Most burn injuries are extremely painful, so burn patients need adequate pain treatment. Burn pain varies but is often very severe, especially the first few days post-injury. Pain is subjective, and in the acute phase, it is commonly overlooked by doctors for various reasons. It is important to pay attention to pain – to assess and manage it – for a burn wound patient.

Doctors may overlook pain as a result of other elements of treatment being prioritized, sometimes due to clinical reasons. The fact that an objective measurement of pain is not possible may contribute to pain management not being prioritized. However, with the rise in patient reported outcome measurements (PROMS), the importance of adequate pain management has become more evident.

It is essential to pay attention to pain and anxiety management in all phases of care, especially during wound inspection and cleansing.

General management of burns patients after 24 hours: Pain management and sedation

Pain assessment

Assess whether pain is due to the burn injury or caused by associated trauma. Use a validated patient reported pain assessment scale to monitor pain levels and always record the findings.

Adult pain scales

Visual Analogue Scale (VAS)

Numeric Pain Rating Scale (NPRS)

Child pain scales

For children aged over 3 years, use the Wong-Baker FACES Pain Rating Scale.

Wong-Baker FACES Pain Rating Scale

For children aged 0-4 years, use a behavioral pain scale:

FLACC Scale (Face, Legs, Activity, Cry, Consolability)

COMFORT Behavior Scale

Pharmacological approaches

Burn pain is highly variable and cannot be predicted by a clinical assessment of the patient. Therefore, a structured approach to burn analgesia that incorporates both drugs and alternative therapies is recommended.

WHO pain ladder

Use the World Health Organization (WHO) pain ladder as a guideline for the use of drugs in the management of pain. For example when changing a dressing on a wound.

1 Always start with step one, which is non-opioid analgesics (paracetamol or non-steroidal anti-inflammatory drugs—NSAIDs).

For wound dressings, you will often need to move to steps two and three:

2 Step two – ‘weak’ opioids – hydrocodone, codeine, or tramadol

3 Step three – ‘strong’ opioids – morphine, hydromorphone, oxycodone, fentanyl, or methadone

For example, 30 to 60 minutes prior to a planned dressing change, provide an oral opioid, such as 5-30mg morphine sulphate orally (immediate-release). Administer every 3-4 hours, when required.

For dressings of larger burn wounds, the use of ketamine is widely recommended, especially in children. Ketamine is relatively safe and very effective. It suppresses awareness and pain, while muscle function (including muscles of ventilation) remains unaffected. Follow hospital protocols for ketamine use during wound dressing.

During any procedure with sedation, monitor pulse oximetry and do not leave the patient alone.

Pharmacological treatment includes paracetamol (acetaminophen) and non- steroidal anti-inflammatory drugs (NSAIDs), which are both of benefit in treating minor burns, usually in the outpatient setting.

Non-pharmacological options

Multidisciplinary interventions from psychologists, physiotherapists and pain management specialists can contribute greatly to the burn patient’s recovery.

In general, there are four broad categories of non-pharmacological approaches to pain management:

• Distraction – e.g. virtual reality therapy, movies, singing
• Relaxation – e.g. breathing exercises, music, stress inoculation, aromatherapy, massage
• Hypnosis
• Cognitive behavioral therapy

Anxiety management

You must differentiate pain from anxiety. To do this, use the Burn Specific Pain Anxiety Scale (BSPAS) in addition to the pain assessment scale you are using.

The most helpful way to address anxiety with psychological support from caregivers, members of the treatment team or specialized experts, if available.

The patient may need benzodiazepines to relieve anxiety associated with their burn injury.