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.

 

 

 

Acute phase:

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. Infusion of opioids with intravenous continuous or patient controlled analgesia is effective. However, bolus doses are absolutely necessary at the beginning of treatment. Pain intensity is a finding that increases the stress response of trauma.

Subacute period:

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.

Rehabilitative phase:

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.

 

 

PAIN TYPES:

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.

 

Opioids and Non-Steroid antiinflammatory drugs are the preferred agents in the first period.

Opioids can be administered by oral, intravenous, intramuscular, transdermal, rectal and central blocks.

Burn pain treatment with local pomades is not an appropriate option because the skin absorption is impaired during the acute phase. The slow onset of intramuscular analgesic activity, the ability to change the duration of absorption and analgesia with tissue perfusion is not preferred due to the fact that the blood level can vary from subterapatical to toxic. In addition, since intramuscular injections themselves are painful, intravenous route is preferred in acute pain treatment. The intravenous route is preferred because of its quick onset of action and ease of dose adjustment. Small burns may be enough on the oral route. However, oral intake is not preferred due to changes in gastrointestinal function during major traumas, irregularities in muscle and skin flow. In the acute phase of Travman ketorolac may be preferred as intravenous NSAID. It should be considered that oral administration of NSAIDs to the intravenous area causes renal failure, clotting disorder, and stressful ulcer formation.

 

In our hospital, opioids are generally used in acute painful periods with HKA method, usually morphine, and they are titrated until painlessness (VAS: 0-2) is achieved. The patient is followed up in the morning and evening by pain examination and their doses are adjusted. The lowest analgesic dose not felt by the pain is detected and used.

Another fearful side effect of the use of opioids is respiratory depression. All opioids have respiratory depressant effects. However, pain is a stimulating effect of respiration and is not a highly visible side effect in patients with pain. However, the patients should be monitored and respiration should be monitored.

Most of the opioids use morphine. Morphine is preferred because of its wide age range and effective in acute and severe pain.

Other opioids used in the acute phase may be tramadol, meperidine, codeine, methadone.

In the treatment of acute pain, opioids and opioids are used as treatment modalities. Opioid use with patient-controlled analgesia allows an analgesic intake according to the patient's pain level while at the same time providing an effective pain palliation during periods of intensification of the intervening process. It is important that patients be carefully monitored to avoid painful periods that may arise from different evaluations between medical personnel and patients. Side effects that may occur due to opioid use can be alleviated with applications to be done at the lowest dose at which the pain can be relieved. The most frightening side effects of opioid use are dependence on tolerance to opioids and high doses caused by tolerance. However, in patients with known pain, opioids can lead to physiological dependence, which is very different from physical dependence. It is known that doses can be gradually reduced during pain treatment to prevent withdrawal syndromes. Burn Pain: acute treatment In the acute phase, the patients suffer from both a constant underlying pain and the pain caused by frequently performed procedures. Many patients also worry about procedures. Anxiety can increase your pain experience. Following are the appropriate treatment options for burn-related pain control.

 

 

 

 

 

 

Opioids

 Opioids are the cornerstones of severe acute pain treatment and various ways of administration have been described and tested in burn patients. There is little evidence that opioid-treated burn patients have a higher risk of developing addiction than in normal populations. The most commonly used drug for both underlying and treatment pain in pain centers is morphine. Besides analgesic effect, sedative and antitussive properties are also available. It can be used intravenously or continuously via HKA. Morphine pharmacokinetics remain unchanged in burn patients Acceptable treatment with acute burn treatment with high-dose morphine can reduce acute pain as well as reduce the risk of post-traumatic stress syndrome. If there are side effects that can not be countered against the morphine, a hydromorphone can be used. Meperidine should not be used in the long term due to the toxicity of the metabolite normeperidine.

Sometimes bolus fentanyl application is also useful for procedures such as dressing exchange. The best infusion of fentanyl is not recommended because it can induce rapid tolerance development. High dose fentanyl should be used with extreme caution because patients with high doses of fentanyl may develop respiratory depression with a temporary rate of approximately 31%, although generally requiring intubation. The oral transmucosal fentanyl citrate acts as much as oral oxychodone in the wound care of children, and the taste can be better and be tolerated. Topical local anesthetics such as lidocaine, epinephrine, and tetracaine, and buffered lidocaine lacerations injected into the wound with fine needles can be anesthetized almost painlessly for suturing.

Methadone has the advantage of N-methyl-D-aspartate (NMDA) receptor antagonist activity, which may at least theoretically be important in the prevention of secondary hyperalgesia, central sensitization or neuropathic pain due to NMDA activation. Oral and intravenous methadone have been shown to be effective for both adult and pediatric pain in acute and chronic burn pain.

In most serious acute burn patients, the best opioid administration mode is intravenous HKA. The medications of patients, usually morphine or hydromorphone, allow their application. It removes the nursing addiction of patients from the middle and gives immediate relief when the need arises. Most patients, even children aged 7-10 years, can learn to control pain using PCA. Continuous infusion of opioids is necessary for adults or young children who can not handle the button. After intravenous bolus of morphine, the onset of analgesia is approximately -10 minutes, so that patients can be prepared prior to painful therapeutic interventions. If the patients have severe underlying pain, then they will need a basal infusion in addition to the needed doses.

 

 

 

Ketamine

 Ketamine is an atypical anesthetic, a potent analgesic, and an NMDA receptor antagonist. Experimental studies have shown that ketamine overpowers the spatial and temporal properties of burn induced hyperalgesia in volunteers, while morphine has not shown such an effect. Pre-injury treatment with ketamine prevents experimentally induced secondary hyperalgesia in humans. Ketamine is effective in reducing pain caused by interventions in both adults and children with burns. It can be used for anesthesia and analgesia in burn patients. The main advantage to opioids is the protection of spontaneous ventilation and airway reflexes. The catecholaminergic system is stimulated by catecholamine release, which can lead to unfavorable postanesthetic phenomines, such as convincing vasculopathies and hallucinations, which can be minimized by the combined use of benzodiazepines. These effects are uncommon in the subanesthetic doses used for analgesia. Cetamine should be used with an antisialogical such as atropine or glycopyrate.

 

 

Acetominophen

 Acetaminophen is a weak analgesic and antipyretic. Minor is a useful first-line treatment for burns, but can also be used as an adjunct to opioids in major burns. Because this drug is primarily central, it does not constitute typical NSAID side effects caused by prostoglandin inhibition in the periphery. Studies have also shown that acetaminophen is beneficial for the underlying pain in the child's neck. Acetaminophen is not suitable for long-term pain management because of toxic and cumulative effects in the liver.

 

Nonsteroid antiinflammatory drugs

 Nonsteroidal antiinflammatory drugs may be used as an adjunct to analgesics for mild or moderate pain, or for more potent analgesics. Reduces inflammation and pain. Side effects, especially in patients with burns, may limit the use of gastrointestinal bleeding because these patients are prone to gastrointestinal bleeding. If used, a prostaglandin analog (eg misoprostol) or H2 blocker (eg ranitidine) prophylaxis should be administered. Worsening renal function has also been reported in patients with burns using NSAIDs. (28). For the treatment of interventional pain, opioids should not be replaced by high-dose NSAIDs. The role of elective cyclooxygenase-2 inhibitors in burn patients still needs systematic investigations.

 

 

 

 

 

 

OTHER TREATMENTS

 Clonidine has both analgesic and sedative effects. It has been reported that opioids are useful in the treatment of burn patients who are not adequately controlled. By reducing sympathetic outflow, it may balance sympathetic stimulation caused by ketamine.

 

 REGIONAL ANESTHESIA

 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.

 

 

SUBAKUT PERIOD:

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.

 

 

REHABILITATIVE PHASE:

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;

1-Warning-induced

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.

 

 

 

PERIPHERAL NEUROPATISS

Traumatic nerve injury

Plexus avulsion

Amplification

Neuralgia

Compression

HIV infection

Polyradiculite

 

CENTRAL NEUROPATITIES

 

Multiple sclerosis

Sirengobulbi

Spinal injury

Stroke

Myelopathies

Multiple sclerosis

Ischemic lesions

Parkinson's disease

Sirengomeli

Cordotomy

Cancer compression

 

 

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.

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Prof. Dr. Altan Şahin, 2018