Guideline for Prescribing Analgesia in the Burns Unit
DO AND RECORD A PAIN SCORE AT EVERY DRUG ROUND!
Simple 4 step- none (0), mild (1), moderate (2), severe (3).
Step One (for mild pain)
Regular Paracetamol 1g 4- 6 hourly (if patient below 50 kg, 15 mg/kg)
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Step Two (for mild pain not alleviated by paracetamol alone)
Carefully consider if adding a NSAID appropriate. Only prescribe if normal renal function, eating regularly, and where no history of peptic ulceration or wheeze associated with NSAIDs.
If above o.k., add 50 mg Diclofenac 8 hourly regularly
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Step Three (for Mild/ moderate pain not eliminated by first 2 steps)
ADD 50-100mg Tramadol regulary 6 hourly
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Step Four (for moderate- severe pain)
ADD Oramorph starting at 10 mg (or oxynorm 5mg) 4 hrly. Consider reduced doses in elderly. If opioids required > 24 hours add MST (or Oxycontin) bd leaving oramorph prescribed for breakthrough pain. Stop tramadol if MST or oxycontin required.
Other drugs to consider
For patients with very painful burns consider adding gabapentin as described overleaf.
Notes to help when prescribing for burn pain
Remember to document pain scores regularly.
If a patient has just been admitted and is in severe pain, give intravenous boluses of morphine and titrate to effect- this means sitting with the patient and assessing pain until the patient is comfortable. Never prescribe intramuscular or subcutaneous analgesia to a newly admitted burn patient as they will not absorb it uniformly.
If a patient is unable to absorb oral medication, remember paracetamol may be given intravenously. Change oral opioid prescriptions to subcutaneous or I.V.
Remember that burn pain is usually composed of background pain and procedural pain. Treat both. Give an oral opioid 30 minutes before painful procedures.
If a patient is requiring regular opioid analgesia, prescribe lactulose.
Always reassess the patient after instituting a change in a patient’s analgesia. Remember as burns heal the analgesic requirements decrease- review and stop unnecessary prescriptions.
If a patient with a large burn has ongoing difficulty with analgesia, gabapentin may be considered. This should be started at 300mg once on day 1, 300mg twice on day 2, and 300mg 3 times on day 3. May be further gradually increased to 600mg 3 times daily. Discuss this with the consultant looking after the patient.
Pain in burned patients, especially those with existing drug habits, may be complex and difficult to treat. Refer difficult patients formally to the Chronic Pain Specialists.
www.cobis.scot.nhs.uk
Reviewed by Prof J Kinsella, Lead Clinician May 2016;
Approved COBIS Steering Group
To be reviewed May 2018
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