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March 2010, Volume 40 Number 3 , p 61 - 62


  • Paul Arnstein PhD, RN


BURNS ARE AMONG the most intensely painful type of injury, because a series of local and systemic processes continue to damage tissue for at least 24 hours after the burn occurs. Irritating substances released from damaged cells, combined with local inflammatory and immune responses, amplify your patient's pain, making it worse before it gets better.This heightened pain perception, called primary hyperalgesia, usually occurs at the center of superficial burns and closer to the edges of the deepest burns. Primary hyperalgesia develops at the site of tissue injury and is associated with an increased sensitivity of the peripheral nerve fibers that transmit pain impulses. The sensitivity then spreads to adjacent body parts. This phenomenon, called secondary hyperalgesia, develops in uninjured tissue surrounding the burn and is caused by enhanced neural responsiveness in the central nervous system.1For example, suppose you're caring for a 25-year-old man who has second-degree burns on his torso and third-degree burns on his right forearm from a gas grill accident 2 days ago. Each day he demands more analgesics, but any more than 5 mg morphine per hour I.V. results in severe pruritus and sedation. He has severe pain, especially during dressing changes, and I.V. ketorolac doesn't seem to help.When you assess your patient, determine if light touch or exposure to cool air triggers pain. If so, the patient is experiencing allodynia (pain from stimuli that aren't normally painful), which denotes damage to pain-signaling nerves. Allodynia or paresthesias increase the risk that your patient will be among the 30% of burn patients who continue to have pain for months and years after the burn wounds have healed.2You may have noticed that your patient's pain has two distinct components—background or constant pain during rest, and pain induced by activity or treatments. Background pain is typically constant, with periodic flares called breakthrough pain that

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