CAPA Pharmacology & Pain Management 5 — Questions and Answers
Question 1: A patient develops sudden-onset muscle rigidity of the chest wall ('wooden chest syndrome') immediately after a rapid IV push of fentanyl. What is the MOST appropriate immediate intervention?
- Administer naloxone 0.4 mg IV
- Provide bag-mask ventilation with high-pressure breaths
- Administer succinylcholine and assist ventilation (Correct answer)
- Position the patient in the recovery position and monitor
Correct answer: Administer succinylcholine and assist ventilation
Opioid-induced muscle rigidity (wooden chest) can prevent ventilation; succinylcholine relaxes the chest muscles while the airway is secured and ventilation is assisted.
Question 2: A patient is receiving a continuous local anesthetic infusion via a wound catheter for postoperative analgesia. Which sign would indicate systemic local anesthetic toxicity (LAST)?
- Localized warmth and redness at the infusion site
- Circumoral numbness, metallic taste, and tinnitus (Correct answer)
- Hypertension and tachycardia only
- Gradual onset drowsiness without other symptoms
Correct answer: Circumoral numbness, metallic taste, and tinnitus
Early CNS signs of LAST include circumoral paresthesia, metallic taste, tinnitus, and agitation, progressing to seizures and cardiovascular collapse if untreated.
Question 3: Which medication is the definitive treatment for local anesthetic systemic toxicity (LAST) once cardiovascular collapse has occurred?
- Epinephrine 1 mg IV
- 20% Lipid emulsion (Intralipid) 1.5 mL/kg IV bolus (Correct answer)
- Sodium bicarbonate 1 mEq/kg IV
- Atropine 0.5 mg IV
Correct answer: 20% Lipid emulsion (Intralipid) 1.5 mL/kg IV bolus
20% lipid emulsion acts as a 'lipid sink,' sequestering lipophilic local anesthetics from cardiac tissue and is the definitive treatment for LAST-induced cardiovascular collapse.
Question 4: A Phase II recovery nurse is reviewing a patient's discharge prescriptions. The patient is going home with oxycodone 5 mg PRN and ibuprofen 600 mg q6h. Which additional analgesic recommendation would BEST complete the multimodal regimen?
- Add tramadol 50 mg PRN for breakthrough pain
- Add scheduled acetaminophen 500 mg q6h alternating with ibuprofen (Correct answer)
- Add hydromorphone 2 mg PRN as needed
- Add a fentanyl patch 12 mcg/hr
Correct answer: Add scheduled acetaminophen 500 mg q6h alternating with ibuprofen
Scheduled acetaminophen alternating with ibuprofen maximizes non-opioid coverage through different mechanisms, reducing opioid consumption and improving pain control.
Question 5: A patient with chronic kidney disease stage 3 requires analgesics after ambulatory urologic surgery. Which opioid is MOST concerning due to accumulation of active nephrotoxic metabolites?
- Fentanyl
- Hydromorphone
- Morphine (Correct answer)
- Buprenorphine
Correct answer: Morphine
Morphine's active metabolite morphine-6-glucuronide (M6G) accumulates in renal impairment, causing prolonged and potentially dangerous CNS and respiratory depression.
Question 6: Tramadol produces analgesia through which COMBINATION of mechanisms?
- COX inhibition and serotonin reuptake inhibition
- Weak mu-opioid receptor agonism and norepinephrine/serotonin reuptake inhibition (Correct answer)
- NMDA antagonism and alpha-2 agonism
- Mu-opioid agonism and GABA-A potentiation
Correct answer: Weak mu-opioid receptor agonism and norepinephrine/serotonin reuptake inhibition
Tramadol provides analgesia via weak mu-opioid receptor binding plus inhibition of norepinephrine and serotonin reuptake, giving it a dual mechanism of action.
Question 7: A post-surgical patient in the PACU is receiving IV ketorolac and reports effective pain control. However, the nurse notes the patient had a coronary artery stent placed 6 months ago and is on clopidogrel. What action should the nurse take?
- Continue ketorolac because the pain control is effective
- Hold ketorolac and notify the surgeon/anesthesiologist immediately (Correct answer)
- Reduce the ketorolac dose by half and monitor platelet function
- Switch to a COX-2 selective inhibitor (celecoxib) IV
Correct answer: Hold ketorolac and notify the surgeon/anesthesiologist immediately
Ketorolac inhibits platelet aggregation and combined with clopidogrel significantly increases bleeding risk; the team must reassess the analgesic plan for this high-risk patient.
CAPA Pharmacology & Pain Management 5
A patient develops sudden-onset muscle rigidity of the chest wall ('wooden chest syndrome') immediately after a rapid IV push of fentanyl.
What is the MOST appropriate immediate intervention?