Psychiatric aspect of burn & pain management in burn patients

The occurrence of psychiatric disorders (mainly substance and alcohol abuse, suicidal thoughts, schizophrenia, attention deficit hyperactive disorder (ADHD), dementia, and personality disorders) is an important risk factor for burn injuries. Also, most burn patients suffer from psychiatric disorders and there is a strong correlation between severity and duration of injuries and mental illness; especially anxiety, depression, and post traumatic-stress disorder (PTSD).There is a negative factor between psychiatric illness during burn hospitalization or recovery and wellbeing. A burn injury is a traumatic experience for patients, as regards psychological aspects after trauma. It is also important to consider the concepts of accident proneness and impulsivity, which may represent a person s disposed to a traumatic event. These concepts are necessary for psychiatric care. Modern medical and surgical advances (particularly painless dressing) have greatly increased the survival rates of major burn patients (at least 25% of body surface involved). Burn patients often suffer severe pain, major psychological trauma, and complicated psychosocial disruption to the lives. Psychiatrists and other mental health workers in the medical or surgical setting have an essential role in the care of the patients.From the onset of burn, a major challenge in the care abuse, of patients is pain management. In fact, some believe that burn pain is the most difficult to relieve among all cause of acute pain. All burns are painful. Additionally, the therapies used to treat burn injuries may exacerbate the difficulty of pain control because most of these interventions are associated with pain; like dressing changes, excision and grafting, or physiotherapy. These therapies are painful which is equivalent to or worse than the pain of an initial burn injury. Therefore, pain management must be basis of burn care. Sufficient pain control is associated with better wound healing, sleep, daily activities and quality of life.Despite improvements in modern burn care, suboptimal pain management persists in all stages of burn treatment. Aggressive pain control can help patients not to suffer from the acute experience of pain and secondary morbidities, including long-term anxiety and post-traumatic stress. The complex interaction of anatomic, physiologic, pharmacologic, psychosocial, and premorbid issues can make the treatment of burn pain particularly difficult. Reliable, valid pain assessment tools in form of verbal adjective, numeric, or visual analog scales can be useful guides for pain management in burns. In adults, visual analog and numeric rating scales are commonly used. Children, especially those who are non-communicative observational scales and physiologic indicators such as heart rate and blood pressure may be used.Pharmacologic interventions to pain control are including NSAIDS, acetaminophen, opioid and benzodiazpins. Oral NSAIDS and acetaminophen can be used in treating minor burns, usually in the outpatient setting. For hospitalized burn patients, opioids are the foundation of pharmacologic pain control. Opiods are available and familiar to clinicians. Opioid requirements are increased in burn patients and may far exceed standard dosing recommendations; therefore, tolerance is a challenge throughout burn care. Patient-controlled analgesia with IV opioids is a safe and efficient method of achieving flexible analgesia in burn injured patients. Mainstay of opioids burn pain treatments via oral or intravenous routes are morphine, oxycodone and methadone.Anxiety is a common issue for burn injured patients and may be closely linked to pain for burn injured patients. Background pain and the anticipation of procedural pain exacerbates anxiety, which can in turn exacerbate the pain. Anxiolytic drugs have commonly been used in conjunction with opioids in the treatment of burn pain. When administered as an adjunct to opioids, benzodiazepines ( specially lorazepam) have been shown to decrease both background pain and pain in those patients with high levels of procedural pain. Furthermore, low dose benzodiazepine administration may reduce burn wound care pain reports. Patients with high anticipatory procedural anxiety and high levels of pain are most likely to benefit from anxiolytic therapy.