Pain management and burns

Although the perception of pain from a burn injury varies from one patient to another, burn wounds are incredibly painful, particularly in the acute setting. In spite of the importance of treating pain in burn patients, a paucity of evidence has been developed to define best practices. The management of pain in burn patients is based upon treating background pain, breakthrough pain, and procedural pain.  Education and expectation-setting about pain is crucial for patients and family members; they need to understand that pain will not be absent as they heal their burn, but that we will work with them to make the pain manageable. Our emphasis here in on the outpatient management of mild to moderate pain, and therefore will include only oral pharmacologic options.

Background pain

Background pain is the baseline inflammatory discomfort that is characteristic of burn wounds.  Background pain tends to be moderate to low intensity but persistent.  Pharmacologic management should emphasize medium duration acting agents administered on a consistent schedule with a goal of opioid sparing. Acetaminophen on an alternating schedule with an NSAID (for those patients who do not have a contraindication) provides a good foundation for pain control in acute burns. Mindfulness and relaxation techniques can be helpful non-pharmacologic adjuncts.

Breakthrough and Procedural Pain

Breakthrough pain may indicate inadequate management of background pain, a change in the progression of the burn wound (proliferation of skin buds OR infection), or discomfort from increased activity. Procedural pain includes pain associated with dressing changes or specific activities with burn therapy. Short-acting oral opioids are the cornerstone of pharmacologic management of breakthrough and procedural pain management.  Non-pharmacologic management techniques include relaxation techniques and use of distraction techniques, which may also help to alleviate anxiety.