Dr. Barnes had previously provided a very thorough guide on burns management, which can be found here. The management of thermal injury has largely stayed the same but there have since been some important points that were highlighted by the ABA Pain management guidelines which were published in 2020 that require some update.
In a 2019 systematic review and meta-analysis, Harshmann and colleagues found that no pain relief medications were provided to burn patients in 10-51% of cases prior to transfer to burn centre.(1) It is important to note however, that few studies described whether pain had truly been assessed.
- This was meant to provide an update to a previously published guidelines.
- Although some areas lack research, this guideline provides expert consensus that can be used to guide management.
Recommendation 1: Burn Assessment in the Adult Patient
- Pain assessments should be done repeatedly during the day during different activities (Level A).
- Pain assessments should be protocolized and recorded by the physician and the nursing staff during various stages of care to ensure consistent language when discussing pain evaluation (Level B).
There are many different scales available for the assessment of pain. No specific scale is recommended as each has their strengths and weaknesses.(2)
In the emergency department we should focus on regular assessments of your patient’s pain and treating it accordingly with regimens that we will discuss shortly. You may be wondering why it is important to treat pain adequately. Other than caring for your patient and treating their symptoms, adequate pain management can have long-term repercussions for our burn patients.
Recommendation 2: Pharmacologic Therapy
- When choosing opioid pain medications, decisions about choice should be based on the physiology, pharmacology and physician experience (Level C).
- Opioid pain medications should not be used in isolation but in conjunction with nonopioid and nonpharmacological measures (Level C).
- Attempts should be made to use as few opioid equivalents as needed to achieve desired level of pain control (Level C).
In their 2014 study, Sheridan and colleagues performed a retrospective review of multiple time point data collection involving a cohort of 147 infants, children and teenagers with 4 years of follow up after serious burns conducted at 4 pediatric burn centers.(3) Their goal was to examine the impact of early opiate dosing on long-term posttraumatic stress symptoms. Their main outcome was the nine-item short form child stress disorders checklist (CSDC). They assessed the impact of total opiate dosing during the first 7 days on these scores. Subjects included in the study had an average age of 11 years and average injury size of 22% TBSA. Opiate units were predictive of CSDC scores up to 4 years with higher opioid units predicting lower stress scores suggesting that improved early pain control continues to have favourable outcomes.
In their 2016 systematic review, Giannoni-Pastor and colleagues evaluated the weight of different variables on PTSD development among adult burn patients. They found that the strongest association was life threat perception, followed by intrusion symptoms during acute care and severity of pain.(4)
Some studies also have found a relationship between poorly controlled pain following burn injury and an increased incidence of mental health disorders (depression, PTSD). Acute uncontrolled pain has also been correlated with increased incidence of attempted suicide after discharge.(5)
Opioid analgesia is the standard practice for management of procedural pain in the majority of burn centers in North America and Europe. There is variability regarding which agents are typically used. Fentanyl has been shown to be safe and effective for pain control in burn dressing changes in both adults and children.(2) It can be used in the intravenous, intranasal and oral transmucosal formulations. It is not recommended to administer opioids intramuscularly as the injections are painful, they need to be repeated and absorption is variable.
- Acetaminophen should be utilized on all burn patients, with care taken to monitor maximal daily dose. While acetaminophen has an excellent safety profile, maximal doses should be monitored to decrease the risk of hepatotoxicity (Level D).
As per the ABA, acetaminophen use is recommended but there are no studies that have investigated the efficacy. It is recommended as an adjunct to opioids for major burns as it has a synergistic effect.(2,5)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in all patients due to their safety profile and efficacy in other settings; however, the patient’s clinical picture including baseline comorbidities and kidney function as well as surgeon preference should be included in this decision (Level D).
In 2011, Promes and colleagues performed a prospective multicenter randomized, double blind trial of IV ibuprofen for treatment of fever and pain in burn patients.(6) A total of 61 patients with second and/or third degree burns overing >10% TBSA were assigned in a 2:1 ratio to receive either 800 mg IV ibuprofen or placebo every 6 hours for 120 hours. No adverse events were observed. It was not possible to assess pain scores as there were not enough patients enrolled.
As well in a previous 1996 study, Tran and colleagues demonstrated that with the use of IV ketorolac rather than opioids, physicians were able to decrease and subsequently wean ventilator support.(7)
Although this evidence is not robust, it does give us some understanding of the role of NSAIDs in burn management. NSAIDs can be used at the discretion of the physician.
- Ketamine should be considered for procedural sedation, utilizing appropriate training and monitoring for the physician and nursing staff who are administering (Level B).
- Low-dose ketamine should be considered as an adjunct to opioid therapy in patients who could benefit from reduced opioid consumption, particularly in the postoperative period (Level D).
In 2011, McGuiness and colleagues performed a systematic review of ketamine as an analgesic agent in burn injuries.(8) They identified 67 patients in 4 experimental trials where burns were induced in a lab environment. They were unable to pool the trials due to heterogeneity. Ketamine was shown to reduce secondary hyperalgesia.
ABA does recommend using ketamine with consideration of intravenous midazolam for patients undergoing dressing changes or if needed for debridement.
Other agents mentioned in the guidelines include lidocaine, cannabinoids, dexmedetomidine, clonidine, gabapentinoids for neuropathic pain as well as regional anesthesia. There is limited role for these adjuncts in the emergency department as they are frequently used with admitted patients for long-term burn management.
Maria’s Approach to Pain for a Burn Patient
Given that there is no true dosing regimen found in the literature, here is a general step-wise approach to analgesia for a burn patient:
- Acetaminophen 975mg PO q6h.
- Consider IV ketorolac.
- Consider IV fentanyl (25mcg – 50mcg) with titration to pain control.
- Consider adding ketamine if not achieving pain control 0.3mg/kg. In children can consider intranasal ketamine 1mg/kg.
Additionally, for the burn patient, is it important to assess for associated trauma. As a reminder, disposition of these patient can be to the trauma team or to plastic surgery with possible admission to the ICU depending on the stability of the patient.
Take Home Messages
- Initiate adequate analgesia promptly. This can be helpful in reducing pain in the emergency department as well as preventing long-term complications for your patient.
- Consider acetaminophen, NSAIDs, short-acting opioids and ketamine for management of pain in the acutely ill burn patient. Ketamine can be used to help with debridement or dressing changes in the ED.
- Follow local referral guidelines as these patients often require trauma or burn center care.