Managing acute pain associated with major burns

Manage acute pain associated with a major burn in hospital under specialist advice. Pain is often severe, with mixed nociceptive and neuropathic components. Initiate multimodal analgesia early and manage each pain type concurrently.

Severe, acute nociceptive pain should be managed using paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) and intravenous opioids. High doses of intravenous opioids are often required for major burns; however, doses should be titrated to effect. Ideally, opioids should be delivered via patient-controlled analgesia (PCA). See Severe, acute nociceptive pain for drug regimens.

The neuropathic component of pain associated with major burns is managed with adjuvants. Gabapentinoids are commonly used (see Acute neuropathic pain). Low-dose ketamine or dexmedetomidine may be used with specialist advice if the patient is agitated or cannot take oral medications.

Pain often occurs with mobilisation, showering and wound care. Patient-triggered inhaled analgesics (eg methoxyflurane) are often used to manage this pain. More painful procedures may require ketamine or opioids—ketamine may be preferred because it carries a lower risk of respiratory depression compared to opioids (see Procedural sedation and analgesia for further advice). Nonpharmacological approaches (including virtual and augmented reality techniques) have also been used successfully (see c_agg7-c04-s1.html#agg7-c04-s1__tagg7-c04-tbl2). Anxiolytics are often used for procedure-related anxiety.