9. Consequences of unrelieved pain
• Activation of pituitary-adrenal axis:
– Stress response: catabolic state
– Suppress the immune system - infection and poor
wound healing.
• Sympathetic activation: negative effects on:
– CVS: cardiac ischaemia
– Gastrointestinal: ileus
– Renal systems
10. Consequences of unrelieved pain
• Reduction of patient mobility, high risk of developing:
DVT, pulmonary embolus, and pneumonia.
• Negatively affect the patient’s welfare and the hospital
performance including pronged hospital stay.
• Affects the psychological state of the patient and
family.
– anxiety and depression.
– sense of helplessness and hopelessness
• Progress to chronic pain
11. Types of burn pain
• Background/rest pain, characterised by
constant and dull pain.
• Breakthrough pain, characterised by:
– Intermittent
– short duration
– rapid onset/offset
– Sometimes excruciating
12. Types of burn pain
• Procedural pain
– Short duration
– Greatest intensity
– Occur with certain activities – wound cleaning,
debridement, dressing changes, joint range of motion
exercises.
• Psychogenic pain
– Anticipatory pain in the absence of mechanical
stimulation
13. Assessment of burn pain
• Regular and ongoing
• All types of pain; nociceptive, neuropathic and
psychogenic
• History taking using the PQRST
• Assess the severity using the recognised tools
– Numeric rating scale
– Wong baker pain scale
– FLACC
14. Assessment of burn pain
• Psychosocial history using the recognised tools
– Emotional distress
– Psychologic disorders
– Spiritual distress
• Function and sleep
• Adverse effects of pain treatment
• Physical examination
15.
16. Burn pain treatment options
• Pharmacological
– Opioids
• Cornerstone
• Effective
• A variety with different ranges of potency and Duration
of action
• Different routes of administration
• Titrated to effect
18. Burn pain treatment options
• Pharmacological
– Paracetamol
• In combination with opioids
• Opioid dose sparing
• Antipyretic
• Excellent risk profile and few contraindications
• Should be used regularly at its maximal dose
19. Burn pain treatment options
• Pharmacological
– Paracetamol
• Maximum PO or PR dose for children (acute
administration for 2 to 3 days): 60 mg/kg/day in term
neonates and infants; 90 mg/kg/day in children aged
between 6 months and 12 years.
• Maximum doses of IV paracetamol are 30 mg/kg/day in
neonates and infants, and 40 to 60 mg/kg/day in
infants and children
20. Burn pain treatment options
• Pharmacological
– NSAIDs
• Effective analgesia, anti-inflammatory and antipyretic
• Synergistic with opioids
• Not recommended for routine use in patients with
significant burn injuries due to high risk of; renal
failure, peptic ulceration, bleeding tendencies
21. Burn pain treatment options
• Pharmacological
– Ketamine
• Powerful analgesic at subanaesthetic doses (0.25-
0.5mg/kg IV, up to 3mg/kg PO for pediatrics)
– Anticonvulsants and antidepressants
• Gabapentin, pregabalin, amitriptyline, nortriptyline
• Neuropathic pain
• Burn itch
22. Burn pain treatment options
• Pharmacological
– Benzodiazepines for anticipatory pain
• Anxiolysis
• 2nd line to nonpharmacological techniques
• Lorazepam, midazolam, diazepam
24. Breakthrough burn pain treatment
– Opioid analgesics preferred
– Immediate release oral morphine (10% of the 24hrs cycle
total dosage). Maximum 6 doses/ 24hrs, if pain persist
increase the base dosage
– Alternative IV morphine 1mg PRN, (0.01mg/kg)
– Daily evaluation of frequency of the breakthrough
medication
– Consider complications e.g. wound infection if there is
sudden increase in pain levels.
25. Procedural burn pain treatment
- Burn pain maximal during therapeutic procedures; dressing
, debridement, physiotherapy
– Under treated: risks poor compliance with treatment,
post-traumatic stress, further ‘wind-up’ of pain, anxiety
– Potent analgesia to cope with short, intense burst of pain
while not rendering the patient unconscious when
unstimulated
– Nonpharmacological techniques considered in addition
• include parental presence and play therapy for children
26. Procedural burn pain treatment
• Procedural pain
– Suitable analgesic plan
• Knowledge of what is likely to occur
• Local resources
• Staff skills
– Options
• Oral opioid and oral benzodiazepine
• Oral ketamine and oral benzodiazepine
• Infusions of opioids with or without sedatives
• Entonox
• General anaesthesia
28. Procedural burn pain treatment
• Dosages:
• IV morphine (0.01mg/kg), ketamine (0.25mg/kg) and
midazolam (0.01mg/kg), titrated to effect
• Oral ketamine (up to 3mg/kg) and midazolam
(0.5mg/kg, max 7.5mg): slower onset of action
• Oral morphine (0.1mg/kg) 30 min before the
procedure: small area dressing change
29. Conclusion
• Deescalate the dosages as burns healing continue
• Burn pain is unique and complex
• Pharmacological and nonpharmacological
treatment improves the patients’ experience
• Address the patients psychosocial needs.
• Good pain control depends on:
– Assessment
– Prompt analgesia titrated to effect
– Regular evaluation
30. Take home message
• Background pain
– Multimodal approach
– Dose adjustments based on patient assessment
– Adverse effects pre-empted and treatments co-
prescribed
– Opioids are anchor medicines(unless
contraindicated)
