Burns - Analgesia and dosing

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 PCH Emergency Department (ED) staff in prescribing analgesia in patients with burns.

General principles

All children with burns will require analgesia
Children with burns requiring admission to hospital will generally require opiates
It is essential that the child has been given appropriate long acting medications prior to transfer to the burns unit.

Management

Medications in the Emergency Department

Pain severity	Drug	Route	Dose	Comments
Severe	Fentanyl - Medication Management Manual (internal WA Health only)	Intranasal	Children > 1 year: 1.5 micrograms/kg via 1ml syringe with an atomiser attached. Dose may be repeated once after 5-10 minutes if required.	Usual maximum dose is 100 micrograms due to volume limitations Intranasal Fentanyl is the first choice but if not available or IV access attained for other reasons, then use IV Fentanyl or Morphine
	Fentanyl	IV	6 months - 17 years: 0.5 - 2 microg/kg/dose initially (initial max 50 microgram per dose).² May repeat half the original dose every 3 to 5 minutes if necessary.	Repeated doses may be required. IV fentanyl is short acting. The use of multiple intravenous opiates is not recommended – choose fentanyl or morphine.
	Morphine - Medication Management Manual (internal WA Health only)	IV	6-12 months: 25microg/kg/dose³ >12 months and <40kg: 25–50microg/kg/dose³ >40kg: 1-2mg per dose⁴ Doses may be given every 15 minutes as required up to a maximum of 5 doses in 60 minutes. Note: Usual adult dose 5-10mg.³	If pain is severe and not controlled by Intranasal Fentanyl, consider adding IV Morphine which is a longer acting option. Prescribe as ‘prn’ on the WA Paediatric NIMC.
	Oral medication (as below)	PO		Give soon after first dose of Fentanyl or Morphine
Mild to moderate	Paracetamol - Medication Management Manual (internal WA Health only)	PO/IV	IV 1 month - 18 years: 15mg/kg/dose (up to 1000mg) every 6 hours; maximum of 60mg/kg (up to 4000mg) in 24 hours.⁵ ORAL 1 month - 18 years: 15mg/kg/dose (up to 1000mg) every 4 - 6 hours; maximum 60mg/kg (not to exceed 4000mg) in 24 hours.⁵ For more severe pain this may be increased to 90mg/kg (not to exceed 4000mg) in 24 hours for a maximum of 48 hours.⁵	Discuss with pharmacy if patient <1 month (See Paracetamol - Neonatal - Neonatal Medication Manual (internal WA Health only) Ideal Body Weight (IBW) should be used to calculate Paracetamol dosage. See Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age - Medication Management Manual (internal WA Health only)
	Ibuprofen	PO	3 months - 18 years: 5 - 10 mg/kg/dose 3 or 4 times a day (maximum 400mg 3 times a day).⁶	For children >3 months old Be aware non-steroidal anti-inflammatory drug (NSAID) use in burns may be associated with risk of necrotising fasciitis.^7,8
Moderate to severe pain	Oxycodone immediate release - Medication Management Manual (internal WA Health only)	PO	6-12 months: 0.05-0.1mg/kg 4 hourly⁹ 1-18 years: 0.1-0.2mg/kg 4 hourly⁹ Initial maximum dose range is 5 to 10mg per dose. Note: More frequent dosing than 4 hourly is written under direction of APS/Palliative Care or Oncology Consultant only and requires a clear escalation plan documented on medication chart.	Not in < 6 month old Use adjusted body weight when calculating initial oxycodone dose Refer to Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age - Medication Management Manual (internal WA Health only)

Medication for Burns Ward inpatients

After hours: when child is admitted to the Burns Ward between 2200-0800 hrs please chart the following on ward medication chart:

Drug	Route	Dose	Comments
Paracetamol - Medication Management Manual (internal WA Health only)	PO/rectal	Birth (at term) - 1 month: Oral/rectal: 15 mg/kg/dose every 6–8 hours; maximum of 60 mg/kg in 24 hours.⁵ 1 month - 18 years: Oral: 15 mg/kg/dose (up to 1000mg) every 4 - 6 hours.⁵ Rectal: 15 - 20 mg/kg/dose (up to 1000 mg) every 6 hours.⁴ Maximum 60 mg/kg (not to exceed 4000 mg) in 24 hours.⁵ For more severe pain this may be increased to 90 mg/kg (not to exceed 4000 mg) in 24 hours for a maximum of 48 hours.⁵	Discuss with pharmacy if patient <3 month Ideal Body Weight (IBW) should be used to calculate Paracetamol dosage. See Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age - Medication Management Manual (internal WA Health only)
Ibuprofen	PO	3 months to 18 years: 5 - 10 mg/kg/dose 3 or 4 times a day (maximum 400mg 3 times a day).⁶	For children >3 months old Be aware NSAID use in burns may be associated with risk of necrotising fasciitis^7,8
Oxycodone Immediate release	PO	6 - 12 months: 0.05 - 0.1mg/kg/dose 4 hourly⁹ 1 - 18 years: 0.1 - 0.2mg/kg/dose 4 hourly⁹ Initial maximum dose range is 5 to 10mg per dose. Note: More frequent dosing than 4 hourly is written under direction of APS/Palliative Care or Oncology Consultant only and requires a clear escalation plan documented on medication chart.	Moderate to severe pain Refer to Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age - Medication Management Manual (internal WA Health only)
Ondansetron⁶	IV/PO	IV 1 month - 18 years: 0.1 - 0.15 mg/kg/dose (maximum 4 mg) 8 hourly. Use the lower end of the range for children < 2 years.^10,11 Oral 18 months - 18 years: 0.1 - 0.15 mg/kg/dose (maximum 8 mg) 8 hourly.^10,11	Treatment of nausea and vomiting

References

AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Fentanyl; [Modified July 2021, Cited 02 Dec 2021,] Available from: Fentanyl - AMH Children's Dosing Companion (health.wa.gov.au)
Clinical Pharmacology [Internet]. Gold Standard Inc. 2021 [cited 2021 Dec 02]. Available from: Fentanyl Indications - Clinical Pharmacology (health.wa.gov.au)
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Morphine; [Modified July 2021, Cited 18 Oct 2021,] Available from: Morphine - AMH Children's Dosing Companion (health.wa.gov.au)
UpToDate [Internet]. Waltham (MA): UpToDate Inc; 2021 [cited 2021 Dec 02]. Available from: Morphine: Drug information - UpToDate (health.wa.gov.au)
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Paracetamol; [Modified July 2021, Cited 18 Oct 2021,] Available from: Paracetamol - AMH Children's Dosing Companion (health.wa.gov.au)
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Ibuprofen; [Modified July 2021, Cited 25 Oct 2021,] Available from: Ibuprofen - AMH Children's Dosing Companion (health.wa.gov.au)
Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine. 2003 Jul;82(4):225-235.
Zerr, D., Rubens, C. NSAIDS and Necrotizing Fasciitis, The Pediatric Infectious Disease Journal: August 1999 - Volume 18 - Issue 8 - p 724-725
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Oxycodone; [Modified July 2021, Cited 02 Dec 2021,] Available from: Oxycodone - AMH Children's Dosing Companion (health.wa.gov.au)
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Ondansetron; [Modified July 2021, Cited 18 Oct 2021,] Available from: Ondansetron - AMH Children's Dosing Companion (health.wa.gov.au)

Endorsed by:	Drug and Therapeutics Committee	Date:	Nov 2021
		Review date:	Nov 2024

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