Pain in burns
Burn is a trauma that requires special, intensive and long-term treatment. Thermal damages contain many complex phenomena together. In the U.S., there are more than 2 million burn injuries every year. Thermal burns are the most common type, as well as electrical and chemical burns. A very high stress response occurs in burn patients due to coagulation disorder due to massive tissue thromboplastin secretion. Pain therapy in acute phase is one of the most important factors that will be effective in healing to reduce stress response. Multidisciplinary follow-up is needed. Multidisciplinary emergency burn treatment teams including doctors in different branches for burn patients are established and thermal injuries Are tried to be treated.
There are various causes of pain in different types of burns in different types of burns. Knowing what causes them and what kind of pain they are causing is an important part of the treatment. Several neuronal and chemical mechanisms are responsible for burn injuries. Shortly after the damage to the follicle, histamine, bradykinin, prostaglandins are secreted and an acute inflammatory process is initiated. Nociceptors located outside the acute inflammation related pain respond to chemical stimuli (thermoreceptors), mechanical distortions (mechanoreceptors) and both exogenous (chemical burns) and endogenous (polimodal receptors). The resulting pain stimulus is carried by the dorsal root with both myelinated delta (20%) and non-myelinated C axons. It plays a role in the sensation of peripheric and central mechanisms such as the formation of a network at the level of the dorsal root, or at the upper centers (reticular tract, thalamus) and cortical complexes. Since the formation of burn pain is a complex phenomenon, each patient's pain should be assessed separately, and patients and their pain should be treated with psychological and social dimensions.
In particular, analgesic treatment in burn pain is totally patient care rather than pharmacological approach. Approximately 30% of patients develop depression, often with appropriate treatment. In addition, physical factors as well as post traumatic stress and related anxiety and panic play an important role in pain formation. There is also a direct correlation between pain and anxiety in patients.
It is known that physical trauma in burn patients is as common as psychological trauma. Negative emotional conditions, such as anxiety and depression, caused by burn injuries can directly increase the pain the patient is hearing. In every step of the treatment of pain, a careful and close psychological support should never be overlooked.
As in all pain types, the perception of pain in the pain of burn patients is affected by medical, demographic, personal, situational and physiological factors.
The incidence of pain grade and pain behavior in burn patients varies according to many factors such as age, sex, ethnicity, education. One of the most important characteristics of burn patients is that they have a wide range of patient groups from newborn to geriatric age group. Pain is felt the same way, but pain behavior varies with age. Pain behavior in children is more aggressive.
The severity of burns depends on the depth, breadth and localization of the wound.
Burns are classified with three degrees according to their depth. By gender, pain varies in character.
First Degree Burns:
Contains the superficial layer of the epidermis and heals within 1 week without scarring. At this level Pain in burns is a characteristic that is described mildly or moderately. There is usually no pain in the first 24 hours.
Second Degree Burns: These burns are caused by partial burning of the dermis layer, resulting in redness and pain, as well as water sacs. The pain is severe, flammable and sinking.
Third Degree Burns: These are prominent Burns that have an image of whitish (boiled burns) or charcoal (burns from high heat sources such as open flames) without affecting the entire dermis layer and forming water vesicles. Grade 3 Due to the nerve damage in the burns, pain is usually present due to edema and inflammation surrounding the burn, although there is usually no pain in the burn area. Pain is acute onset and severe.
Burns are often seen as a mixture of more depth in one area. Theoretically, the wider surface of the burn is more painful and the deeper burns cause less pain. In practice, however, this theory is not valid since epidermal superficial and deep dermal burns coexist. In addition, the nerve endings are mechanically hyperalgesia due to arachidonic acid metabolism and central mechanisms in fully damaged tissues, leading to a more severe and persistent pain. Because of all the nested mechanisms, burn pain is a type of pain that is recognized by the patient and many factors play a role. Detection of burn depth may be time consuming, but burns should be started quickly because burns that are sterile within the first 24-48 hours may still be infected if not properly treated.
The pain level of the wound will help determine the severity of the burn. In the first degree burns, the pain must disappear in the first 24 hours. Deeper Burns will cause pain at an increasing rate.
Burned patients are examined in three periods. These are acute, subacute and rehabilitative phases.
Reducing stress response and providing maximal perfusion and oxygen delivery to burned tissues is the main goal. In addition, caution should be exercised in ensuring vital signs and stabilization. The acute phase is the phase in which the resuscitation of the patient is the forerunner. Post traumatic stress and massive and nociceptive stimulation of the affected tissue constitute the source of pain. Patient controlled analgesia (PCA) is the most effective method for patients with different pain responses. However, bolus doses are absolutely necessary at the beginning of treatment. Pain intensity is a finding that increases the stress response of trauma.
From acute phase to wound closure. In this period, wound care is the focus. Subacute periods include debridement, skin grafting, dressing, analgesia and anesthesia. In the subacute period, different types of pain can be seen together in patients. Acute surgical pain, painful dressing, postoperative pain, and continuous pain from injured tissue and open nerve endings can be seen.
It is a long-standing period that requires a series of surgical reconstructions, starting with the discharge process from the patient and afterwards. In this period, neuropathic pain is frequently confronted with pain except surgical pain. It is also the pain of the rehabilitative phase in sympathetic pain.
Burn pain is not an entity alone. It includes various components that cause patients to experience a severe and prolonged pain. Patients are described as the worst of pain experiences on the side. However, acute phase after burn in burn patients is mainly due to interventions and complications. Our clinical observation is that the severity of pain varies at different times of the day in subacute phase patients. While at rest, the pain is partially alleviated, but when therapeutic procedures such as dressing, physical therapy are applied, they are suffering from severe pain. As a result, burned patients should be followed up continuously by pain teams and a continuous pain palliation should be provided by evaluating each period separately.
Acute phase pain
Patients admitted to the burn unit were also treated with wound care, fluid resuscitation, and systemic resuscitation, which is of primary importance in the first 72 hours. However, it is also important that the patient's analgesia is initiated at an early stage and that the stress-induced anxiety is removed, and plays an important role in the patient's healing process. In our hospital, every patient who visits the burn unit is consulted simultaneously with anesthesia pain unit and acute pain treatment is started. Acute pain can be severe, widespread, or sometimes uncomfortable due to damage to nerve endings. However, even if there is no pain on the first visit, pain is not felt with the developing inflammation process.
Possible hypovolemia, reduced plasma volume and low cardiac output should be considered when selecting analgesic agents and method in acute phase therapy in burn patients. This is important because it will alter the pharmacokinetic properties of the drugs to be used. It should also be taken into account that central venous effects of drugs may change with changes in partial blood carbon dioxide levels due to hypoventilation.
The route and doses of the medicines should be selected according to the patient and the level of burns for the above reasons.
Regional anesthesia can be used if the burn injury is limited and it allows the intervention of a regional anesthesia technique. However, the use of regional anesthesia is limited because of the risk of sepsis and multiple restrictive conditions, such as large burns that often fall outside the scope of a single block of influence. Intravenous lidocaine has been shown to be effective in some burn patients. . Epidural and spinal anesthesia and analgesia are relatively contraindicated in the presence of hypotension or sepsis.
In the subacute period Burns are usually associated with interventions. Details of the 'Anesthetic Approach to Burnable Disease' section on pain and dealing with treatment during debridement, dressing, etc., in which the disease in this period is applied, are mentioned. Post-operative pain in the subacute period is treated as postoperative pain and pain treatments applied in acute period are applied.
In this period, neuropathic pain is frequently confronted with pain except surgical pain. It is also the pain of the rehabilitative phase in sympathetic pain. Neuropathic Pain A primary lesion in the nervous system is the pain caused or initiated by a dysfunction
From a clinical point of view, when neuropathic pain is examined, it is seen as a symptom of various diseases ranging from cancer to diabetes. Depending on the diseases that are also caused by localization, it can originate from a place between the peripheral receptor and the brain. Neuropathic pain is classified according to anatomic localization and etiology (Table 1).
There are two major types of neuropathic pain;
2-Alert-independent pain (spontaneous pain)
It is characterized by the findings of warning-induced pain (mechanical, chemical, thermal), hyperalgesia and allodynia.
Alert-independent pain can be paroxysmal or persian as a characteristic and can be diagnosed as fever, stinging and burning. Paresthesias defined as abnormal senses and dysesthesias defined as unpleasant abnormal senses may be spontaneous or alert. Neuropathic pain is also classified as central neuropathic pain, peripheral neuropathic pain.
Traumatic nerve injury
The autonomic nervous system also plays a role in neuropathic pain. Neuropathic pain caused by the autonomic nervous system is under the name of complex regional pain syndrome. Complex regional pain syndrome type I is referred to as reflex sympathetic dystrophy earlier than when it is not related to major nerve root damage. Complex regional pain syndrome type II is referred to as 'kosalgia' for major neuromuscular injury syndromes.
In a majority of patients with neuropathic pain, the entry of nerves into the regeneration phase can be achieved by good physical therapy and rehabilitation. In some patients, the event develops and chronic neuropathic pain syndrome develops. Many pain specialists do not accept pain as chronic pain unless it lasts for 3-6 months.
First, the patient is assessed in detail and a treatment strategy should be developed to identify the detectable mechanism (diagnostic work) and remove the underlying central nervous system dysfunction, thereby reducing the signs and symptoms of the related disease. Antidepressants, anticonvulsants, and antiarrhythmics may be used in the treatment of neuropathic pain.16 Randomized, controlled studies evaluating the efficacy of these drugs in reducing the symptoms of specific neuropathic pain or alleviating neuropathic pain in humans should be avoided today.
As a result, pain in burned patients should be treated with caution. Acute phase pain therapy should be initiated according to the differences in pain over time. Burn pain is a dynamic process. Patient and doctor relationship and trust are important. Treatment of burned tongue, treatment of pain and absolutely psychiatric support. We believe that the success rate of multidisciplinary treatment is higher.