burn pain management - page 2

Hello all. I have a question. My little 12 y/o brother has 1st, 2nd and 3rd degree burns over his chest covering about 8% of his body. He has been sent home in my care to perform debridement and dressing changes bid. I am a... Read More

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    Originally posted by renerian
    Is the doc ordering the care a FP/IM/Pediatrician? Maybe he needs to see a burn specialist and I am sure that doc will sign for home health. Would your insurance cover it? You can always call your insurance company and find out if they work with a case management company and start there. Sometimes, alot of the times actually, you have to know how to work the system. People do it all the time. Start calling. You can always call the burn doc and get them to call in something stronger. I am sure they would.

    The doctor is a general surgeon, as there are no "burn" doctors in the area, and he did not feel the need to refer my brother to someone further away or to contact home health. I asked, I was denied. I specifically asked for stronger meds than Lortab, but the dr. said "I think 7.5 mg of Lortab should be just fine for this." Even though the kid was screaming as he cleaned the burns. :angryfire

    I think I will call the Dr. yet again and BEG for stronger meds, and I will also call the insurance co. to see if they do have case mgt. Thanks, renerian!

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  2. 0
    Part of Oncology is pain control. The best drug I can see is a once daily dose of Roxonol. Liquid Ms, perfectly titrated to Mg/KG by a Pediatrician.
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    My thinking is to go with a shorter acting drug which would get him through the procedure, but wouldn't have him zonked the rest of the day. If his pain isn't a constant issue, then this could work.

    Depending on what he weighed, you could try Actiq. It's a transmucosal form of Fentanyl which would have a pretty rapid onset. My holdback on this drug is that it starts it's dosing range at 200mcg and (as I said, depending on his weight) could readily send him on the road to CS, or deeper into sleep.

    If we can't get the fentanyl dose low enough to do the trick, I would suggest Dilaudid LIQ. While MS LIQ would also do the trick here, Dilaudid would be a little better punch for severe pain I am sure he is having. This has a nice quick onset, and if given correctly shouldn't be too sedating.

    As far as an all day control medication you're pretty much stuck with either Oxycontin or MS Contin (or another time release MS). Avinza is really good, but again the lowest dose is going to be too much. I think you're going to be looking at doing OxyIR 4/5 times a day and schedule it to where he can have a constant dose.

    Finally, on Lortab. I do ALOT of pain management and I REALLY like Lortab. BUT... It is almost useless alone. Minor issues will be covered by it, but for anything severe at all, you're going to need stronger. However, when needing a PRN in combination with Methadone (AND Methadone would be GREAT in this case, but I've just never seen it used in kids) or MS Contin... you get GREAT results.

    Sorry I couldn't be more help. I don't a huge amount of PEDS pain management. My knowledge mainly applies to adults

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    Loratab?? Hardly.

    Not enough in my humble opinion.

    Delight, you are not the only one. All around bad.

    (former burn patient & nursing student)
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    Burn care requires careful instruction to family members performing the procedures. You should have sterile gloves and other supplies. This is NOT appropriate, and from the other posts ive seen from you on the matter his care overall seems very inappropriate. Lortabs are NOT appropriate. Our kids depending on age if they are yuoung and light of wt get tylenol #3, or vidocin 30 min prior to dressing changes. It is going to hurt and he may holler a bit no matter what you do, it is the nature of an injury, and this is coming from a nurse who keeps her pts as doped as possible during bad dressing changes. But these treatments seem VERY inapprotriate. Many regional burn centers have outpatient clinics where you can make an appointment or simply walk in as an outpatient. Some of my pts come from as far as 1 1/2 hours away or more, but this care is very tricky and not may practitioners know how to take care of these things properly. Also if you are unsure of the dressing changes you should demand home health at least for a few days of instruction, the problem is that many home health nurses also are not skilled in this area. This is an infectin waiting to happen so you must be very careful!
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    To original poster...how is everything? I was reading over this thread and I get so angry at this doctor that tells you how your child should respond to his orders. Switch doctors. Ask for a second, third fourth opinion.
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    Thanks everyone. Let me update you on the goings-on. My brother is now scheduled to have a skin graft. HE still does not have any adequate pain control. My brother begged the Dr. personally for something else, and the dr. refused. This surgeon is NOT a burn specialist, just a general surgeon. However, a burn specialist has been scheduled to come in and perform the skin graft. There apparently is no burn specialist in the area, so someone comes from out of town. The dr. has said that he will "probably" give my brother stronger pain meds following the graft. I hope the burn surgeon will be more inclined to treat pain. My brother, in the mean time, has decided to forego the Lortab prior to dressing changes altogether, as he says it feels exactly the same with it as without it. The dr. NEVER told us that burn care should be sterile, and in fact when I asked him if the care needed to be sterile, he said no. My brother does NOT even come close to being sterile, and sometimes not even clean when trying to clean the burn! He's 12, and somehow just doesn't understand that he needs to use clean water to clean the burn, not the same water he is bathing in. His burn oozes a nasty greenish pururlent stuff that covers each dressing. Really nasty. Some of the burned areas have healed and are now covered with a nice, pink shiny skin. Other areas look like ground beef. I don't have any knowledge of burn care, so I don't know what to do with it. I have asked my mother to follow up on the specifics of his care and to make sure that the burn is not infected. Beyond this, I don't know what else to do. Thanks to everyone who has given me suggestions and thanks for your support and encouragement! I'll let you know how things go.
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    I'm so sorry that you and your brother are going through this. I wish you lived in this neck of the woods so I could come over there and help out. It sounds like this doc is not only beyond clueless but cruel as well! You can bet that if it were one of his loved ones suffering, the narcotics would be flowing like water! And yes, burn wound care is done with sterile technique.... how could he not know this!!! And his pain control is completely inadequate! Hopefully the burn doc who does his surgery will provide the appropriate care and pain control. In our unit we premedicate for drsg changes, in addition to the meds used during the change itself. Usually the premed includes something for pain, such as oxycodone, as well as something for anxiety, such as valium or versed. I think the anti anxiety aspect of this is very important, and the versed is especially good as it has a somewhat amnesia causing effect. Please let us know how your brother's surgery, and his follow up care, goes.
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    Thanks everyone for your caring and support. Dave, I actually OFFERED the physician some of your suggestions, but he said that nurses have different ways of choosing to treat pain, and he didn't treat pain in those ways. :angryfire

    Anyway, my brother had the skin graft already and is doing well. BOth the graft site and the donor site are healing just fine. He NEVER did get adequate pain control, though. It makes me sick. Maybe, when I grow up (he he) I will be a pain control NP just to make sure that people don't have to suffer needlessly!!

    Thanks to everyone for your wisdom and support, and for caring.
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    I work in a burn unit and am surprised your son was sent home for care. Have you adjusted the timing of when he takes the med? Can you, with the physician's approval, give more, like one and a half tabs?
    Truth be told, when I push 20 of morphine on my burn patients, they still have much pain when we treat their burns. It is going to hurt.
    Forgive if you've said so, but why has your son not received skin grafts for those burns? That in itself just is not right.

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