The management of pain in the burns unit

The adverse sequalae of inadequate pain control in the burn population have been long recognised, yet control of pain remains inadequate globally. The dynamic evolution of burn pain both centrally and peripherally, and the many factors which influence pain perception illustrate the need for a therapeutic plan which is similarly dynamic and flexible enough to cope with the facets of background, breakthrough, procedural and post-operative pain. Regular, ongoing and documented pain assessment is key in directing this process.The family of opioid analgesics provide the backbone of analgesia to burn patients. Together, they provide an excellent range of potencies, duration of actions and routes of administration. However, they must be used judiciously as side-effects may be clinically relevant and furthermore, recent data has implicated them as being capable of inducing pain. NMDA receptor antagonist such as ketamine and gabapentin are increasingly recognised as useful adjuncts, capable of marked opiate sparing effects in this population. The simple analgesic paracetamol (acetaminophen) has both anti-pyretic and opioid-sparing properties and justly deserves its place in the pharmacological treatment of every burn patient.Non-pharmacological methods of pain control can play an important role in suitable patients but resources vary widely between units.With this review article, we have set out to give practical guidance to all healthcare professionals with examples from our practice. We have found the addition of pain specialists as an integral part of the burns multi-disciplinary team, and an environment where pain is given a high clinical priority to be invaluable in our approach to pain control.     

The characteristics of elderly burns in Shanghai

Objective

This study aims to analyse the epidemiologic characteristics of severe burn in the elderly in Shanghai and to discusses a possible prevention programme for this population.

Methods

A retrospective review of all medical records of elderly patients (aged 60 and older) admitted with acute burns to the Burn Center of the RuiJin Hospital between January 1996 and December 2004 was carried out. Patient demographics, etiology of burn, mechanism of injury, burn extent, anatomical areas burned, number of operations, and outcomes were reviewed.

Results

A total of 201 (5.8% of hospitalised patients) elderly patients (mean age (±SD) of 69.3 ± 7.1 years (range 60–90 years)) were admitted. Majority of the patients were men (62.2%) and the most common etiologies were flames (52.7%) and scalds (39.8%). The majority of burns occurred at home (73.6%), followed by burns at workplace (15.9%) and public areas (10.5%). The median total body area burned was 11.7% (range 0–84%), and the majority of burns were classified as mild (60.2%) and moderate (32.8%). Predominant anatomical areas involved were the legs (76.1%), arms (67.2%), head and neck (49.8%) and hands (49.3%). The most common pre-injury conditions were cardiovascular diseases (25.9%), diabetes (8.5%) and neurological diseases (6%). Eighty-seven patients (43.3%) required surgical treatment. The most common complications were multiple organ failure (2%), pneumonia (1%) and wound infection (1%). Sixteen patients (8%) died: half of them in hospital, and the rest at home. There was a significant correlation between post-injury complications and death (r = 0.69, p < 0.001). The mean total hospitalisation cost was ¥22993.09 (US$ 3381.34).

Conclusions

Domestic and workplace burns with devastating consequences are very common in the elderly population in Shanghai. Burn prevention education and implementation of safety measures at home and at workplace would help reduce such incidences.     

The treatment of pain in patients with serious burns

The assessment and treatment of pain in patients with serious burns concerns continuous pain and occasional pain provoked by care procedures.The patient must be included in this therapeutic project.The control of pain is a measure of the quality and effectiveness of the care provided.     

Hypnosis and pain in patients with severe burns: a pilot study

This report presents a pilot study on the effectiveness of hypnosis in the control of pain during dressing changes of burn patients. Eight patients were treated, and all evaluated the interventions as beneficial. The treatment of four patients was more closely analysed by obtaining pain and anxiety ratings daily. Results show a 50-64 per cent decrease in reported pain level for three patients and a 52 per cent increase of pain for one patient. The mean decrease for these four patients was 30 per cent (for overall as well as worst pain during dressing changes). A 30 per cent reduction of anxiety level and a modest reduction of medication use were achieved concurrently. It is concluded that hypnosis is of potential value during dressing changes of burn patients. Comparison of global evaluations and daily pain ratings shows that systematic research in some cases leads to conclusions opposite from clinical observations or follow-up evaluations. Limitations of this study are discussed and recommendations for future studies are given.     

Foot pain in later life: some psychosocial correlates

What we have just described is a collection of problems that mark our aged of today and clearly indicate that primary foot care should be provided as a primary health service for the elderly, the mentally ill, the emotionally ill, the retarded, the blind, and others with chronic diseases. For if any of the primary problems were present on any other part of the body, except the foot, they would be provided as a covered service under the current Medicare regulations. One might ask if the foot is not a part of the anatomy and if perhaps we have forgotten the words of the classic song, which proclaims that the foot bone is connected to the head bone. The author might add a "footnote" ... in so many ways. To achieve the desired outcome of having podiatric services available to all aging patients, foot care must be integrated into all comprehensive forms of health care delivery, so that podiatric care becomes a primary service, thus permitting patients to maintain an optimal level of foot health and general health. The ability to walk requires a catalyst--foot health. Keeping patients walking is a goal that has been a part of the podiatric profession since its inception over a century ago. With the high prevalence of foot problems in the elderly, and especially in those with chronic disease and mental impairment, the needs for the future are significant. It has been projected that we as a nation and society cannot afford to deliver a maximum level of health care for the elderly. In truth, we cannot afford not to provide these basic and needed services. For it is our society that has prolonged life. It is now our responsibility to provide life for these precious given years and to assure dignity for those who have made life better for all of us.     

Ocular chemical burns in the workplace: Epidemiological characteristics

BackgroundEpidemiological studies focusing on occupational pathologies can be an important medium through which to bring about change with respect to workplace accidents, both in terms of prevention planning and management as well as the appropriate care following an accident. Ocular chemical burns benefit from urgent attention as, if not treated early and appropriately, the tissue of the eye and its functionality can be seriously compromised. The objective of this study was to collate epidemiological data on workplace ocular chemical burns which could in turn serve to identify key action points in terms of occupational health.MethodsCohort study with 604 cases of chemical burns to the eye occurring in the workplace between 2014 and 2015. Criteria inclusion were diagnosis of chemical burn, patient seen at the medical centre of the mutual society, workplace acquired ophthalmic pathology leading to the issuing of a sickness certificate. No exclusion criteria were defined.ResultsOcular chemical burns were the second most common workplace eye injury (12.68%) behind foreign bodies in the eye (43.42%). Men accounted for 68.54% of cases of ocular chemical burns. In around 75% of cases, sickness certification was for less than 7 days, although 6 patients suffered permanent disability. The occupational sector which was most affected particularly the industry service industry. The economic costs with these workplace injuries were extracted.ConclusionsAppropriate early medical assistance is essential. The production and distribution of clinical guides for health care workers could optimise first line assistance and mitigate possible training deficiencies.     

Microbiology and clinical characteristics of industrial oil burns

IntroductionInfections complicating burns generally transition from Gram-positive to Gram-negatives over the first couple weeks, but this depends on multiple factors. The microbiology of infections complicating crude oil (CO) and hydraulic fracturing (FRAC) burns is unknown.MethodsWe performed a retrospective study of patients with industrial thermal burns hospitalized >2 days with ≥1 day in the ICU between 4/2011–11/2016. Burns were oil-related (ORB; CO or FRAC) or non-oil related (NORB). Epidemiology and microbiology during the first 15 hospital days was compared.Results149 patients were included, with 11 FRAC and 24 CO. CO burns were more severely burned than those with FRAC and NORB (p < 0.05). Mortality was 17% and 18% for CO and FRAC burns compared to 3% in NORB (p < 0.01). More cultures were obtained from ORB than NORB (p < 0.05). ORB were associated with Stenotrophomonas maltophilia and FRAC associated with Serratia marcescens and Candida glabrata. Patients with FRAC, CO and NORB had a median of 13, 3.5, and 4 days to first positive culture respectively (p = 0.03).ConclusionORB were associated with more severe burns and unique microbiology. FRAC burns had longer to initial positive culture, potentially suggesting our current methodology is inadequate to diagnose infections associated with FRAC.     

Incidence and characteristics of non-accidental burns in children: A systematic review

IntroductionThe estimated incidence of non-accidental burns varies between 1–25% in children. Distinguishing non-accidental burns from accidental burns can be very complicated but is of utmost importance for prevention of future injuries. Several studies concerning non-accidental burns have been published, however a clear overview is lacking.AimTo conduct a systematic review of the existing literature to identify the incidence and characteristics of burns due to intentional causes and neglect.MethodsThe protocol of this systematic review was prospectively registered in an international database (PROSPERO, National Institute for Health Research, York, United Kingdom). We searched literature in electronic databases published from 1948 until July 2018 written in English, Dutch, German and French. Two researchers screened, selected and graded the included articles, using standard methodology. We included primary studies of confirmed non-accidental burns in children. We excluded literature reviews, case-reports and unpublished data. We extracted data regarding demographics, burn characteristics, Child Protective Services (CPS) referral information and parent/household characteristics.Results825 studies were screened, 17 were included. The incidence of non-accidental burns was pooled out of 10 studies and is 9.7%. Indicators raising a very high suspicion of intentional burns are deep partial thickness and full thickness burns, burns to the posterior trunk and burns caused by hot tap water. Indicators raising a high to moderate suspicion of an intentional cause are burns to buttocks, genital and legs, a younger age of the child, additional injuries such as cutaneous injuries/bruises and fractures. More commonly caused by accidents are burns to head, neck, anterior trunk, upper extremities and feet. Little data are available regarding burns as a result of neglect. Quality of studies was often low to moderate mostly due to a high heterogeneity. This review is mainly based on retrospective studies.ConclusionFrom this review of the literature, the incidence of non-accidental burns in children was 9.7%. Indicators raising a very high suspicion of intentional burns are: location at the posterior trunk, deep partial thickness and full thickness burns and burns caused by hot tap water.     

The characteristics of chronic pain after non-traumatic,non-compressive myelopathy: Focus on neuropathic pain

Objectives: The aim of this study was to assess the characteristics of neuropathic pain after non-traumatic, non-compressive (NTNC) myelopathy and find potential predictors for neuropathic pain.

Design: We analyzed 54 patients with NTNC myelopathy. The Short Form McGill Pain Questionnaire (SF-MPQ) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were used to assess pain. Health-related QOL was evaluated by the Short Form 36-item (SF-36) health survey.

Results: Out of 48 patients with pain, 16 (33.3%) patients experienced neuropathic pain. Mean age was significantly lower in patients with neuropathic pain than in patients with non-neuropathic pain (39.1?±?12.5 vs. 49.8?±?9.3, P?=?0.002). There were no statistically significant differences in the other variables including sex, etiology of myelopathy, pain and QOL scores between the two groups. A binary logistic regression revealed that onset age under 40, and non-idiopathic etiology were independent predictors of the occurrence of neuropathic pain. Both SF-MPQ and LANSS scores were significantly correlated with SF-36 scores, adjusted by age, sex, presence of diabetes mellitus, and current EDSS scores (r?=?–0.624, P?Conclusion: Neuropathic pain must be one of serious complications in patients with NTNC myelopathy and also affects their quality of life. Onset age and etiology of myelopathy are important factors in the development of neuropathic pain in NTNC myelopathy.     

Psychosocial correlates of low-back pain in adolescents

Knowledge is sparse concerning associations between juvenile low-back pain (LBP) and psychosocial factors. A cross-sectional study was performed to study whether juvenile LBP may be associated with self-reported headache and wellbeing, and with social class and parental LBP reported by the parents. The material comprised all adolescents (n=105), aged 14.1-16.1 years, in a rural municipality and in a nearby urban area in inland Norway. The response rate was 84% (n=88). Data were supplied from questionnaires filled out by the adolescents and their parents. Associations were calculated by bivariate and multivariate methods. The level of significance was set at P< or =0.05. In multivariate analyses, associations were found between LBP and both female gender and poor wellbeing, in particular poor self-perceived fitness. There was a tendency towards an association between weekly headache and LBP. No associations were found between social class, parental LBP and juvenile LBP. The results do not confirm hypotheses that social class and parental LBP are related to juvenile LBP. The findings indicate that poor wellbeing, in particular poor self-perceived fitness, is associated with LBP among adolescents.     

Epidemiological and outcome characteristics of major burns in Tokyo

The Tokyo Burn Unit Association (TBUA) was established in 1983 funded by the Tokyo Metropolitan Government, and is organized by 13 burn units in Tokyo. TBUA covers more than 90% of severe burn patients occurring in Tokyo, and all of the cases are registered according to the burn injury registration format. The purpose of this study is to analyze the registered data and to elucidate epidemiological and outcome characteristics of major burn injuries in Tokyo. The total of 6988 hospitalized patients had data for epidemiological analysis, and 6401 patients had complete data for outcome analysis as well, and were included in this study. The characteristic profiles for the analysis included age, sex, cause of burns, inhalation injury, %BSA, burn index (BI), length of burn unit stay, and outcome, and were analyzed by age groups. The mean age of the patients was 40.4 years, and 63% of them were male. It was noteworthy that 25% of the total patients were elderly patients over 60 years of age. Flame was the most common cause making up 45.6% followed by scalding (32.0%). The overall mortality rate was 15.4%. Inhalation injury was accompanied in 27.3% of burn patients. The mortality rate was 34.6% with inhalation injury, and 8.2% without inhalation injury. Causes of death showed that multiple organ failure made up 36.9% of total mortality, followed by sepsis 25.2 and shock 19.0%. The burn size (%BSA and BI) and inhalation injury were the factors for high mortality rate in all age groups whereas age was a predictor for high mortality in the patients older than 16 years of age. Gender was not a factor for high mortality in any age group. The mortality rate showed mildly decreasing tendency since 1995 for which implementation of skin bank was thought to be responsible.     

Hypnosis for reduction of background pain and pain anxiety in men with burns: A blinded,randomised, placebo-controlled study

Introduction

‘Background pain’ and ‘pain anxiety’ are among the numerous problems of patients with burns. Non-pharmacological and pharmacological interventions have been used to reduce background pain and pain anxiety. This study compared the effectiveness of hypnosis and ‘neutral hypnosis’ (as a placebo in the control group) in decreasing the background burn pain and pain anxiety of adult male survivors with burns.

Impact of a pain protocol including hypnosis in major burns

Background

Pain is a major issue after burns even when large doses of opioids are prescribed. The study focused on the impact of a pain protocol using hypnosis on pain intensity, anxiety, clinical course, and costs.

Methods

All patients admitted to the ICU, aged >18 years, with an ICU stay >24 h, accepting to try hypnosis, and treated according to standardized pain protocol were included. Pain was scaled on the Visual Analog Scale (VAS) (mean of daily multiple recordings), and basal and procedural opioid doses were recorded. Clinical outcome and economical data were retrieved from hospital charts and information system, respectively. Treated patients were matched with controls for sex, age, and the burned surface area.

Findings

Forty patients were admitted from 2006 to 2007: 17 met exclusion criteria, leaving 23 patients, who were matched with 23 historical controls. Altogether patients were 36 ± 14 years old and burned 27 ± 15%BSA. The first hypnosis session was performed after a median of 9 days. The protocol resulted in the early delivery of higher opioid doses/24 h (p < 0.0001) followed by a later reduction with lower pain scores (p < 0.0001), less procedural related anxiety, less procedures under anaesthesia, reduced total grafting requirements (p = 0.014), and lower hospital costs per patient.

Conclusion

A pain protocol including hypnosis reduced pain intensity, improved opioid efficiency, reduced anxiety, improved wound outcome while reducing costs. The protocol guided use of opioids improved patient care without side effects, while hypnosis had significant psychological benefits.