Pain relief in burns by Dr. Sunil Keswani, National Burns Centre, Airoli

Dr Sunil KeswaniDr Laksmi VasDr Vandana Keswani

NATIONAL BURN CENTRE, Airoli, Mumbai

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com 1

Circumferential chest burns-pain restricts full respiratory excursions ,atelectasis and pneumonias

Pain prevents patients from eating well-nutrition affected.

Pain depresses the patient-psychosomatic problems

Pain contributory to Post burn psychosis Pain-poor compliance during physiotherapy-

poor rehabilitation-poor functional outcome

PAIN IS A FORM OF STRESS AND PRODUCES ELEVATION IN STRESS HORMONES AND CATECHOLAMINES.

PAIN RELIEF ADVANTAGES:- LESSER CHEST INFECTIONS-better compliance in Physiotherapy LESS CATABOLISM AND ENDOCRINE DERANGEMENTS. FEWER THROMBOEMBOLIC COMPLICATIONS-Earlier mobilisation BETTER NUTRITION-Better appetite in absence of Pain BETTER PSYCOLOGICAL STATUS-No pain no depression and

positive outlook to healing and DESIRE TO LIVE. PAIN FREE DRESSINGS MAKE PATIENTS MORE COMFORTABLE

AND DECREASES THE MORBIDITY AND MORTALITY. SHORTER HOSPITAL STAY.

Defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Acute pain < 6wksSurgery,Trauma or Acute illness

GRADE 1:Nonopioids +/- adjuvants

GRADE 2:Opioids for mild to moderate +/- nonopiods+/- adjuvant

GRADE 3:Opioids for moderate to severe pain+/- nonopoids+/- adjuvant

PAIN KILLERS e.g ULTRACET

ANTIDEPRESSANTS e.g TRYTOMER,FLUDAC.

PHENCYCLIDINE DERIVATIVEe.g KETAMINE

OPIOIDSe.g MORPHINE, HYDROMORPHONE FENTANYL.

ROUTES OF ADMINSTRATION- ORAL OR INTRAVENOUS THROUGH PATIENT CONTROLLED ANALGESIA PUMPS (SYRINGE INFUSION PUMPS)

Antidepressant & Serotonin-uptake inhibitor

Dose-20 mg daily-for depression

Other names-Fluchem, Fludawn, Flugen

Availability-10 mg, 20 mg, 60 mg caps

Phenylpiperidine -analogue of codeine

Mechanisim 1) Activates opioids receptors 2) Inhibits Neuronal uptakes of nor-

epineprhrine 3) Potentiates release of serotonin 4) Decending inhibition of nociception

Names-Ketalar,Ketamax,Ketmin

Profound analgesiaPharangeal & Laryngeal reflexes

retainedDissociative AnaesthesiaBP increases but returns back within

15 mins after IVDr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com 9

Synthetic opioid

IV 75-125 times more potent than Morphine Patch 30-40 times more potent than

Morphine Opioid profile of analgesia Respiratory depression Muscle rigidity abolished by Naloxone CVS –hardly any effect Availability 50mcg/ml and 2,10ml Names-Fendrop,Fenlate,Trofentyl

15Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

FIRST DAY:-ON ADMISSION, ALL MEDICINES TO BE GIVEN ORALLY.

Body wt < 10KG 3mg midazolam+50mgketamine

mix it with fruit concentrate and give orally.

Body wt. 10—15kgs—upto 2 years of age.

4.5mg midaz+75 mg of ketamine,

ADULTS:-body wt-25-50kg— 10-15mg Midaz+175-250mg

Ketamine

ALL PATIENTS Fludac 10mg in the morning Tryptomer 10mg HS . Pregabalin 75mg HS

MILD PAIN / MIXED BURNS / LESS%BURNS

Tab Ultracet 1tds for men .1/2 to1-1/2 for small women and children.

Tab Tryptomer 10 mg HS. Tab Fludac 10 mg in the morning.

ASSESS PAIN

MOD PAIN /MIXED BURNS/HIGH % BURNS

Start Ketamine 100mg,Tramadol 100mg,& Midazolam 10mg Infusion

Set pump rate at 1ml/hour.For 60kg-1-2ml/hr.

For 70kg- 1-4ml/hr.

ASSESS PAIN and TITRATE

If increasing give bolus of 1ml at a time assess,set basal flow rate again.

Starvation protocol as for anaesthesia 6hours for solids & milk,2hours for juices

& water. Jonac suppository / IM Dynapar Start infusion of ketamine,tramadol,

midazolam. Dresssings soaked in 30cc 2%Xylocaine-

in 500 cc saline for 15 mins and then removed

Patient should be talking all the time. Patient should not become unconscious at

any time. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com 20

Visual Analogue Scale

McGill Pain Questionnaire

(1) What Does Your Pain Feel Like?

(2) How Does Your Pain Change with Time?

(3) How Strong is Your Pain?

Interpretation:

• minimum pain score: 0 (would not be seen in a person with true pain)

• maximum pain score: 78

• The higher the pain score the greater the pain.

PHYSICAL DEPENDENCE:-PHYSIOLOGIC ADAPTATION OF THE BODY TO THE PRESENCE OF AN OPIOID. IT DEVELOPS IN ALL PATIENTS ON OPOIDS FOR SEVERAL WEEKS.

THIS IS NOT ADDICTION. WITHRAWAL CAN BE AVOIDED BY TAPERING THE

DOSE OF OPIOIDS.

TOLERANCE IS THE NEED FOR A HIGHER DOSE TO PRODUCE THE SAME PHARMACOLOGIC EFFECT.

THIS TOO IS NOT ADDICTION.

ADDICTION OR PSYCHOLOGICAL DEPENDENCE:-CHARACTERISED BY COMPULSIVE BEHAVIOR PATTERN INVOLVED IN ACQUIRING OPIOIDS FOR NONMEDICAL REASONS AS OPPOSED TO PAIN RELIEF.

INCIDENCE BEING 0.1%.

PSEUDO ADDICTION:-REPEATED REQUESTS FOR OPIOIDS MAY MIMIC ADDICTION.

THIS IS DUE TO INADEQUATE PAIN RELIEF.

“The purpose of a physician is to relieve pain and cure disease”

THANK YOUNATIONAL BURNS CENTRE

BURNS HELPLINE 027793333www.burns-india.com

Pain relief in burns by Dr. Sunil Keswani, National Burns Centre, Airoli

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