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140 Burns
for moderate-to-severe burn-associated pain. The IV route for opioid anal-
gesics is preferred over PO administration because of the rapidity and consistency
of absorption and onset. This makes titration to an effective dose
easier, but care must be taken to provide dosing with appropriate frequency
to maintain the analgesic effect (a particular issue if fentanyl is used). The
fact that control of burn pain often requires relatively higher doses of opioid
analgesia may be in part related to changes in volume of distribution, protein
binding, and clearance. 15
For some opioids, other sites of rapid absorption may also be utilized.
For example, IN fentanyl has been favorably compared to PO and IV opioids
for control of procedural pain in burn patients. A small double-blind RCT
suggested that IN fentanyl (1.4 μg/kg) was as effective as PO morphine
(1 mg/kg) in reducing the pain of dressing changes in 24 children with
burns. 16 Similar results were reported in a study of 26 adult burn patients
treated with IN fentanyl (1.48 μg/kg) or PO morphine (0.35 mg/kg). 17
Preliminary assessment of the use of topical morphine for burn analgesia
had disappointing results. 18
A small pilot study of 10 patients suggested that the analgesic qualities of
oral controlled-release morphine were comparable to those of continuous IV
morphine sulfate infusions. 19
In addition to the general risk of respiratory depression with opioids, their
use in patients with burns may have some association with the immune
suppression frequently seen in severely burned patients. However, evidence
on this subject is conflicting. 20,21
Intravenous infusion of lidocaine (1 mg/kg bolus followed by 2–4 mg/min
infusion) and other local anesthetics has also been investigated with some
promising results. 22–26 Although timely provision of regional nerve blocks
may not be feasible in many ED settings, this approach can provide exceptional
relief of burn pain.
Topical application of local anesthetics or opioids may have salutary
effects on local physiology, but this approach has not otherwise been successful,
and it is not recommended for pain management. 27
Anxiolytics, particularly benzodiazepines, have been shown to be useful
adjuncts to pain therapy in burns. Care must be exercised in administering