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Burns 139
well as assist in decontamination. In cold-induced injury (e.g. chilblain,
frostbite), the severe pain of rewarming will usually require NSAID and
opioid supplementation of regional analgesia, nifedipine, orprostaglandins.
There is very limited high-quality evidence comparing various therapeutic
approaches for cold-induced injury. An animal study suggests that
the mechanical allodynia and thermal hyperalgesia associated with frostbite
may be ameliorated with opioids such as fentanyl. 4
While the burn itself can cause intense pain, thermal injury causes significant
local and systemic responses that may both potentiate the pain from
additional stimuli and alter the physiologic response to medication. In order
to obtain pain relief, patients with burns frequently require higher doses of
pain medication than would be needed for other patients with similar pain
levels. In addition, anxiety associated with the burn injury and manipulation
of the burn during ED evaluation may further increase the patient’s pain
response.
Although this discussion focuses on pharmacologic approaches to analgesia,
burn pain is a case in which adjunctive therapies such as covering and
cooling the burn can be critical to optimal pain management. 5–7 Local cooling
applied immediately following a burn may contribute significantly to pain
relief, in part by reducing further injury to (and pain from) nearby tissue. 8
Optimal cooling is performed by continuous irrigation with tap water, but
cooling with saline soaked gauze is far simpler. 9 Either technique is acceptable,
as long as care is taken to avoid overzealous cooling that can lead to
systemic hypothermia or worsen injury to viable tissue. 10
A survey of North American burn centers found that IV morphine is the
most frequently used analgesic for wound care. 11 The survey reported that
the most common background pain medications are IV morphine and PO
acetaminophen (paracetamol) (with or without codeine). Although supporting
high-level evidence is lacking, case reports from the USA and other
areas with more limited healthcare resources indicate the utility of ketamine
(e.g. 1.5 mg/kg IV) analgesia for burn care. 12–14
While minor burn pain may be managed with acetaminophen (1 g [or
15 mg/kg in children] every 4–6h)orNSAIDs (e.g. ibuprofen 400–800 mg [or
10 mg/kg in children] every 6–8 h), opioids are the mainstay of therapy