Seidlovŕ D.¹, Zemanova J.¹, Cundrle I.¹, Suchanek L.²

¹Department of Anesthesiology and Resuscitation and Department of Burn and Reconstructive Surgery,
²Faculty Hospital in Brno Bohunice, Czech Republic

SUMMARY. Them ic injury is always associated with pain. The objective of authors was to create algorithm of analgesia for children with burn injuries during pre-hospitalization and hospitalization.

ZUSAMMENFASSUNG
Management der Schmerztherapie bei verbrannten Kinder.

Thermischer Unfall wird jedes Mal mit Schmerz verbunden. Die Autore vorschlagen dine Vorgangsweise bei der Analgesia verbranter Kinder im Rahmen einer vorarztlichen and arztlichen Behandlung.

Key words: burn injury, pain management

Pain is defined as an uncomfortable sensory and emotional experience associated with real or potential damage to the tissue, or is described in terms of such damage. Burn injury, more than any other type of injury, is associated in our mind with intensive pain. Acute pain is, besides signs of an injury, one of the triggers of stress response to trauma. The goal of analgesia apart from pain relief itself is also elimination of the stress impact. It should eliminate useless vegetative fluctuation and activation of sympathicus and prevent immunosuppression. It also should prevent formation of "pain memory", which can hardly be overseen. Analgesia must be used!

As it implies from the definition of pain, it is subjective phenomenon and its interpretation by the child was and is questioned. Treatment of pain in children has long been omitted. Pain of an injured child is associated with a lot of myths that many of us still believe, such as: child has an immature perception of pain, child has a high pain threshold, child tends to forget pain fast and develops dependency on analgesia quicker or unwanted side effect develop.

Since we are constantly confronted with cases, where analgesia is not provided at all, not sufficiently or provided incorrectly, we are offering a model of analgesic treatment in children. This model could certainly be used also in other then burn care. We use three main principles of analgesia:

1. Efficiency
2. Safety
3. Accessibility

Our suggestions are concerning children that have to be transported to the hospital. Children suffering with burn injury involving more than 5%c of body surface, or have smaller burned surface that involves face, neck, genitals and deep burns of hands or when inhalation injury is suspected.

Prior to hospitalization general practitioner's care is organizational: contact with medical first aid service and burn center. The medical care itself involves:

1. Sterile wound dressing
2. Cooling of smaller areas, in extensive burns cooling of hands and face
3. No liquids by mouth
4. Secured transportation
5. Analgesia and sedation: paracetamol 10-15 mg/kg by mouth, intramuscularly, suppository 3-6 months 1/2 supp., 6 months-1 year 1 suppository

Tramadol 1-2 mg/kg gtt, suppository, injection

Midazolam 0.2 mg/kg by mouth, intramuscularly, injection, also nasally.

Medical care in medical first aid ambulance is much broader and it involves:

1. Monitoring
2. Intravenous access of crystalloids
3. Continuation of cooling, beware of hypother mia
4. Analgesia and sedation: ketamin in analgesic dose: intravenous 0.5 mg/kg, intramuscular, by mouth: 3 mg/kg

Midazolam intravenous, intramuscular, injection 0.1-0.2 mg/kg

Opiates intravenous, injection - individual dosage

Concerns to administer opiates in extensive burns and consequent inhibition of respiratory center can be understood, but because of the existence of antidote nalaxon, its denial is unsubstantiated.

Hospital care involves primary management of burned areas in general anesthesia in the operating room, associated with overall support of the child.

Children with extensive burns are placed on Intensive Care Unit, where:

1. Cannula is placed in the central venous System - allows adequate substitute of loss of liquids, parenteral nutrition, analgesia and sedation. Considerable advantage is troublefree, painless introduction to repeated general anesthesias used for all extensive dressing changes.
2. We are trying to arrange surgeries at the beginning of the program in order to minimally disturb the child's biorhythms.
3. For sedation and analgesia Midazolam with Sufentanil proved useful, continually in accustomed dosage together with bolus dosage with Chlorpromazin, 0.75-1 mg/kg.
4. After major surgeries associated with demanding postoperative adaptation, we often choose very slow weaking up from the anesthesia. The child is mechanically ventilated with overall support. There is no need to question importance of mechanical ventilation and long term resuscitation of patients with burn shock.

Children that can be placed on children's unit:

1. Hospitalization with parent is preferred
2. Majority of dressing changes is done in general anesthesia
3. The child is introduced to the operating room in advance
4. Pre medication by mouth - Midazolam, Plegomazin
5. The child has the choice to introduce the general anesthesia intravenously of by inhalation.
6. We are trying to minimize the invasion.
7. Because of the cooperation with the of children's department, we can gradually reduce the general anesthesia and at the same time follow up by postoperative analgesia.
8. Our aim is to minimize stress for the child, parents and staff.

Everyone is aware that care for a burned patient in the acute phase is just a first step. Repeated reconstruction surgeries follow, as well as plastic surgeries, outpatient and home care. If the child is not carrying pain experience that has not been attended from the hospital, we can expect its trust and better cooperation, together with better results.

CONCLUSION

There could be discussion about the choice of medications, or about the form of administration. In our work we drew up from experience on our local burn center as well as from medications that are accessible to any general practitioner and medical doctor in medical first aid ambulance.

Address for correspondence:

D. Seidlova
Department of Anesthesiology and Resuscitation
Faculty Hospital Brno
Jihlaushfd 20
625 00 Brno
Czech Republic