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Sedation, as an adjunct to analgesia, can improve pain relief. This has been shown for
lorazepam combined with morphine (Patterson et al, 1997 Level II); patient‐controlled sedation
with propofol may also be effective (Coimbra et al, 2003 Level IV). A propofol/ketamine
combination resulted in less ‘restlessness’ during burn dressing changes compared with a
propofol/fentanyl combination, with no difference in emergence phenomena (Tosun et al, 2008
Level II). Dexmedetomidine may be effective for sedation in the intensive care unit for
paediatric burn patients but further trials are required (Walker et al, 2006 Level IV).
Topical analgesic techniques, such as lignocaine (Brofeldt et al, 1989 Level IV) or morphine‐
infused silver sulfadiazine cream (Long et al, 2001 Level IV) may be effective, however a topical
gel dressing containing morphine was no more effective than other gel dressing in reducing
burn injury pain in the emergency department (Welling, 2007 Level II).
9.3.2 Non-pharmacological pain management
Hypnosis, distraction, auricular electrical stimulation, therapeutic touch techniques and
massage therapy have been used for the treatment of burn pain, including procedural pain.
A lack of prospective randomised trials makes comparisons with conventional therapies
difficult (Kinsella & Rae, 2008) (see Section 8.1.3). A study comparing two psychological support
interventions, hypnosis and stress‐reducing strategies, found that visual analogue scale (VAS)
anxiety scores were significantly better after hypnosis although there was no significant
difference in pain reports (Frenay et al, 2001 Level II).
Distraction by virtual reality (VR) techniques reduced pain scores in children during burn
dressings (Das et al, 2005 Level III‐3) including in a hydrobath (Hoffman et al, 2008 Level III‐3) and
following burn physical rehabilitation (Sharar et al, 2007 Level III‐3). Simply watching television
during burn care may be as effective as VR in reducing pain scores (van Twillert et al, 2007
Level III‐3).
Augmented reality techniques (interactive computer programme) produced a statistically
significant reduction in pain compared with usual care during paediatric burn dressings lasting
longer than 30 minutes, however further research is required to determine the clinical utility
of these methods (Mott et al, 2008 Level II).
Key messages
1. The use of biosynthetic dressings is associated with a decrease in time to healing and a
reduction in pain during burn dressings changes (N) (Level I [Cochrane Review]). CHAPTER 9
2. Opioids, particularly via PCA, are effective in burn pain, including procedural pain (S)
(Level II).
3. Augmented reality techniques (N) (Level II), virtual reality or distraction techniques (N)
(Level III‐3) reduce pain during burn dressings.
4. Gabapentin reduces pain and opioid consumption following acute burn injury (N)
(Level III‐3).
5. PCA with ketamine and midazolam mixture provides effective analgesia and sedation for
burn dressings (N) (Level IV).
Acute pain management: scientific evidence 247
