Case Report #40: Managing Pain in Adult Burns by Dr Harriet Scott and Dr Joe Hussey

The management of pain in a patient with burn injuries presents a particular set of conditions to the patient and doctor, with additional complexities in their management.

With a burn injury, acute pain arises from heat, cold, chemical and mechanical stimuli activating nociceptors. There may be damage to nociceptors and peripheral sensory neurons. Local inflammatory cascades and systemic inflammatory response to a burn can cause complex alterations in pain pathways and burn-induced pain can persist despite skin healing. There is often overlap of nociceptive and neuropathic elements of the pain.

Additionally, management of burns involves repeated painful events: pain of the initial injury, the surgical pain of excision, grafting, escharotomy, fasciotomy and amputation, procedural pain of repeated washing and dressing changes and pain during rehabilitation exercises. There is often ongoing problematic pruritis and the development of chronic pain.

Burn injuries are frequently sustained by vulnerable patients: the young, the elderly and those with complex social and psychological needs. These factors also need additional consideration for the holistic management of their pain.

Case

The patient is a 21-year-old Syrian asylum seeker. He suffered burns when the lithium-ion battery of his e-bike caught alight whilst charging and he was trapped in his flat. A neighbour called the fire brigade who extricated him. The HEMS team assessed him as GCS 12 at the scene but due to the severity of his burns and evidence of soot in the nostrils and mouth, he was intubated at the scene before transfer to hospital.

He is admitted to the Burns Intensive Care Unit (BICU) with an estimated 60% total body surface area flame burns to his head, face, chest, arms and legs, of which 50% are assessed as full thickness burns. At bronchoscopy, he is assessed as having moderate inhalational injury.

Under general anaesthetic in the intensive care admissions room, his wounds are exposed, cleaned and redressed. The anaesthetist notices that his pulse and blood pressure increase during scrubbing with betadine and administers fentanyl boluses and increases his depth of anaesthesia.