Intravenous analgesia is the preferred route in severe burns. Intramuscular, subcutaneous and oral analgesics are absorbed unreliably following burn injury due to fluid shifts and gastrointestinal stasis. Absorption of inhaled opioids may be unreliable in patients with inhalation injury. Morphine is the preferred drug in the management of acute pain in severe burn injuries.

Adults: 2-5mg morphine repeatedly every 5 minutes, titrating to the patient's clinical response. 

Re-assess pain score and adjust analgesia accordingly. The patient will require additional analgesia during wound care. Consider a morphine infusion for ongoing pain relief. 

Types of pain

Background pain

Background pain can be described as a continuous burning and/or throbbing sensation which is present at rest and is relatively constant. The severity of background pain varies between individuals 

It is best treated with regular slow-release analgesics to keep plasma drug concentrations steady such as slow-release tramadol or, if more severe, a slow-release morphine or equivalent. 

Procedural pain

Procedural pain is usually more intense. Mechanical stimulation of the injured site during removal of dressings, cleansing and debridement can be a major source of pain which can continue for minutes to hours after the procedure is complete. It is often described as having an intense burning or stinging sensation. 

Procedural pain during the acute phase after injury can be mild to excruciating. If the dressing is expected to be painful, additional short-acting analgesia 45 minutes before the dressing will ease procedural pain. 

Pain assessment

Assessment is essential to guide the effective management of burns pain. The most common pain assessment tools are verbal self-report instruments such as the 0 – 10 numeric rating scale. 

Fluid resuscitation

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