Burn related pain

I have n of 1, myself. However the mods won't let us talk about personal medical care, so say I had this 1 patient. The patient got burned over the torso and had SEVERE pain, remarkable relief with Lyrica. No relief with ibuprofen, lidoderm, compounded ketamine/lidocaine/ kenalog, oral steroids, TCA's, cymbalta, flextor patch, aloe vera, icy cream every topical you can think of, daytime narcotics not used for occupational reasons, nighttime oxycodone did work. The burning and stinging are severe and also itching. It was like a swarm of bee attacks. The pain can last months, I pity anyone in the burn unit. It is the worst pain imaginable. Don't forget to give him sleep medication, nothing is worse than severe pain and not sleeping night after night

Pain Applicant1 said:

81 yo F with severe burn related bilat buttock pain s/p nightgown catching fire from fireplace. Multiple grafts. Altered mental status with nearly all meds. No response to topical compounds including ketamine. I just put her on low dose fentanyl and hoping she can tolerate. Considering adding a TENS unit.

Anyone with consistent luck with any treatment for burns.

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There seems to be some preliminary data to show that the elderly have less sedation with the Fentanyl patch compared to Morphine:

http://informahealthcare.com/doi/abs/10.1185/030079904X2114

I have found this as well in my experience.

Why the sedation with " all meds" ? Or is this just with opioids / hypnotics ? Does this pt have hepatic or renal failure ?

If she gets analgesia but can't tolerate side effects, maybe she's a pump candidate. Maybe even Prialt.

try Butrans?

still a long acting opioid, but in terms of morphine equivalents, its less than fentanyl at its lowest. or tramadol ER...

thinking outside the box, anyone do lidocaine IV infusions for neuropathic burn pain?

I do IV Lido for all kinds of things, but mostly periop or as a test before starting an oral like mexilitine. My sense is this lady would likely not tolerate any oral equivalent. Haven't really seen any prolonged benefit with IV infusions aside from breaking a headache cycle.

drf said:

I do IV Lido for all kinds of things, but mostly periop or as a test before starting an oral like mexilitine. My sense is this lady would likely not tolerate any oral equivalent. Haven't really seen any prolonged benefit with IV infusions aside from breaking a headache cycle.

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in fellowship, we did a few trials of IV lido, qdaily x1-2 weeks, to see if it helped neuropathic pain. on a couple, it seemed to help long term (i.e. 2-3 months).

I had considered Nucynta for the neuropathic pain, it sounded like it should work, but didnt need to because of the Lyrica

lobelsteve said:

Butrans is partial agonist and tramadol has my binding affinity of 1/6000 that of morphine. It is opiate like, but not an opiate. Butans is a true opiate, just not a pure agonist.

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yes, and the reason i was thinking that butrans may be an option, as a partial agonist/antagonist, is because he was willing to try fentanyl.

i have gotten Butrans covered precisely because patients have failed morphine, fentanyl and methadone due to side effects.

I avoid long-acting opioids in the elderly - and I definitely avoid morphine in the elderly due to metabolite accumulation.

i have had some luck with Lyrica for intractable burn site pain - but this is a tough pain to treat.

i have had some luck with Lyrica for intractable burn site pain - but this is a tough pain to treat.[/QUOTE]

Yeah, I said that,
why do i feel like i am talking to my kids some days?
I lived through this, it was awful. The lyrica was a Godsend, except I gained 20 pounds