Burns - Procedural pain management

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To guide Emergency Department (ED) and PCH Inpatient Ward staff in reducing anxiety and pain for infants and children during the cleaning and application of dressings for a burn injury.

Risk

Failure to follow this guideline may lead to sub-optimal and ineffective procedural pain management causing further discomfort and distress for the patient, the family and healthcare professionals alike.

Background

Procedural pain management is crucial in burn treatment. Both the patient and parent can be supported through a safe environment and a well-planned approach to pharmacological and non-pharmacological interventions.

All burn procedures, regardless of injury size, can cause discomfort, anxiety, and potential post-traumatic stress without proper preparation and management.^{1 -6}

Analgesia dosing tables – quick links

Refer to Appendix 1: Burns Medication in the Emergency Department

Refer to Appendix 2: Burns In-patient Analgesia Dosing Guide PRE-PROCEDURE

NOTE TO ED PRESCRIBERS: For patients transferring from ED to a ward, ensure analgesia is prescribed as per Appendix 2 prior to transfer. This ensures timely analgesia upon admission, preventing delays and gaps in pain management. 

Pharmacological interventions
To ensure pain and anxiety management is sufficient during a procedure, consider consultation with: Burns Clinical Nurse Consultant (CNC) Burns Registrar Keeping Kids in No Distress (KKIND) Acute Pain Service (APS) eReferral (Requires Burns Consultant approval) Patient / carer.
Mild Pain	Moderate Pain	Severe Pain
Prescribe	Prescribe	Prescribe
Paracetamol Ibuprofen	Paracetamol Ibuprofen Opioid	Paracetamol Ibuprofen Opioid
Consider	Consider	Consider
Clonidine Sucrose	Clonidine Sucrose Nitrous Oxide / Oxygen	Clonidine Ketamine (ED / APS only) Fentanyl (ED / APS only) Midazolam (ED / APS only) Dexmedetomidine (ED / APS only)
Non-Pharmacological Interventions
Psychological	Physical	Environmental
Consider	Consider	Consider
Comfort position Breathing exercises Blowing bubbles Comfort Card Patient Profile	Smiley Scope Pacifier Breast-feeding Buzzy Bee TV / iPad Music	Calm atmosphere Low stimuli Quiet room Dim lights Temperature of room

Guide to prescribing medication

If a patient requires a dressing change, please consider a medication plan in accordance with Appendix 2: Burns In-patient Analgesia Dosing Guide PRE-PROCEDURE.

• Doses outside of the recommended ranges should be prescribed in consultation with ED consultant or APS if an inpatient.
• Obtain an accurate patient weight before prescribing medication for administration.
• For overweight and obese children, obtain a height so that an ideal body weight can be calculated.
  • Refer to the Drug Dosing in Overweight and Obese Children 2 to18 Years of Age
• Complex dressings to be discussed with Burns Team regarding a plan
  • +/- Theatre
  • Acute Pain Service (APS) review for procedural sedation.

Key considerations

• Consider staffing requirements and the potential need for fasting where multiple agents may be required.
  • Refer to Nursing Care: Increased Level of Observation and/or Supervision policy (PCH Operational Manual).
• Children, adolescent and parents / carers should be allowed time to express their views, fears and concerns as a burn experience can be frightening and traumatic.²
• It is important the parent / carer who remains present for the procedure is aware of their role in the room. This will optimise their ability to assist the child throughout the procedure and ultimately reduce anxiety and distress.^2,9
• Ensure collaboration between staff, the patient and parent / carer to develop a procedural plan that involves both pharmacological and non-pharmacological interventions.
  • Considering the following KKIND principles.
    • Promotion and delivery of trauma informed care.
    • Minimise paediatric medical traumatic stress.
    • Recognition and response to anxiety and distress.
  • Implement a procedural plan.
    • Refer to the Procedural Management Plan.
  • Consider the use of consumer resources such as Health Fact sheets that can assist patients, parents / carers and KKIND
• Consider the biological, psychological, and sociocultural influencing factors when assessing pain and distress.
• Consider the intended goals of sedation appropriate to the procedure e.g., anxiolysis or analgesia or combination of both. Commonly used medications are presented in Appendix 2: Burns In-patient Analgesia Dosing Guide PRE-PROCEDURE. Information needs to be consistent, clearly explained and age appropriate.^3,4,10
• Be observant. Watch for changes in behaviour, appearance and activity level.¹⁰

Procedural Management Plan

Pre-procedure

Steps: Pre-procedure	Additional information
1. Create a safe environment for successful procedure	Understand the mechanism of injury, how and when did burn occur and location of the burn e.g., hand / feet / chest. Patient assessment; level of anxiety / distress, past experiences (positive / negative). Use an appropriate pain assessment tool. Refer to the pain assessment guideline - Assessment of Acute Pain in Infants, Children, and Adolescents. Review analgesic plan: Ensure accurate weight and height is documented prior to transfer to the ward. Is this adequate for the anticipated duration? Is this adequate for the level of pain / distress expected? Is an adjunct required? Set up for success. Know medication time to peak effect. Ensure all staff are available and discuss roles. Complete and record a full set of baseline observations on the Observation and Response Tool and record additional information on the Clinical Comments chart. Warm the room where possible.
2. Inform patient and family on procedure	Provide developmentally appropriate explanations to the patient and their parents / carers. This can have long term consequences on behaviour, memory, pain perception and developmental outcomes for the child as well as the flow on effect to parents/carers.7,8 Optimise parents / carer’s role during procedure. Comfort positioning and clinical holding principles should be considered with the parent / carer. Refer to the Clinical Holding guideline. Receive consent/assent. When a clinical hold is required, clinical staff are required to document the following statement in a patient’s record. “Consent to clinically hold (patient’s name) (part of body held, e.g. left arm) for (assessment / treatment / procedure, e.g. PIVC insertion) was provided by (name of patient/parent/guardian).”
3. Consider need for psychological support	Consider KKIND Comfort card and implement the KKIND principles / distraction techniques planned.

During the procedure

Steps: During the procedure	Additional information
4. Non-pharmacological & pharmacological strategies	Engagement– provide positive alternative focus which can help reduce perceptions of pain during dressing change. Refer to Appendix 2: Burns In-patient Analgesia Dosing Guide PRE-PROCEDURE.
5. Deep breathing exercise	Used for coping strategies. Assist in regulating anxiety.
6. Maintain calm environment	A quiet and low stimuli room helps prevent the patient from becoming distressed. Aim for one voice directing the procedure. Support the parent / carer. Comfort Positions.
7. Monitor analgesia effect	Complete and record a full set of observations on the Observation and Response Tool and record additional information on the Clinical Comments chart. Frequency of observations as per the Procedural Sedation or as per the medication monograph or as clinically indicated. Assess sedation using the University of Michigan sedation scale (UMSS). Timing of medication peak effect +/- breakthrough analgesia and adjuncts.

Post Procedure

Steps: Post-procedure	Additional Information
8. Promote recovery	Important to have positive experience before and after a procedure, to reduce negative association with the procedure. Allow the patient to make choices. Encourage recovery techniques e.g., cuddles, distraction. Debrief and discuss what worked well and what did not, from the patient and parents / carers perspective. Staff to identify what worked well and/or what could be improved for next time. Consider additional analgesia if required and to chart.
9. Documentation	Document the child’s outcomes, procedure positions, parents / carers involvement, and non-pharmacological interventions used. Effects of medication (utilizing pain scores, functional activity, and behavioural assessment). Document pain scale utilised. Provide recommendation for improvement for the next change of dressing.

 

Nursing considerations

• Ensure all care and timing of procedures is clearly communicated to clinicians, patient, family and carers involved in the procedure with an aim to minimise trauma. Liaise with the medical team to confirm review times to coordinate wound care.
• Familiarise yourself with medication pharmacology – know the peak time effect. This will ensure the dressing change is undertaken while medication is effective.
• If required liaise with APS for guidance with Burn Consultant approval.
• Consider fasting requirements (dependant on medication used and dosages).
• Burn patient’s to be fasted ONLY if instructed by APS or the Burns Consultant. If requiring Procedural Sedation.
• The Clinical Nurse Manager (CNM) and Hospital Clinical Manager (HCM) is to be notified if a 1:1 nursing special is required.
• Conscious sedation is only permitted within the hours 08:00-15:00hrs / otherwise consider Theatre.
• If staffing additional staffing resources are not available, consider scheduling the procedure on Burns theatre days.

Discharge criteria

Patients can be considered for discharge if the following criteria are met:

• Return to baseline level of consciousness.
• Vital signs within the patient’s normal limits and pain under control.
• Motor function returned to baseline.
• Patient is tolerating fluids or deemed able to maintain hydration post discharge.
• For booked admissions to the Ward 1B PCH, if the patient received opioid medications they must remain under observation for a minimum of four hours, and until alert with no respiratory or sedative effects.
• A responsible adult is present to accompany the patient home.
• Nursing staff to provide,
  • Burns Discharge education.
    • Appropriate Burns Health fact sheets,
    • Analgesia education on discharge.
  • Burns follow up appointments.

References

1. K. Storey, R. Kimble & M. Holbert. The Management of Burn Pain in a Paediatric Burn -Specialist Hospital. Paediatric drugs 2021
2. Heijden M, De Long A, Rode H, Martinez R, Dirk M. Assessing and addressing the problem of pain and distress during wound care procedures in paediatric patients with burns 2018
3. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006
4. Schechter N, Berde C, Yaster M. Pain in Infants, Children, and Adolescents 2nd Edition 2003)
5. P. Richardson & L Mustard. The Management of pain in the burn unit, 2009
6. K. Storey, R. Kimble & M. Holbert. The Management of Burn Pain in a Paediatric Burn -Specialist Hospital. Paediatric drugs 2021
7. Stock. A, Hill. A, Babl. F, Practical communication guide for paediatric procedures. Emergency Medicine Australia (2012) p 641-646
8. Oliveira N, Gaspardo C, and Linhares M. Pain and distress outcomes in infants and children: a systematic review. Brazilian Journal of Medical and Biological Research. (2017)
9. Sydney Children’s Hospital Network, Procedural Sedation (Paediatric Ward, Clinic, and Imaging Areas) Jan 2019.
10. Malviya S, Voepel-Lewis T, et al. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). British Journal of Anaesthesia. 2002; 88(2): 241-245.
11. AMH Children Dosing Companion PtyLtd. Oxycodone. Australian Medicines Handbook [online]: Australian Medicines Handbook Pty Ltd. Cited February 14, 2025 https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/oxycodone?menu=hints
12. AMH Children Dosing Companion Pty Ltd. Ibuprofen Australian Medicines Handbook [online]: Australian Medicines Handbook Pty Ltd. Cited March 11, 2025 https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/Ibuprofen
13. AMH Children Dosing Companion Pty Ltd. Fentanyl. Australian Medicines Handbook [online]: Australian Medicines Handbook Pty Ltd. [Cited 18th March 2025] https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/fentanyl
14. AMH Children Dosing Companion Pty Ltd. Morphine. Australian Medicines Handbook [online]: Australian Medicines Handbook Pty Ltd. [Cited 18th March 2025] https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/morphine
15. AMH Children Dosing Companion Pty Ltd. Paracetamol. Australian Medicines Handbook [online]: Australian Medicines Handbook Pty Ltd. [Cited 18th March 2025] https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/paracetamol
16. Pain Assessment and Management (Neonatology Guideline)

Endorsed by:	Drug and Therapeutics Committee	Date:	May 2025
		Review date:	May 2026

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