Abstract
Burn pain can cause psychologic and functional difficulties, and is difficult to predict from wound depth. The initial painful stimulation of nerve endings by the burn with continued painful stimuli result in peripheral and central mechanisms causing amplification of painful stimuli, and the development of chronic pain syndromes that can be difficult to treat. In order to assess the effect of analgesic interventions it is essential to measure the patient’s pain in a simple and reproducible manner. A number of tools exist for this measurement, ranging from longer and more detailed techniques such as the McGill pain questionnaire most suited to relatively stable pain, to visual analogue scores and picture-based scores for children. Pain management begins with the acute injury, with initial measures such as cooling of the burn and use of inhalational agents such as oxygen/nitrous oxide mixtures. On arrival in hospital, for any but trivial burns, intravenous opioids are appropriate and should be administered as small intravenous boluses titrated against effect. Following the initial resuscitation, pain may be divided into background pain and that associated with procedures. These often require different analgesic interventions. Background pain may be treated with potent intravenous opioids by infusion or patient controlled analgesia and then on to oral, less potent opioids, followed by other oral analgesics. Often drug combinations work best. More severe procedural pain may be treated with a variety of interventions from a slight increase in therapy for the background pain to more potent drugs, local blocks, or general anaesthesia. In addition to drug-based methods of managing burn pain, a number of nonpharmacologic approaches have been successfully employed including hypnosis, auricular electrical stimulation, massage, and a number of cognitive and behavioural techniques.
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References
Scott J.R., Watson S.B. Surgical management of burns. In: Kinsella J., editor. Balliere’s clinical anaesthesiology: burns. London: Balliere Tindall, 1997; 11 (3): 473–474
Williams E.E., Griffiths T.A. Psychological consequences of burn injury. Burns 1991; 17: 478–480
Taal L.A., Faber A.W. Post-traumatic stress, pain and anxiety in adult burn victims. Burns 1997; 23: 545–549
Ptacek J.T., Patterson D.R., Montgomery B.K., et al. Pain, coping, and adjustment in patients with burns: preliminary findings from a prospective study. J Pain Symptom Manage 1995; 10: 446–455
Choiniere M., Melzack R., Rondeau J., et al. The pain of burns: characteristics and correlates. J Trauma 1989; 29 (11): 1531–1539
Van-der-Does A.J. Patients’ and nurses’ ratings of pain and anxiety during burn wound care. Pain 1989; 39: 95–101
Pedersen J.L., Kehlet H. Hyperalgesia in a human model of acute inflammatory pain: a methodological study. Pain 1998; 74: 139–151
Pedersen J.L., Andersen O.K., Arendt-Nielsen L., et al. Hyperalgesia and temporal summation of pain after heat injury in man. Pain 1998; 74: 189–197
Imokawa H., Ando K., Kubota T., et al. Study on the kinetics of bradykinin level in the wound produced by thermal injury in the ear burn model in mice. Nippon Yakurigaku Zasshi 1992; 99: 445–450
Coderre T.J., Melzack R. Cutaneous hyperalgesia: contribution of peripheral and central mechanisms to the increase in pain sensitivity after injury. Brain Res 1987; 404: 95–106
Atchison N.E., Osgood P.F., Carr D.B., et al. Pain during burn dressing change in children: relationship to burn area, depth and analgesic regimens. Pain 1991; 47: 41–45
Osgood P.F., Szyfelbein S.K. Management of burn pain in children. Pediatr Clin North Am 1989; 36: 1001–1013
Ma Q.-P., Woolf C.J. Progressive tactile hypersensitivity: an inflammation induced incremental increase in the excitability of the spinal cord. Pain 1996; 67: 97–106
Thomson S.W.N., King A.E., Woolf C.J. Activity dependent changes in rat ventral horn neurons in vitro; summation of prolonged afferent evoked post-synaptic depolarisations produce a D-2-amino-5-phosphonovaleric acid sensitive windup. Eur J Neurosci 1990; 2: 638–649
Raja S.N., Campbell J.N., Meyer R.A. Evidence for different mechanisms of primary and secondary hyperalgesia following heat injury to the glaborous skin. Brain 1984; 107: 1178–1188
Dahl J.B., Brennum J., Arendt-Nielsen L., et al. The effect of pre- versus postinjury infiltration with lidocaine on thermal and mechanical hyperalgesia after heat injury to the skin. Pain 1993; 53: 43–51
Pedersen J.L., Callesen T., Moiniche S., et al. Analgesic and anti-inflammatory effects of lignocaine-prilocaine (EMLA) cream in human burn injury. Br J Anaesth 1996; 76: 806–810
Moiniche S., Dahl J.B., Kehlet H. Peripheral antinociceptive effects of morphine after burn injury. Acta Anaesthesiol Scand 1993; 37: 710–712
Raja S.N., Campbell J.N., Meyer R.A., et al. Role of kinins in pain and hyperalgesia: psychophysical studies in a patient with kininogen deficiency. Clin Sci 1992; 83: 337–341
Jun J.H., Yaksh T.L. The effect of intrathecal gabapentin and 3-isobutyl gammaaminobutyric acid on the hyperalgesia observed after thermal injury in the rat. Anesth Analg 1998; 86: 348–354
Ilkjaer S., Dirks J., Brennum J., et al. Effect of systemic N-methyl-D-aspartate receptor antagonist (dextromethorphan) on primary and secondary hyperalgesia in humans. Br J Anaesth 1997; 79: 600–605
Ilkjaer S., Petersen K.L., Brennum J., et al. Effect of systemic N-methyl-D-aspartate receptor antagonist (ketamine) on primary and secondary hyperalgesia in humans. Br J Anaesth 1996; 76: 829–834
Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain 1975; 1 (3): 277–299
Choiniere M., Melzack R., Girard N., et al. Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. Pain 1990; 40: 143–152
Choiniere M., Auger F., Letarjet J. Visual analogue thermometer: a valid and useful instrument for measuring pain in burned patients. Burns 1994; 20: 229–236
Geisser M.E., Bingham H.G., Robinson M.E. Pain and anxiety during burn dressing changes: concordance between patients’ and nurses’ ratings and relation to medication administration and patient variables. J Burn Care Rehabil 1995; 16: 165–171
Perry S.W. Undermedication for pain in a burn unit. Gen Hosp Psychiatry. 1984; 6 (4): 308–316
Davies J.W. Prompt cooling of burned areas: a review of benefits and the effector mechanisms. Burns Incl Therm Inj 1982; 9 (1): 1–6
Alexander L., Wolman R., Blache C., et al. Use of morphine sulfate (MS Contin) in patients with burns: a pilot study. J Burn Care Rehabil 1992; 13: 581–583
Braam M.J., Bath A.P., Spauwen P.H., et al. Survey of analgesia regimens in burns centres in the UK. Burns 1994; 20: 360–362
Herman R.A., Veng-Pedersen P., Miotto J., et al. Pharmacokinetics of morphine sulfate in patients with burns. J Burn Care Rehabil 1994; 15: 95–103
Kinsella J., Glavin R., Reid, WH Patient controlled analgesia in burn patients. Burns 1988; 14: 500–503
Choiniere M., Grenier R., Paquette C. Patient-controlled analgesia: a double-blind study in burn patients. Anaesth 1992; 47: 467–472
Perry S., Heidrich Management of pain during debridement. Pain 1982; 13: 267–280
Concilus R., Denson D.D., Knarr D., et al. Continuous intravenous infusion of methadone for control of burn pain. J Burn Care Rehabil 1989; 10: 406–409
Sheridan R.L., McEttrick M., Bacha G., et al. Midazolam infusion in pediatric patients with burns who are undergoing mechanical ventilation. J Burn Care Rehabil 1994; 15: 515–518
Patterson D.R., Ptacek J.T., Carrougher G.J., et al. Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain 1997; 72: 367–374
Gaukroger P.B., Chapman M.J., Davey R.B. Pain control in paediatric burns — the use of patient controlled analgesia. Burns 1991; 17: 396–399
Shir Y., Shenkman Z., Shavelson V., et al. Oral methadone for the treatment of severe pain in hospitalised children. Clin J Pain 1998; 14 (4): 277–279
Sim K.M., Hwang N.C., Chan Y.W., et al. Use of patient-controlled analgesia with alfentanil for burns dressing procedures: a preliminary report of five patients. Burns 1996; 22: 238–241
Sharar S.R., Bratton S.L., Carrougher G.J., et al. A comparison of oral transmucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia. J Burn Care Rehabil. 1998; Nov–Dec; 19 (6): 516–521
Chambers J.A., Guly H.R. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation 1994; 27: 153–158
Lee J.J., Marvin J.A., Heimbach D.M. Effectiveness of nalbuphine for relief of burn debridement pain. J Burn Care Rehabil 1989; 10: 241–246
Patterson D.R. Non-opioid-based approaches to burn pain. J Burn Care Rehabil 1995; 16: 372–376
Foertsch C.E., O’Hara M.W., Kealey G.P., et al. A quasi-experimental, dual-center study of morphine efficacy in patients with burns. J Burn Care Rehabil 1995; 16: 118–126
Honari S., Patterson D.R., Gibbons J., et al. Comparison of pain control medication in three age groups of elderly patients. J Burn Care Rehabil 1997; 18: 500–504
Collins H.W., Jonsson C.E., Ericsson F. Impairment of renal function after treatment of a burn patient with diclofenac, a non-steroidal antiinflammatory drug. Burns 1995; 21: 471–473
Tran H.T., Ackerman B.H., Wardius P.A., et al. Intravenous ketorolac for pain management in a ventilator-dependent patient with thermal injury. Pharmacotherapy 1996; 16: 75–78
Lyons B., Casey W., Doherty P., et al. Pain relief with low-dose intravenous clonidine in a child with severe burns. Intensive Care Med 1996; 22: 249–251
Viggiano M., Badetti C., Roux F., et al. Controlled analgesia in a burn patient: fentanyl sparing effect of clonidine. Ann Fr Anesth Reanim. 1998; 17 (1): 19–26
Fewtrell M.S., Sapsford D.J., Herrick M.J., et al. Continuous axillary nerve block for chronic pain. Arch Dis Child 1994; 70: 54–55
Brofeldt B.T., Cornwell P., Doherty D., et al. Topical lidocaine in the treatment of partial-thickness burns. J Burn Care Rehabil 1989; 10: 63–68
Jonsson A., Cassuto J., Hanson B. Inhibition of burn pain by intravenous lignocaine infusion. Lancet 1991; 20: 338 (8760): 151–152
Laird S.M., Gray B.M. Intemittent inhalation of methoxyflurane and trichloroethylene as analgesics for burn dressing procedures. Br J Anaesth 1971; 43: 149–159
Filkins S.A., Cosgrave P., Marvin J.A. Self administered anaesthetic: a method of pain control. J Burn Pain Rehabil 1981; 2: 33–34
Firn S. Enflurane analgesia. J R Soc Med 1982; 75 (S1): 36–38
Patterson D.R., Questad K.A., de-Lateur B.J. Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement. Am J Clin Hypnosis 1989; 31 (3): 156–163
Van-der-Does A.J., Van-Dyck R. Does hypnosis contribute to the care of burn patients? Review of the evidence. Gen Hosp Psychiatry 1989; 11 (2): 119–124
Everett J.J., Patterson D.R., Burns G.L., et al. Adjunctive interventions for burn pain control: comparison of hypnosis and ativan: the 1993 Clinical Research Award. J Burn Care Rehabil 1993; 14 (6): 676–683
Patterson D.R., Adcock R.J., Bombardier C.H. Factors predicting hypnotic analgesia in clinical burn pain. Int J Clin Exp Hypn 1997; 45 (4): 377–395
Gilboa D., Borenstein A., Seidman D.S., et al. Burn patients’ use of autohypnosis: making a painful experience bearable. Burns 1990; 16 (6): 441–444
Lewis S.M., Clelland J.A., Knowles C.J., et al. Effects of auricular acupuncture-like transcutaneous electric nerve stimulation on pain levels following wound care in patients with burns: a pilot study. J Burn Care Rehabil 1990; 11 (4): 322–329
Turner J.G., Clark A.J., Gauthier D.K., et al. The effect of therapeutic touch on pain and anxiety in burn patients. J Adv Nurs 1998; 28 (1): 10–20
Field T., Peck M., Krugman S., et al. Burn injuries benefit from massage therapy. J Burn Care Rehabil 1998; 19 (3): 241–244
Miller A.C., Hickman L.C., Lemasters G.K. A distraction technique for control of burn pain. J Burn Care Rehabil 1992; 13 (5): 576–580
Blew A.F., Patterson D.R., Quested K.A. Frequency of use and rated effectiveness of cognitive and behavioural coping responses to burn pain. Burns 1989; 15 (1): 20–22
Patterson D.R. Practical applications of psychological techniques in controlling burn pain. J Burn Care Rehabil 1992; 13 (1): 13–18
George A., Hancock J. Reducing pediatric burn pain with parent participation. J Burn Care Rehabil 1993; 14 (1): 104–107
Foertsch C.E., O’Hara M.W., Stoddard F.J., et al. Treatment-resistant pain and distress during pediatric burn-dressing changes. J Burn Care Rehabil 1998; 19 (3): 219–224
Watkins P.N., Cook E.L., May S.R., et al. The role of the psychiatrist in the team treatment of the adult patient with burns. J Burn Care Rehabil 1992; 13 (1): 19–27
Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991; 78 (4): 497–498
Gerding R.L., Emerman C.L., Effron D., et al. Outpatient management of partial-thickness burns: biobrane versus 1% silver sulfadiazine. Annals Emerg Med 1990; 19 (2): 121–124
Smith Jr D.J., Thomson P.D., Garner W.L., et al. Burn wounds: infection and healing. Am J Surg 1994; 167 (1A): 46S–48S
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Gallagher, G., Rae, C.P. & Kinsella, J. Treatment of Pain in Severe Burns. Am J Clin Dermatol 1, 329–335 (2000). https://doi.org/10.2165/00128071-200001060-00001
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DOI: https://doi.org/10.2165/00128071-200001060-00001