# Burn Patients in Hospital



## johnrsemt (Feb 9, 2011)

My wife asked me this question last night and I dind't know how to answer; and it has me wondering:

   Why with critical  (or not so critical) burn patients do they only give pain meds for debridements?  Why don't they just totally knock them out?   

   The few times I have been in a burn unit the patients being debrided (sp?) were in severe pain and the doc/nurses state that they can't give them enough meds to take pain away without killing them.

  if anyone could answer I would appreciate it.

thank you in advance


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## Veneficus (Feb 9, 2011)

johnrsemt said:


> My wife asked me this question last night and I dind't know how to answer; and it has me wondering:
> 
> Why with critical  (or not so critical) burn patients do they only give pain meds for debridements?  Why don't they just totally knock them out?
> 
> ...



There are risks to general anesthesia and long term invasive life support. A burn patient is already at serious risk for a lot of those complications.

It really would help to have pain managed by anesthesiologists though. Unfortunately the patients are often managed by mid level "pain management" specialists who are beholden to protocol or in some places surgeons who as part of their practice priviledges at the given facilty administratively limit the available options.


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## Journey (Feb 9, 2011)

Were the patients you saw intubated? What were the signs that indicated pain? How many days post injury? Was this during a sedation vacation?

The first 24 hours are difficult but if the patient is intubated, sedation and pain management will be taken very seriously. There will also be many adjustments of medications for BP fluctuations as the fluids are infused and pressors are titrated accordingly pending degree of shock and agressive ventilator setting from the fluids and/or burns. It may be a give and take to maintain BP for several days.  In a few sitatuations the patient may also require paralysis which will then need effective sedation.  So for severe burn patients who are intubated, they are sedated and medicated for patient. However, some may still appear uncomfortable due to asynchrony with the ventilator. The fluid and hemodynamic status also make HR and BP unpredictable indicators of pain.  Very difficult to assess some of these patients and you want to be cautious about overtreating what might be perceived to be pain from the burns and miss something else.  For tubbing, dressing changes and various procedures, the patients in our burn ICU  usually have their pain managed very well and also may be well sedated. 

Patient management for a patient who is not intubated may present with more challenges but Burn Units across the country are striving to meet the goals for pain management. 

Slacking off on pain management was a thing of the past like the 80s and prior. There are now enough studies to show pain management should now be accomplished to promote healing.  In the 80s and before, small children and babies were not given very much for sedation or pain even during surgery. Medicine has since reconsidered that practice.  The physicians at your burn unit may be stuck in the 1960s somewhere for their pain management. This still  happens.

As a Paramedic you might consider taking a burn course but only if it is offered through a Burn Center and presented by the MDs and RNs who staff their unit.


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## Dutch-EMT (Feb 13, 2011)

Well, my experience out of the hospital:
Burned legs and abdominal region / lower back, pain can be managed with epidural analgesia. Works very fine!
A big problem with this is that patients wouldn't be able to move their legs and can't feel problems like bedsore wounds, beginning infections. Also a urine-catheter must be placed because a patient can't pee anymore. Next problem: possible infections of the bladder. 

Giving morphine and other opiates can kill the pain, but causes constipation, especially when the patient isn't able to walk around. Also patients are getting sleepy, nauseas and intake will be worser. And that's not what we want. A burn patient needs proteins wich is good for the healing-proces.

Most critical burnvictims are in the Netherlands treated in special burn-clinics.
When burn-victims aren't critical, a regular hospital can treat the patient.

Mostly the smaller burns are creamed with silversulfadiazine.
It feels cool, and the silver works anti-bacterial. 
Wounds are treated 2 to 3 times a day and covered with sterile aluminium-coated bandage. Surgery comes later, when it's more visible how the wounds would heal.


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## usafmedic45 (Feb 13, 2011)

Veneficus said:


> There are risks to general anesthesia and long term invasive life support. A burn patient is already at serious risk for a lot of those complications.
> 
> It really would help to have pain managed by anesthesiologists though. Unfortunately the patients are often managed by mid level "pain management" specialists who are beholden to protocol or in some places surgeons who as part of their practice priviledges at the given facilty administratively limit the available options.


It depends on how extensive or involved the debridement is and on the burn center in question.  One place I worked at used ketamine for debridements.  Another would just give additional doses of morphine.  Personally, I'd take the ketamine if I were the patient.  Burn debridement and toilet without disassociation or heavy sedation tends to be pretty high on my list of things I would not want to experience or would wish upon even people I hated.


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## Veneficus (Feb 13, 2011)

usafmedic45 said:


> It depends on how extensive or involved the debridement is and on the burn center in question.  One place I worked at used ketamine for debridements.  Another would just give additional doses of morphine.  Personally, I'd take the ketamine if I were the patient.  Burn debridement and toilet without disassociation or heavy sedation tends to be pretty high on my list of things I would not want to experience or would wish upon even people I hated.



Ketamine is good, but once anesthesia gets involved a who new world of pain management becomes available. (like spinal blocks)

I do not agree with undermanaging of pain at all. Just explaning some of the issues that interfere with its management as asked by the OP.


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## Journey (Feb 13, 2011)

Veneficus said:


> Ketamine is good, but once anesthesia gets involved a who new world of pain management becomes available. (like spinal blocks)



You just have to understand the different types of sedation (Moderate Sedation Versus Deep Sedation/Anesthesia) and goals when using Ketamine and if the patient is intubated or not. The same would apply for Propofol. Ketamine is still an excellent med for pediatric burn patients.  Propofol and fentanyl is also still a popular combo.


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## usafmedic45 (Feb 14, 2011)

> Ketamine is good, but once anesthesia gets involved a who new world of pain management becomes available. (like spinal blocks)



Screw that.  For something like a burn debridement, I want to be out for it.


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## Veneficus (Feb 14, 2011)

usafmedic45 said:


> Screw that.  For something like a burn debridement, I want to be out for it.



Many people want that, but in places I have seen, it rarely is the outcome.

As I eluded to, the very worst is when there is a pain management PA who decides to start you with some PO opioids for your 18+% circumferential burns because that's what her protocol (often refered to as "practice guidlines" as opposed to protocol) starts with.

(not making this stuff up, I have seen it)


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## usafmedic45 (Feb 14, 2011)

> (not making this stuff up, I have seen it)



Oh, I know.  Used to work a burn unit.


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## Ronny Woods (Jun 4, 2018)

I worked for quite awhile 9n a hospital when I was younger. Really loved it but school got in the way. I never worked in the burn unit. My small hospital didn’t have one. I did however attend several patients who had severe burn wounds. We got them ready to be Med-evaded toburn hospitals. I was always told they had to keep the patient aware during debridemant because they only wanted to cut away damaged skin not skin that could still feel. When someone is burned very bad, then the nerves in the burned area die. The skin underneath still have live nerves and can cause SEVERE pain. When they decried an area they have to cut down to this area and remove only the damaged and dead tissue. You have to be awake obviously so you can scream when LIVE tissue is reached. Barbaric but makes sense if you think about it. Was I told wrong? I truely hope so, I’ve had many nightmares about this and it has caused a bit 0f fear when around fire...


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