Um And that's really the only type of pain that mefenamic acid is licensed for use in. Um, but it can be really effective. Um And again, just make sure that you're warning these patients, um, they only need to take it on the days when they're in pain. Uh They don't need to take it to sort of prevent the pain from coming on. Um Just because if they're taking it for long periods of time, then they're again, gonna be at risk of things like a gastric ulcer and then the final one is Naproxen. Um Naproxen works sort of similarly to ibuprofen. Um, you can give it for a broad um variety of different pains. Um And some people find that it does work a little bit better for them, but Naproxen is a prescription only version of Ibuprofen. Um So let's move on to our weak opioids. Um So firstly, we've got codeine, so codeine tends to be the go to medication to prescribe um in anyone who's needing that little bit extra to manage their pain. Um It's sort of fairly cheap, easy to give and it can come sort of premixed with paracetamol as Cocodamol. Um The things we're aware of codeine is it can be very constipating. So all opioids um can definitely cause constipation. And whenever you're prescribing someone, an opioid, you wanna warn them about that and also just co prescribe them a laxative in case they need it. But codeine tends to do it the worst. So if someone's saying that they really struggle with constipation when they've been taking medication like this, then you wanna avoid codeine and maybe try a different one to see if that helps. Um And then codeine, um you wanna avoid that in um any um patient who's got severe, either renal or liver impairment just because um it won't be