Burns Flashcards
Learning Points
By reading this article you should be able to:
- Describe the epidemiology of major burn injuries and the possible mechanisms of injury.
- Recall the structure and function of the skin.
- Use burn depth classification and surface area to assess a patient’s burn wound.
- Describe the initial management of a major burn.
Key Points
- An adult with a major burn, defined as >15% of total body surface area burned,
will require resuscitation and care at a specialised burns service. - Depth of burn is assessed by the degree that the dermis has been affected
and determines subsequent surgical management.
3.Major burns have local tissue and wider systemic effects.
In burns >25% total body surface area,
a systemic inflammatory response occurs.
- Timely but safe transfer to a specialist centre is often required
with attention to airway, invasive catheters,
fluids and temperature maintenance - Early surgical management with
total or near-total burn wound excision in <48 h of injury
has been shown to decrease blood loss,
burn wound sepsis and length of stay.
Epidemiology
Risk factors
Risk prediction
Low socioeconomic status;
overcrowding; households where young girls have domestic roles;
kerosene;
generalised poor health; and poor safety practices
Burns are a preventable injury and strategies to decrease the incidence focus on awareness,
education and health and safety legislation.
revised Baux score, which takes into account age, %TBSA burned and the presence of inhalation injury.
The point of futility with 21st century burn care is now 160 and the Baux50 (the Baux score at which predicted mortality is 50%) is 109.6
Pathophysiology
The epidermis cannot regenerate without the presence of dermal tissue
Epidermis
1. Fluid Loss
2. Barrier to micoorganisms
3. Immune system activity
4. Neurosensory
Dermis
Rregulation Body temp
-dermal vascular plexus
-Sweating
- Piloerection
Responsible for skin druability and flexibility
Classifcation
- Superficial
Upper Dermis damaged -
Vascular plexus and adnexal structures intact - Deep partial
Deep dermis
affecting vascular plexus
not all dermis destroyed
Deep adnexal intact - FUll thickness
Extended entire thickness of dermis
no dermal tissue remains
Clinical characteisitcs
- Superficial Partial thickness
Pale pink moist
Blisters form fluid leak because blood vessel damage
Very painful exposed nerve endings - Deep partial thickness - Drier, Red, Non blanching
dermal plexus coagulated by heat
less sensate - Full thickness burns waxy and white
Charred and not painful
Local and systemic effects of major burns
CVS
Hypovolaemia
Myocardial depression
reduced Co
Vascular
Increased cap permeability
Na and protein leak
Tissue Oedema
Resp effects
Bronchoconstriction
ARDS
Periperhal and splanchnic vasocon
AKI
Ileus
GI Stress ulcer
Fluid resus
Tissue oedema
Oedema
ACS
Systemic inflammatory response
HPA Activation
ADH
SNS RAA
Hypercoag
Initial management
First aid
1. First aid at the scene is vitally important in burns and can prevent more severe injury. In particular there is a strong evidence base that a burn should be managed under cool or tepid running water for 20 min even up to 4 h after the injury is sustained
- By arresting tissue damage, wounds are not as deep as they otherwise would have been, with subsequent improvement in healing and decreased scar formation
- op the burning process, cool the burn and then cover in a non-adherent dressing
- Burn must be cooled, the rest of the patient must be warmed to prevent hypothermia.
For chemical burns the patient should be removed from the area of exposure and all contaminated clothing removed. Chemical burns should be irrigated with running water or sterile fluids
. Irrigation is key in such burns as removing the chemicals stops the burning process. It is recommended that acid burns be irrigated for 45 min and alkali burns for 1 h.
Airway and breathing
Indications for intubation are:
- reduced conscious level requiring airway protection
(e.g. because of head trauma during escape from a fire also requiring c-spine immobilisation, - systemic toxicity from inhalation injury, medical or substance use causing collapse);
- actual or impending upper airway obstruction owing to deep neck,
- perioral or intra-oral burns and oedema;
- respiratory distress from inhalation injury requiring ventilatory support; or to facilitate safe transfer to a burns centre.
Inhalation injury
+
Intubation
Hot gas causes direct burn injury to the upper airway, particulate matter and chemicals enter the lower airways causing acute lung injury and carbon monoxide and hydrogen cyanide cause systemic toxicity. Inhalation injury is more common if facial burns are present, but not all patients with facial burns have an inhalation injury.
Signs and symptoms include cough, soot in the nose, mouth and sputum and singed eyebrows and nasal hair, but in the absence of a facial burn these are unlikely to signal an airway emergency.
Voice changes, hoarseness and stridor, however, are particularly concerning as these signs may not develop until swelling is already obstructing the airway
plan for a difficult intubation including a surgical airway as the tissues may be erythematous, ulcerated and distorted by oedema.
A videolaryngoscope should be used if available and an uncut tracheal tube is vital to allow for further soft tissue swelling that might otherwise make a cut tube recede into the mouth. A larger-diameter tracheal tube is preferable to facilitate bronchoscopy and respiratory toilet.
Ventilation
In full thickness burns the dead tissue or ‘eschar’ is non-compliant and may prevent adequate ventilation and adversely affect cardiac pre-load, necessitating escharotomies to the chest before transfer
Impaired gas exchange may also be the result of inhalation injury and associated carbon monoxide poisoning.
Hypoxaemia will persist despite adequate oxygen saturation by pulse oximetry, so it is important to check the co-oximetry results on an arterial blood gas
The time to carbon monoxide washout is reduced by ventilation in 100% oxygen, but hyperbaric oxygen therapy is not currently recommended.22 Patients’ lungs should be ventilated with 100% oxygen until the carboxyhaemoglobin level is <3%,
Hydrogen cyanide poisoning should be considered in patients with inhalation injury, cardiovascular instability and increasing blood lactate levels not responding to treatment, and the specific antidote – hydroxycobalamin – should be given
Circulation
Burns and burn shock are not an immediate cause of hypovolaemia. Any haemodynamic instability must be assessed as possible bleeding in the first instance
Ideally, access is not placed through burned tissue but this may be unavoidable and if unable, intraosseous access must be gained before proceeding to definitive central venous access.
The Parkland formula guides resuscitation
fluids in the first 24 h for burns of >15% TBSA.
The principles are as follows:
Parkland formula: 2–4 ml × actual body weight (kg) × %TBSA burned
Parkland formula
The Parkland formula guides resuscitation
fluids in the first 24 h for burns of >15% TBSA.
The principles are as follows:
Parkland formula: 2–4 ml × actual body weight (kg) × %TBSA burned
–
From the time burn sustained
–
½ in first 8 h, ½ in subsequent 16 h
–
Subtract any fluid already given
–
Use warm, isotonic balanced crystalloid
Disability
Disability
Reduced Glasgow Coma Scale at presentation in major burns is not caused by the burn itself and must lead to a search for the cause and appropriate management. As described previously, these include poisoning by inhaled toxins (carbon monoxide and hydrogen cyanide); overdose; trauma including head injury and medical comorbidities leading to collapse.
Exposure and estimation of % TBSA burned
All clothing and jewellery must be removed; however, exposure of the patient must be kept to a minimum as almost all major burns patients become hypothermic.
Erythema alone is not counted in the estimation of burn surface area. All areas of superficial partial thickness burn or deeper are included
Lund and Browder chart or the Wallace Rule of Nines,
but more recently the
Mersey Burns app has gained popularity for ease of use and accuracy
Wallace’s rule of 9s
Head and Neck
Upper limbs 9
Trunk 36 (18 front + 18 Back)
Lower limbs 18 each
Genitals 1
Indications for escharotomy
- Initial surgical management at the referring centre
should be either life or limb saving. - Escharotomies are surgical incisions through
non-compliant full thickness burn, - which restricts ventilation on the
chest and abdomen or - causes significantly reduced perfusion in
circumferential burns to the limbs - Escharotomies to produce decompression should be performed as soon as they are required for ventilation or perfusion;
- the incision is longitudinal from unburned skin to unburned skin if possible, and deep enough to reach subcutaneous fat and release the eschar
- Anaesthesia will be required,
diathermy is usually used so blood loss should be minimal
and prophylactic antibiotics should be given.
Secondary survey
- Other common areas of injury in major burns include
corneal damage and
examination with fluorescein stain is required. - Risk of rhabdomyolysis, and a creatine kinase level should be measured.
- Pain relief using intravenous opioid titrated to effect should be given
- Decompression with NG
- Routine abx - not required
Criteria for referral to a specialist unit and initial management
- All major burns will need referral and transfer to specialist services.
- Severe burns thought to be non-survivable should also be discussed as accurate estimation of burn size, site of donor areas, age and comorbidities are essential in making this decision, which is best done using the expertise of the burns centre.
Goals
- Occurs after resus + stabilisation
- Scure airway - resus oedema - worsens
NG - Not intubated - sat up - oedema
- Invasive monitoring
- Lines secured w/ sithces
- Provision for large volumes
COnsider vasopressor - Active warming - lose heat / severe hypothermic / acidotic
Probably shouldnt delay to heat an already cool - Cling film - not too tight for blood flow
Acceptance flow sheet
Place
Admission room
burns theatre
Burns ICU
People
Burn teams members
Plan
Shared decision
Prep space admission
Warmed room
Equipment / Monitor / Machine checks
Drugs + Fluids
Dressings
Theatre equipment + diathermy
PPE
Team leader
Introducition transfer team
Confirm weight
Move to warm room
Exchange of monitor / infusion
Stability
Handover
questions to complete
Transfer complete
Primary survey - surgical team
Emergenecy resus / interventions PRN
Secondary survery + interventions
Anaesthetic
Airway secure
Monitoring
Vascular access
Plan for ongoing anes / sedation
warming devices
Infusions check
Bronch
Feeding tubes
cyano kit
Surgery
Complete surveys
Confirm TBSA + depth
Surgical plan
Consent
Eyes
Photographs
Cathter
shave
eschartomy
Dressigs
BICU
Hopsital id
admit
Height
bands
Bloods
Swabs
Infusions
Blood alcohol / Tox
Dressings as appropriate
GP summary
ALL
Confirm Resus plan
Surgical plan
WHO checklist
Huddle + Transfer
Burn and crit care needs - all members
WHO sign out
Prep transfer
Notes
radiology
update familly
Early surgical Mx
Debrieded
Deep and partial - tissue excision
wound closure grats
Removal within 5 days
Reducing nectrotic load
drives SIRS
Decreases Blood loss / sespis + LOS
Improved cosmetic outcome
Wound closure
decrease fluid loss
Prevent dessiccation
infection
Temporay
covering allogtraft
synthetic skin subs
Perm autology SSG
SSG - gold strandard
Ability cover all permanent -
size area
availibity donor sites
Major burn undergo repeated ops
dressing changes
Specialist ICU care
Burns 2
By reading this article you should be able to:
*
Describe the main challenges of caring for a patient with major burns in the operating theatre or ICU.
*
Explain the ways for optimising intravenous fluid therapy to avoid under- and over-resuscitation.
*
Outline how to recognise and manage infectious complications in patients with major burns.
*
Illustrate the pharmacological and non-pharmacological techniques available to mitigate the hypermetabolic response to burn injury.
1Key points 2
1 Involvement of the multidisciplinary burns team is vital for the care of patients with major burns.
*
- Thermoregulation, blood loss and coagulopathy are key considerations for the anaesthetist during surgery for major burns.
* - The Parkland formula should be used to guide resuscitation and fluids titrated to urine output, haemodynamic and laboratory variables.
* - Human albumin solution, given in addition to crystalloids, may reduce fluid requirements.
*
5.The hypermetabolic response to major burns can be attenuated by early excision, appropriate nutrition and specific pharmacotherapy.
Conclusions
As a result of vast improvements in burn care in recent decades,
clinicians are now responsible for managing patients
who have suffered burn injuries of increasing severity and complexity.
It is challenging to provide high-quality anaesthetic and intensive care.
These patients often require numerous and complex surgical interventions.
Areas that require special focus include
airway management,
management of blood and fluid loss,
thermoregulation and
overcoming monitoring difficulties.
Patients who have suffered major burns are
also at high risk of infection,
excessive catabolism,
significant pain and psychological distress,
all of which are associated with adverse long-term consequences.
Managing this myriad of complex issues
requires expert input from a wide multidisciplinary team.
Anaesthesia and burn surgery
Subsequent operations including temporising
cadaveric autografts,
xenografts (such as pig skin) or
synthetic dermal substitutes until
skin coverage with autografts is possible
(using unburned patient donor skin)
elective surgical procedures are frequently required to help restore function and improve cosmesis
Location of surgery
Burns surgery should be carried out in a
dedicated burns operating theatre,
ideally in close proximity to intensive care facilities.
appropriately warmed in order to reduce heat loss
Preoperative assessment
Should include knowledge of the extent of the burn,
associated injuries and details of the planned surgery,
including positioning needed a
nd estimated blood loss
Given the large volumes of i.v. fluids often required
and the potential for associated renal injury,
a thorough assessment of circulating volume status
and electrolyte abnormalities should also be made
Nutritional support should generally be continued
throughout the operative period in patients who have
been mechanically ventilated before surgery,
and fasting times kept to a minimum in those requiring airway intervention.
Airway
- Airway assessment should include clinical examination and a careful review of previous anaesthetics
- ventilation may have already been established before transfer to the operating theatre, particular care is required to prevent accidental extubation,
- Formation of a tracheostomy may be indicated for various reasons and is commonly required for patients with complex facial burns in order to maintain skin health around the mouth and nose
- Burns involving the face or neck may not present any airway difficulties initially, subsequent contractures may severely limit neck extension and mouth opening.
- Advanced techniques such as awake fibreoptic intubation may be indicated. A difficult airway trolley with equipment for emergency front of neck access should always be immediately available.
Intraoperative management
Monitoring
Temp
- Monitoring can prove challenging.
Electrocardiogram electrodes sometimes require sutures or skin clips for reliable contact.
- Pulse oximetry and blood pressure cuff positioning may also be difficult, and suitable sites for i.v. access and direct arterial monitoring may be limited
- It is mandatory to monitor the patient’s core temperature.
- Methods to minimise heat loss include minimising exposure,
using forced air warmers and heat lamps,
humidifying anaesthetic gases,
infusing warmed i.v. fluids and maintaining
an ambient temperature in theatre of 28–33°C.
Ventilation
Care should be taken to assess a patient’s ventilatory requirements preoperatively and lung protective ventilation should be continued throughout the intraoperative period.
Patients who have also suffered an inhalation injury may have increased requirements for oxygen and PEEP.
particularly important to avoid alveolar derecruitment with the loss of PEEP during transfer to a transport or theatre ventilator
increased oxygen consumption and carbon dioxide production, higher than expected oxygen concentrations and minute volumes may be required.
EBL
Blood loss can be as much as 3.4% of
total blood volume for each per cent TBSA excised
Rsks are increased in patients with infected burn tissue, deeper thickness burns and by prolonged operative time
Reduced
Tourniquests
Topical adrenaline
compression
TEG
General vs regional anaesthesia
Most patients with major burn injuries will require general anaesthesia for surgical interventions. However, regional anaesthesia, either alone or in combination with general anaesthesia, may be suitable
Intensive care management
Fluids
Fluid management
- Under-resuscitation may lead to
impaired tissue perfusion,
end organ damage and
extension of burn depth
Risks excess
electrolyte disturbances such as hyponatraemia,
exacerbation of tissue oedema,
pulmonary and cerebral oedema,
abdominal and limb compartment syndromes.
Fluids formulae
The Parkland formula remains the most commonly used tool to calculate fluid requirements
May overestimate
Suggestions Initial calculation by Parkland
then regular reassess - de esclation
based on physiology
Goal-directed fluid therapy
The most common and easy method of ensuring appropriate fluid resuscitation is by targeting an hourly urine output of 0.5–1 ml kg−1 ideal body weight.
< 0.5ml/kg/hr
Fluid challenged 250 x3
Increased norad
Increased baseline 10%
1-2
Reduce by 10%
> 2
Reduce 25%
Consider Colloid resucse
if >6ml/kg TBSA
1/3 crystalloid w/ 4.5 Albumin
Persiste low urine out
Other than under-resus
Renal failure from
acute tubular necrosis or
rhabdomyolysis can result in
oliguria, as can
increased anti-diuretic hormone release in response to injury
asoplegia, low cardiac output and abdominal compartment syndrome should also be considered.
Reassess
- peripheral perfusion
MAP
PPV - BLood lac
HCT
BE - Cardiac Output monitor
- Measure IAP
Choice of fluid
Choice of fluid
Balanced crystalloids such as Hartmann’s solution are the mainstay of fluid resuscitation in major burn injuries.
reduce the incidence of significant electrolyte disturbances such as hyperchloraemic metabolic acidosis
Fluid Creep
colloids such as human albumin solution in combination with crystalloids may reduce overall fluid volume requirements, mitigate against ‘fluid creep’ and lessen increases in intra-abdominal pressures compared with crystalloids alone
Thermoregulation
thermodysregulation, with an initial propensity to hypothermia driven by heat and fluid loss from the burn wounds themselves
Most patients with major burns will subsequently develop a raised core temperature.
<-
hypothalamic setpoint for thermoregulation by pyrogens such as interleukin-1 (IL-1) and tumour necrosis factor.
Temperatures exceeding 40°C, can occasionally occur
and may lead to multiorgan failure
Techniques include debulking dressings, giving antipyretics such as paracetamol, applying ice to non-burned areas, infusion of cooled i.v. fluids, and irrigating the bladder and stomach with cold fluids. More invasive approaches such as intravascular heat exchange catheters or extracorporeal circuits may also need to be considered.
Nutrition
Basal metabolic rate can increase significantly after a burn injury, more than doubling in patients with burns >40% TBSA
- loss of lean body mass, immune compromise and impaired healing.
= loss of lean body mass and adverse events, including infectious complications and death
Timing of nutritional support
Benefits Early
- enteral nutrition in the hours immediately after injury
has been shown to have
beneficial effects on stress hormones,
improve gut integrity,
reduce intensive care length of stay,
improve wound healing and
reduce wound infections.
- Enteral nutrition should be started as soon as possible
in major burns, ideally within 6–12 h after the injury. - Total body weight loss should not exceed 10% of the patient’s weight at admission.
Route of nutrition
As with most critically ill patients,
the enteral route is preferred.
Postpyloric feeding may be required if
gastric stasis is present and impairing calorie delivery
risk of aspiration, especially in patients requiring multiple interventions under general anaesthesia
Parenteral nutrition is rarely required, but when used, caution should be exercised because of the associated risks including infection, overfeeding and erratic blood glucose control.
Aim nutrition
Overfeeding complications
The aim of nutritional support in patients with major burns
is to meet the substantially increased caloric requirements
in these patients while avoiding harmful overfeeding.
Complications of overfeeding include
1. hyperglycaemia,
2. hypertriglyceridaemia,
3. hepatic steatosis,
4. hypercapnoea and
5. prolonged duration of mechanical ventilation.
How Assess Nutrition
specialist input from a dietician within the burns team is essential.
Most accurate method is indirect calorimetry,
but this remains mainly a research tool.
Formulae
Harris–Benedict
Toronto
Harris Benedict
Men: 66.5 + 13.75 (weight in kg) + 5 (height in cm) – 6.76 (age in yrs)
Women: 66 + 9.56 (weight in kg) + 1.85 (height in cm) – 4.68 (age in yrs) Multiplied by factor determined by burn size:
<20% TBSA ×1.5
20–40% TBSA ×1.6
> 40% TBSA ×1.7
Macronutrients
carbohydrates, proteins and lipids –
provide substrates
- for adenosine triphosphate (ATP) biosynthesis,
- wound repair,
3.immune function and - maintenance of lean body mass
- Carbs preferred
Prevent reliance muscle proteolysis
Solely = hyperglycaemia
Insulin resistance in critically ill
Glucose 55% total energy requirement
Hyperglycaemia managed
*
- Excess lipid
Accum liver
Impaired immune function
15-30%
(propofol)
*
- Protein - wound repair
maintenance LBM
Increasing protein intake - supraphysiological values - doesnt prvent catbolism
PRevents negative nitrogen balance
15-g-2g
Protein enriched feeds
Micro nutrients
copper,
selenium, zinc and
vitamins B, C, D and E may become
depleted because of the intense inflammatory response,
exudative losses and haemodilution
resulting from resuscitation with i.v. fluids.
antioxidant defences, wound healing and immune function.
uce infectious complications, improve wound healing and reduce intensive care length of stay.17
Infection
The loss of skin, the primary barrier to infection, coupled with relative immunosuppression in patients with major burns lead to an increased risk of infectious complications.
estimated 42–65% of deaths after burn injury.
Burn wound colonisation and infection
Patients can become colonised with multiple, often resistant, organisms.
Consequently, specific criteria for the diagnosis of sepsis in patients with burns have been proposed
(i) Temperature >39°C or <36.5°C
(ii) Heart rate >110 beats min−1
(iii) Ventilatory frequency >25 bpm
(or minute ventilation >12 L min−1 if invasively ventilated)
(iv) Thrombocytopenia <100×109 L−1
(>3 days after initial resuscitation)
(v) Hyperglycaemia >11.1 mmol L−1 or
insulin infusion dose requirement >7 units h−1
(vi) Intolerance of enteral feed
Biomarkers
With such difficulty in relying on clinical signs and traditional biomarkers such as C-reactive protein (CRP), other markers such as procalcitonin (PCT) may have better discriminatory capacity in diagnosing sepsis in patients with major burns
Rx infection
Patients with infections should be treated with appropriate antibiotics, ideally as advised by the medical microbiology team and based on colonising organisms. Surgical debridement may be require
Common pathogens
- Gram-positive bacteria such as
Staphylococcus aureus,
Streptococcus and Enterococcus species. - Gram-negative bacteria such as
Pseudomonas aeruginosa can translocate from the
gastrointestinal tract or the environment
and thrive in the moist environment of a burn wound.
typically green/yellow colour and foul smell and can lead to invasive infection with necrosis. - Resitance
VRE
Recognised risk factors include the use of broad-spectrum antibiotics, colonisation at hospital admission, need for escharotomy, prolonged hospital or intensive care stay and multiple surgical procedures
- Fungal colonisation and invasive fungal infections are also significant problems.
Candida albicans is the most common pathogen
Toxic shock syndromes
Toxin-producing strains of S. aureus can cause toxic shock syndrome (TSS)
group A Streptococcus, has a similar presentation
macular rash, vomiting and diarrhoea, thrombocytopenia, lymphopenia and deranged liver function tests.
reduce exotoxin production, such as clindamycin and linezolid, should be considered.
Hypermetabolic and inflammatory response
Most pronounced in the acute phase,
some changes can persist for several years
after a burn injury has healed
(i) Increased resting energy expenditure
(ii) Increased serum and urine cortisol and catecholamines
(iii) Increased cytokines including
IL-6, IL-8 and granulocyte colony-stimulating factor (G-CSF)
Appropriate skin closure, nutritional support and analgesia are fundamental to mitigating this response. Several therapies have been proposed,
Long-term effects of burn injuries.
1.Immune
Increased incidence of respiratory infections (influenza, pneumonia)
Increased hospital admissions with infective diseases
Increased mortality from infections
*
- Cardiovascular
Increased risk of ischaemic heart disease,
hypertension,
heart failure and stroke
Reduced exercise tolerance
Myocardial fibrosis
*
- Gastrointestinal
Increased risk of disease of alimentary tract,
gallbladder, biliary tract and pancreas
Increased hospital admissions with diabetes mellitus
- Musculoskeletal
Increased fracture risk
Joint pain and stiffness
Reduced mobility
Increased hospital admissions with musculoskeletal disorders
*
- Central Nervous
Increased hospital admissions with epilepsy, migraine and nerve problem
*
- Miscellaneous
Increased all-cause mortality
Increased cancer risk (perhaps worse in females)
How to prevent long term effects?
Beta-blockers
Beta-adrenergic blockade with drugs, such as propranolol, suppress the catabolic effects of a burn by reducing energy expenditure, limiting insulin resistance, preventing muscle wasting and acting as anti-inflammatory agents
wound healing and reduced muscle catabolism
*
- Oxandrolone
Oxandrolone is an androgen receptor agonist,
which stimulates protein synthesis and muscle growth
with much less virilising activity than testosterone,
making it more suitable for use in women and children
minimise weight loss, improve urinary nitrogen balance, increase muscle strength and reduce healing time.
Pain management
Types of pain
Background pain
Breakthrough pain
Procedural pain
Pharmacological management
Opioids
Non-steroidal anti-inflammatory drugs
Ketamine
Gabapentinoids
Gabapentin and pregabalin
Dexmedetomidine
Psychological sequelae of burn injuries
Pain management
Nurn injury can be excruciating and is often difficult to manage. Some studies suggest higher pain scores during hospital admission are associated with poorer long-term outcomes such as increased mental health problems
the complexities and challenges of effective pain management, a specialist pain service should be an integral part of the burns team
Types of pain
Although the burn injury is usually the most significant source of pain,
there are many other causes.
These include pain from associated injuries,
tracheal tubes,
invasive lines and catheters,
skin autograft donor sites,
pressure areas and
interventions including position changes
hree main types of pain: background, breakthrough and procedural pain.
Background pain
Patients will experience a degree of persistent pain after a burn injury and multimodal analgesia should be prescribed to maintain adequate control
. Infusions should be titrated to a targeted effect, maximising clinical benefit while avoiding unwanted adverse effects.
Critical Care Pain Observation Tool (CPOT) for use in the ICU
Non-pharmacological measures such as
appropriate dressings,
comfortable positioning,
cutaneous stimulation,
acupuncture
and techniques such as
cognitive behavioural therapy and
music therapy may also help alleviate this form of pain
Breakthrough pain
Breakthrough pain occurs on top of
well-controlled background pain,
either as an exacerbation of background pain
or originating from another source.
evoked, spontaneous, predictable or unpredictable
managed with boluses of rapid-acting agents, increases in the rate of opioid infusions or, if predictable, anticipatory doses of longer-acting agents.
Procedural pain
Procedural interventions include
dressing changes and mobilisation.
Analgesic interventions should be timed appropriately
to gain the maximum benefit from the agent being used
Include opioid boluses,
inhaled agents including nitrous oxide and
methoxyflurane or analgosedative agents such as ketamine
Other non-pharmacological methods may be beneficial, including hypnosis, virtual reality systems and other distraction techniques
Pharmacological management
Opioids
Opioids remain the mainstay of pain management in burn injuries.
patient factors including renal function and conscious level.
Patient-controlled analgesia (PCA) is commonly used
but relies on a conscious and alert patient
significant burn injuries often require large doses of opioids. Adverse effects include ileus, respiratory depression, delirium, hypotension and potentially dependence.
Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs such as ibuprofen and diclofenac are infrequently used in critically ill patients because of the potential risks of gastrointestinal haemorrhage and renal impairment. Although they may be of benefit in selected patients, they should be used with caution.
Ketamine
Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist
with potent analgesic effects.
Ketamine can be given as an i.v. infusion,
often to reduce opioid requirements,
or in sedative or anaesthetic doses for painful interventions.
Ketamine may also have a role in preventing the
development of neuropathic pain and
has been shown to reduce secondary hyperalgesia
and ‘wind-up’ phenomenon in healthy volunteers
Wind up
Wind-up is a frequency-dependent increase in the excitability of spinal cord neurones, evoked by electrical stimulation of afferent C-fibres.
Gabapentinoids
Gabapentin and pregabalin have been used in the
management of burn pain and pruritus,
both acutely and in those who develop chronic symptoms
improved pain scores and reduced opioid consumption.
g evidence of harm from dependence, abuse and overdose, they should be used with caution
Dexmedetomidine
Dexmedetomidine is a highly selective
α2 receptor agonist with both analgesic and sedative effects.
It can be used in the ICU as part of an analgosedative regimen,
in combination general anaesthesia,
as a sedative for painful procedures and also as an adjunct in PCA
dexmedetomidine are bradycardia and hypotension
isk of pyrexia associated with dexmedetomidine use, caution is advised in the context of hypermetabolism after burns.
Psychological sequelae of burn injuries
Survivors of burn injuries can be left with long-lasting mental health problems such as
depression,
anxiety,
suicidal ideation and
post-traumatic stress disorder (PTSD).
ognitive impairment, physical limitations, chronic pain and pruritus
post-intensive care syndrome (PICS
Burns Risk factors
Patients with major burns often have a
prolonged hospital admission,
numerous invasive procedures,
multiple risk factors for developing delirium
and significant pain issues
Rx
Psychological support staff should form part of the multidisciplinary team.
Routine psychological assessment is advised and
robust care pathways should be in
place in order to provide help and
support to burn victims and their families
support groups, charities, websites and opportunities for peer support
psychosocial screening may help identify patients at the highest risk of developing problems after burn injury, allowing prompt intervention to address the psychological, emotional and social challenges these patients may face.
