Pain Management in Burn Patients

Pain management is essential for both children and adults who have major burns. When the pain is well managed, fewer physiological stressors are placed on the body that needs all the energy it can get to partake in the healing process. Pain relief encourages better outcomes, including a decreased risk of complications, a lesser incidence of post-traumatic stress disorder, and post-injury depression.

Burn injuries can be excruciating, and the consequences may last a lifetime. If you or a loved one has sustained serious burn injuries from an accident due to someone else's negligence, you may be entitled to compensation to cover your damages and personal losses. Our burn injury attorneys can help you file a personal injury claim. Call us for free, friendly advice at (916) 921-6400. 

All types of burns can cause pain. First and second-degree burns are more painful initially, with pain even when air flows across the burn or when clothing touches the burn. After a few days, the pain can change in character to be more of a dull ache from inflammation and swelling deep to the burned areas. Third-degree burns are more confusing. They initially cause little pain to pinpricking, but patients with third-degree burns are likely to experience deep, inflammation-related pain. As the eschar falls off, there is an increase in pain during pinpricking, and there comes to pain related to the nerve endings in the dermis growing back, causing pain of a different quality. Because of the inflammation around the burned area, the area of the body involved in pain can be the surrounding tissue and the burned area.

Burned tissue releases a lot of pain mediators such as interleukin, which intensifies the perception of pain following a burn injury. Burns can be painful even at rest because of the psychological and emotional issues surrounding the burn; there is little correlation between the size of the burn and scores of the amount of pain a person is having.

Patients with burns often have a great deal of anxiety about times when the burn needs to be treated and the anticipation of pain during treatments. These same patients can experience depression related to anticipation of pain treatments. Depression sets up a vicious cycle, where depression increases the perception of pain, which triggers more depression and more pain. This cycle can be broken by adequately controlling the level of pain the patient is experiencing.

Patients with full-thickness burns need to have the nerves regenerate before the full degree of pain is experienced. Regardless of the methods used to heal pain, nerve regeneration occurs about 5-6 weeks following the injury but can take up to 6 months for the nerves to completely regenerate. During this time, there is neuropathic pain, which is directly related to the healing of the nerves around the burned tissue.

Some people can develop chronic pain syndromes such as causalgia and phantom pain after a burn. This is more likely to occur when the burn is allowed to heal secondarily rather than through excision and grafting. Phantom pain is also more likely to happen when a limb has had to be amputated due to severe burns. If the patient does not develop chronic pain syndromes, the pain may eventually subside over several months.

Measuring pain can be difficult for burn patients as the degree of pain is different during the various burn cares necessary for treating burns and during times of rest. The pain difference can be so significant that there needs to be a reassessment of pain needs during times of actually working on the burn during care and rest. Pain scales are often used for this purpose and can be rated on a scale of 1-10, 0-5, or just using pictures of faces experiencing varying degrees of pain. This latter technique is most useful in children who identify better with images than with number scales.

Offering the patient the opportunity to describe the pain level on a scheduled basis is essential. It can help determine the schedule of giving pain medications and shows the patient that the staff really does care about the patient’s perception of pain and knows that pain is part of the patient’s problems in a burn unit. Regularly asking about and providing pain relief based on pain scales can reduce the anxiety around the pain that most patients experience.

In adults, the best way to measure pain is to ask them to rate the pain on a scale, such as 0 to 10. Another way of doing it is to use pictures showing faces in varying amounts of pain. When asked, most patients preferred using the faces scale to determine their level of pain.

It is more difficult to assess pain in children, especially those who cannot talk. In such cases, behavioral scales have been devised that look at crying behaviors and facial expressions observed by the staff, indicating varying pain levels. A unique pain gauge called the Children’s Hospital of Eastern Ontario Pain Scale. There is also a pain scale called the “Observer Scale.” These techniques are good ways to identify the amount of pain in children who cannot tell the staff how much pain they are in.    The OPAS or Observational Pain Assessment Scale has also been good in describing how much pain a child aged 0-3 is experiencing.

Anxiety and itching are other phenomena that happen during the healing process of having a burn. There are scales using pictures and/or numbers that can be used to assess these features of healing burns.

Most pain in the burn setting involves using medications that treat pain. The staff must first believe that if a patient states they are having pain, they mean it. Pain medications are also best given on a scheduled basis to cover pain over an extended time, rather than waiting for the pain to return to treat the pain.

Pain medication in a burn setting should not be given intramuscularly because there is pain involved in getting the injection which could color the patient’s perception of pain. Intravenous pain relief is preferable in a burn unit setting and provides reliable pain relief. Oral pain medications can be used for mild to moderate pain.

In the emergency phase of pain relief, the patient’s pain may be extreme, necessitating pain-relieving medications. The staff also will need to manage the pain of procedures done to the wound. A patient can be given medicines that are strong but that have a short duration of action, and care must be given not to over-sedate the patient, which can result in respiratory depression. Pain treatment in the early phases of the management of burns is also essential for decreasing the incidence of post-traumatic stress disorder in burn patients.

Sedating the patient can be challenging when dressings need to be changed. There is the above-noted problem with respiratory depression, and sometimes there is a need to keep the patient away from foods and liquids before giving them strongly sedating medications. The ideal protocol for giving pain medication for procedures should have a rapid onset of action, a deep relief of pain, and a short duration of action without major side effects. Several established protocols can be used to reduce the perception of pain during procedures.

Commonly used medications in controlling pain in a severely burned patient include:

• Midazolam for anxiety
• Propofol for sedation
• Morphine for pain
• Dilaudid for pain
• Ketamine
• Nitrous oxide

When the patient is recovering, and in the rehabilitative stage of burn recovery, there can be pain from contractures, including scarring and aching pain, similar to the pain of arthritis. Mild pain relievers such as acetaminophen, codeine, and oral anxiolytic medications should be used during this healing phase. Ibuprofen and other NSAIDs are often preferable because they treat inflammation and are nonsedating compared to narcotic drugs. Acetaminophen has a good safety profile with few side effects for chronic pain.

Itching also needs to be treated during rehabilitation. Many burn centers use diphenhydramine (Benadryl®) for the relief of itching, as well as long-acting benzodiazepines to treat the anxiety involved in itching.

Methods such as guided visualization, biofeedback, and meditation can be used to manage the pain and itching that can last a long time after initially receiving the burn.

The following video explains the different types and severity of burn injuries and how they are treated.

If you or a family has been hurt in a burn injury accident, call our skilled Burn Injury Attorneys in Sacramento at (916) 921-6400 or (800) 404-5400for free and friendly case advice.

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Editor’s Note: This page has been updated for accuracy and relevancy [cha 5.26.22]

Photo by: ab [cs 1513]