What is the recommended approach for managing pain in patients with 3rd degree burns?

Pain Management for Third-Degree Burns

Use multimodal analgesia with titrated intravenous opioids as the foundation, combined with IV ketamine for severe pain, and titrate all medications based on validated pain assessment scales. 1

Pharmacological Approach

Primary Analgesic Strategy

• Administer titrated intravenous opioids as the mainstay of treatment for severe burn pain, using short-acting agents that can be adjusted rapidly based on patient response 1, 2
• Use patient-controlled analgesia (PCA) wherever applicable to maintain steady plasma drug concentrations and allow patients to manage breakthrough pain 3
• Titrate all medications based on validated comfort and analgesia assessment scales (such as Numerical Rating Scale) to reduce risk of under- and overdosing, particularly important given the inflammation, hypermetabolism, and capillary leakage that occur with burns 1

Ketamine as Essential Adjunct

• Add titrated intravenous ketamine to the analgesic regimen for severe burn-induced pain, as it is highly effective and provides significant opioid-sparing effects 1, 2
• Ketamine can limit morphine consumption while providing excellent analgesia for the intense pain characteristic of third-degree burns 1

Additional Pharmacological Considerations

• Administer IV acetaminophen every 8 hours as part of multimodal analgesia for its opioid-sparing and antipyretic properties 4, 5
• Consider locoregional anesthesia techniques when anatomically applicable to the burn location 1
• For highly painful procedures (such as dressing changes or debridement), general anesthesia is an effective and appropriate option 1, 2

Non-Pharmacological Interventions

When Patient is Stable

• Combine non-pharmacological techniques with analgesic drugs for dressing changes and procedures when the patient's hemodynamic status permits 1
• Apply cooling to limited burned surfaces (in adults with <20% TBSA, children with <10% TBSA, and absence of shock) to improve pain control 1, 2
• Cover burns with fatty substances (such as Vaseline) and appropriate dressings to reduce pain 1
• Utilize virtual reality or hypnosis techniques to reduce pain intensity and anxiety in patients without life-threatening injuries 1

Critical Implementation Points

Assessment and Monitoring

• Use written protocols for pain management and perform regular pain assessments using validated scales 1
• Document pain scores at regular intervals to guide titration of analgesics 1
• Third-degree burns cause extremely intense pain that often represents an indication for admission to a burns center 1

Common Pitfalls to Avoid

• Do not substitute opioids with high-dose NSAIDs for managing severe procedural pain in third-degree burns 3
• Do not use topical antibiotics as first-line treatment; reserve them for infected wounds only 2
• Avoid undertreating pain due to unfounded concerns about opioid dependency, as there is no clear evidence that appropriate opioid use in acute burn pain increases likelihood of developing dependency 3
• Do not delay analgesia for wound care procedures; burn wound dressing changes require deep analgesia or general anesthesia and should be performed in a clean environment 1, 2

Timing Considerations

• Pain management should begin immediately and continue throughout all phases of care 6
• Intravenous opioids should be administered as small IV boluses titrated against effect rather than fixed doses 6
• Background pain and procedural pain often require different analgesic interventions and intensities 4, 6