What are the options for managing uncontrolled burn pain in a 14-year-old patient after administering total 30 milligrams of morphine (Morphine) and 1000 milligrams of acetaminophen (Tylenol, Acetaminophen)?

From the Guidelines

For uncontrolled burn pain in a 14-year-old after Tylenol 1000 mg and Toradol 30 mg, I recommend adding ketamine as an effective drug for burn-induced pain, which can limit morphine consumption, as suggested by the 2020 study in Anaesthesia 1. The management of burn pain is crucial, and the use of written protocols for pain management and regular assessment of pain should be encouraged, as stated in the same study 1. Key considerations for managing burn pain include:

• The use of short-acting opioids, such as morphine, which are probably the best drugs for the management of burn-induced pain, according to the study 1
• The potential benefits of inhaled nitrous oxide, especially when no intravenous access is available, as mentioned in the study 1
• The importance of non-pharmacological treatments, such as cooling limited burned surfaces and covering burns with a fatty substance, which might improve pain control, as suggested by the study 1
• The potential use of virtual reality or hypnosis techniques to reduce the intensity of pain and the patient’s anxiety, as stated in the study 1 It is essential to titrate drugs to reduce the risk of under- and overdosing, considering the inflammation, hypermetabolism, and capillary leakage triggered by burn injuries, which may increase the risk of adverse effects from analgesics or sedative drugs, as explained in the study 1. Regular reassessment of pain using age-appropriate scales is crucial to adjust the regimen as needed, and a multimodal approach to pain management is necessary, as burns activate multiple pain pathways simultaneously.

From the Research

Managing Uncontrolled Burn Pain

• The management of burn pain is crucial to improve patient outcomes and reduce potential morbidities, especially in pediatric patients 2.
• A multimodal approach to pain management is recommended, combining pharmaceutical and non-pharmaceutical techniques, such as cold running water, multimodal distraction devices, hypnotherapy, and bubbles 2.
• Opioids, such as fentanyl, nalbuphine, and ketamine, have been shown to be effective in controlling acute pain in burn patients, whereas gabapentin and lidocaine did not show any efficacy 3.
• However, the efficacy of opioids in managing burn pain can be reduced due to alterations in the functional state of the immune system and the expression levels of receptor, effector, and signaling molecules within the spinal cord's dorsal horn 4.
• Different opioids may signal preferentially via differential signaling pathways, implying that burn injury may reduce the antinociceptive potency of opioids to different degrees, in a drug-specific manner 4.

Pharmacologic Management

• Combination therapies can increase the efficacy and reduce toxicity of pain management by offering a multimodal approach that targets different receptors in the peripheral nervous system and central nervous system 5.
• A stepwise algorithm approach to pharmacologic management is recommended, assessing the chronicity and type of pain to guide treatment 5.
• Patient-controlled analgesia and opioid-based analgesia, including challenges of effective opioid therapy in opioid-tolerant patients and opioid-induced hyperalgesia, are important considerations in burn pain management 6.

Pediatric Considerations

• Pain management is crucial in reducing pain and anxiety in both pediatric patients and their parents, and should be commenced from initial contact with healthcare workers 2.
• Uncontrolled pain can negatively affect pediatric patients, both short and long term, and may cause anticipatory anxiety for future medical procedures, decreased wound re-epithelialization, and increased risk of post-traumatic stress disorder 2.