Ver el código de «Complex regional pain syndrome»

==Background==
===Abbreviation===
*CRPS

===Other Names===
*Reflex sympathetic dystrophy (RSD)
*Causalgia
*Reflex neurovascular dystrophy (RND)
*Amplified musculoskeletal pain syndrome (AMPS) 

===Definition===
*Disorder of the extremities characterized by regional pain that is disproportionate in time or degree to the usual course of any known trauma or other lesion
*Pain is not in a specific nerve territory or dermatome
*Pain usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings
*CRPS often worsens over time
*35% of patients report symptoms throughout their whole body.<ref name="Sch">Schwartzman RJ, Erwin KL, Alexander GM (May 2009). "The natural history of complex regional pain syndrome". The Clinical Journal of Pain. 25 (4): 273–80. doi:10.1097/AJP.0b013e31818ecea5. PMID 19590474.</ref>

===Sub-Types===
{| class="wikitable"
|-
| '''Type I''' || NO evidence of peripheral nerve injury (edema, erythema, numbness), 90% of clinical presentations
|-
| '''Type II''' || YES evidence of peripheral nerve injury, considered more serve type
|}

===Causes===
*Generally unknown
*Inciting event
**Found in about 90% of cases - usually begin 4-6wks after fractures, crush injuries, sprains, and surgery.<ref name="Sand">Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain 2003; 103:199.</ref>
*Proposed mechanisms
**Classic inflammation, neurogenic inflammation, and maladaptive changes in pain perception at the level of the central nervous system

==Clinical Features==
[[File:CRPS Feet.png|thumb|Type II CRPS showing skin changes<ref name="Duch">Ducharme, Jim, MD. "Tips for Managing Complex Regional Pain Syndrome - ACEP Now." ACEP Now. N.p., 11 Sept. 2015.</ref>]]
{| class="wikitable"
|-
| '''Pain''' || burning, stinging, or tearing sensation that is felt deep inside the limb, usually continuous but can be paroxysmal.<ref name="Birk">Birklein F, O'Neill D, Schlereth T. Complex regional pain syndrome: An optimistic perspective. Neurology 2015; 84:89.</ref>
|-
| '''Sensory''' ||  hyperalgesia, allodynia, or hypesthesia
|-
| '''Motor''' || weakness, occasional tremor, myoclonus, or dystonic postures
|-
| '''Skin''' || warmth, skin color changes, sweating, or edema, other skin/hair/nail changes
|}

==Differential Diagnosis==
*[[Cellulitis]]
*[[DVT]]
*[[Infection]]
*[[Compartment syndrome]]
*[[peripheral arterial disease|Peripheral vascular disease]]
*[[Peripheral neuropathy]]
*[[Thoracic outlet syndrome]]
*[[Rheumatoid arthritis]]
*[[Chronic inflammatory autoimmune disease]]
*[[Raynaud’s disease|Raynaud phenomenon]]
*[[Erythromelalgia]]
*[[Conversion disorder]]
*[[Factitious disorder]]

==Evaluation==
===Clinical: Budapest consensus criteria:===
''At least 1 symptom in three of the following four categories:''
{| class="wikitable"
|-
| '''Sensory''' || allodynia, hyperalgesia
|-
| '''Vasomotor''' || temperature asymmetry, skin color changes, skin color asymmetry
|-
| '''Sudomotor''' || edema, sweating
|-
| '''Motor/trophic''' || decreased ROM, weakness, tremor, dystonia, trophic changes (hair, nail, skin)
|}
;And, there is no other diagnosis that better explains the signs and symptoms

===Rule-Out Emergent Etiologies===
*XR 
*CBC 
*[[Ultrasound]]

===Other Imaging===
*CT/MRI/XR are all NOT diagnostic for CRPS<ref name="Birk">Birklein F, O'Neill D, Schlereth T. Complex regional pain syndrome: An optimistic perspective. Neurology 2015; 84:89.</ref>

==Management==
===[[Ketamine]] for Flare-Ups===
*Initial bolus - 0.2–0.3 mg/kg of infused over 10mins.<ref name="Duch">Ducharme, Jim, MD. "Tips for Managing Complex Regional Pain Syndrome - ACEP Now." ACEP Now. N.p., 11 Sept. 2015.</ref>
**Avoid IV push - could cause dissociative side effects.
**Diagnostic- pain should resolve by the end of the 10min bolus and if so, continue 
*Infusion - 0.2 mg/kg/hr over 4-6hrs.

===No discharge prescription usually required. If needed:===
*[[Ibuprofen]] - 400-800 mg TID or [[naproxen]] 250-500 mg BID<ref name="Hard">Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med 2013; 14:180.</ref> 
*[[Amitriptyline]] or [[nortriptyline]] - 10-25 mg at bedtime as initial dose for both<ref name="Birk">Birklein F, O'Neill D, Schlereth T. Complex regional pain syndrome: An optimistic perspective. Neurology 2015; 84:89.</ref>
*[[Gabapentin]] - 100 mg-300 mg at bed time 
*Topical [[lidocaine]] cream - 2-5% or topical [[capsaicin]] cream 0.075% 

'''[[Opioids]] should NOT be used for chronic or acute CRPS. Patient education on this is important.'''

==Disposition==
*Outpatient follow-up with pain management
*Referral for PT/OT - important for all CRPS patients 
*Consider psychiatric referral if warranted

==See Also==
[[Acute pain management]]

==External Links==
*[http://www.acepnow.com/article/tips-for-managing-complex-regional-pain-syndrome/ ACEP - Tips for Managing CRPS]
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914601/ NIH - Validation of Budapest Criteria for CRPS]

==References==
<references/>

[[Category:Neurology]]