Pain

management in
Burn patients
Alaa Alibrahim, MD
Burn Fellow
Outlines

01 02
Understanding different types Approaching pain related to
of burns different types of burns
 (ABA National Burn Repository 2015)

• Survival Rate: 96.8%

• Gender: 68% Male, 32% Female

Epidemiology • Ethnicity: 59% Caucasian, 20% African-American, 14%
of burn Hispanic, 7% Other

injuries • Admission Cause: 43% Fire/Flame, 34% Scald, 9% Contact, 4%

Electrical, 3% Chemical, 7% Other

• Place of Occurrence: 73% Home, 8% Occupational, 5%

Street/Highway, 5% Recreational/Sport, 9% Other
 hyperalgesia
complex, involving (increased
multiple areas response to
(physical, painful
emotional and stimuli, e.g.,

Characteristics psychological) wound

debridement)

of pain in burn
patients allodynic
components
Posttraumatic
stress disorder
has been reported
(painful responses
to occur in up to
to nonpainful
30% of patients
stimuli, e.g.,
with severe burn
touch)
injury
Pathophysiology of burn pain
 Variability of pain
Dosing of analgesics
CHALLEN
GES IN Pharmacokinetics
MANAGIN
G BURN Route of drug administration
PAIN
Opioid tolerance
Hyperalgesia
 Selection of analgesia

2- Limitations imposed by
1- The clinical need for Patient:
analgesia - IV access,
- Treatment of - Endotracheal tube
background - Opioid tolerance
- Procedural Or clinical facilities :
- Postoperative pain available monitoring
capabilities and personnel
 Background • at rest
• due to tissue injury
pain • low-moderate

Procedural • short

BURN pain • intense

PAIN Breakthrough • spikes

PARADIG pain

M Postoperative • 2-5 days

• new additional pain at donor sites
pain

• Most commonly neuropathic due to sustained nerve

Chronic Pain damage
Background pain • ALL BURN WOUNDS ARE PAINFUL!
Which burn wounds are • Types and depth predict the severity of pain, however …
painful?
Management of background pain
•  Mildly to moderately potent analgesics administered so that plasma
drug concentrations remain relatively constant

Pharmacologic
• patient-controlled
analgesia (PCA)
• long-acting opioids
• Around the clock NSAID
or Tylenol
Nonpharmacologic
• Relaxation techniques
including meditation,
progressive muscle
relaxation, and guided
imagery
Procedures
we do on the
floor
Management of
procedural pain
• Anticipatory anxiety is an important issue that can develop with the repeated
performance of wound care
• Dressing changes produce pain that is more intense and shorter in duration
than background pain
• Severe procedural pain – General anesthesia, deep sedation, or regional
anesthesia 
• Mild-to-moderate procedural pain
 Nonopioid analgesics, anti-inflammatory agents ( e.g, Tylenol,
Ibuprofen)
 IV opioid analgesics (eg, fentanyl, remifentanil) 
 IV anesthetic agents (eg, Ketamine, Dexmedetomidine)
 Orally administered opioid analgesics (e.g Oxycodone, Dilaudid)
 Oral Ketamine
 Oral transmucosal fentanyl
 Inhaled nitric oxide
Breakthrough pain

The cause of breakthrough pain includes:

• Inadequate background analgesic
management
• Development of opioid tolerance
• Changes in the burn wound that increase
pain (eg, proliferation of epidermal skin
buds during the spontaneous burn healing
process, burn wound infection)
Split thickness skin graft Full thickness skin graft

Burn surgeries and treating post operative pain

 Pharmacologic management of
postoperative pain includes a
temporary (approximately one to
four days) increase in background
Management opioid analgesic support.
of post
operative pain The optimal management
includes the use of continuous
regional block techniques and
additional opioid dosing
 Most commonly neuropathic

Other causes associated with

Chronic Pain deconditioning

Treatment: opioids, NSAID,

Gabapentin (help with itching) and
antidepressants
Thank You!