Appendix 1 and 2

Appendix 1: Burns Medications in the Emergency Department
Pain Severity	Drug	Route	Dose	Comments
Mild to moderate	Paracetamol	PO / IV	IV 4 weeks - 18 years:15 mg/kg/dose (up to 1000 mg) every 6 hours; maximum of 60 mg/kg (up to 4000 mg) in 24 hours. ORAL 4 weeks - 18 years:15 mg/kg/dose (up to 1000 mg) every 4 - 6 hours; maximum 60 mg/kg (not to exceed 4000 mg) in 24 hours. 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.	Discuss with pharmacy if patient <4 weeks (SeeNeonatal Paracetamol Monograph). Ideal Body Weight (IBW) should be used to calculate Paracetamol dosage. Refer toGuidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age.
Mild to moderate	Ibuprofen¹²	PO	3 months - 18 years: 5 - 10 mg/kg/dose (maximum 400 mg) every 6-8 hours.	Not used in < 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	PO	6 - 12 months: 0.05 - 0.1 mg/kg/dose 4 hourly 1 - 18 years: 0.1 - 0.2 mg/kg/dose 4 hourly Initial maximum dose range is 5 to 10 mg per dose.	Not used in < 6 months old. Use adjusted body weight when calculating initial oxycodone dose. Refer toDrug Dosing in Overweight and Obese Children 2 to 18 Years of Age.
Moderate to severe pain	Nitrous Oxide / Oxygen self-demand	Inhaled	As per Nitrous Oxide guideline or as prescribed by ED Consultant.
	Ketamine	IV	As prescribed by ED consultant	Increase Blood Pressure and heart rate Refer toKetamineMonograph for dosing and administration.
	Midazolam	IV / oral	As prescribed by ED consultant	Refer toMidazolamMonograph for dosing and administration.
Severe	Fentanyl	Intranasal	Children > 1 year: 1.5 microg/kg/dose via 1 mL 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 (Emergency Department only)	Children > 6 months: 0.5 - 2 microg/kg/dose (maximum of 50 microgram per dose) initially. May repeat half the original dose every 3 to 5 minutes if necessary.	Repeated doses may be required. IV fentanyl is short acting. Not to be used in combination with other opioid medication
	Morphine	IV	6 - 12 months:25 microg/kg/dose >12 months and <40 kg:25 – 50 microg/kg/dose⁴ >40 kg:1 – 2 mg per dose⁵ Doses may be given every 15 minutes as required up to a maximum of 5 doses in 60 minutes.³	IV Morphine should be considered when pain is severe and not controlled by Intranasal Fentanyl. Not to be used in combination with other opioid medications. Doses may be given every 15 minutes as required up to a maximum of 5 doses in 60 minutes.³
	Dexmedetomidine	Intranasal	*Children >10 kg and > 1year* 2-4 microg/kg (max 200 microg) as a single dose	Discuss with ED Consultant prior to prescribing. Administered for procedural sedation Onset time 20 – 30 minutes

Appendix 2: Burns In-patient procedure Analgesia Dosing Guide PRE-PROCEDURE
Simple / Minor Procedures
	SIMPLE ANALGESIA		ADJUNCTS		OPIOID ANALGESIA
	PARACETAMOL	IBUPROFEN¹²	CLONIDINE	SUCROSE¹⁷	OXYCODONE		MORPHINE ELIXIR
PO Dose	4 weeks –18 years: 15 mg/kg 4-6 hourly	3 months – 18 years: 5–10 mg/kg 6-8 hourly	1 month – 18 years: 0.5-2 microg/kg 8 hourly	Birth (term) – 4 weeks: 0.5-1 mL per procedure 4 weeks – 18 months: 1-2 mL per procedure	6 months – 1 year: 0.05-0.1 mg/kg 1 year – 18 years: 0.1-0.2 mg/kg		4 weeks – 1 year: 0.1-0.2 mg/kg 1 year – 18 years: 0.2-0.5 mg/kg
Frequency / Maximum dose	4 – 6 hourly (Maximum QID)	6 – 8 hourly (Maximum TDS)	8 hourly		4 hourly		4 hourly
Time to reach peak effect	10 to 60 minutes	60 minutes	45 to 60 minutes	2 minutes	30 to 60 minutes		45 to 60 minutes
Mechanism	Analgesia	Analgesia	Analgesia Anxiolytic	Analgesia	Analgesia		Analgesia Anxiolytic Sedative
Cautions	• Renal impairment • Hepatic impairment • G6PD deficiency	• Group A Streptococcal • Active or history of GI disease • Renal impairment • Use of other NSAID medications i.e. Parecoxib	• Bradycardia • Hypotension • Can cause somnolence	• Only effective if placed on the tongue	• Nausea & vomiting – consider antiemetic • Constipation – consider aperients • Sedation		• Nausea & vomiting – consider antiemetic • Constipation – consider aperients • Sedation
Considerations	• All medications should be based on IBW. Refer to PCH Guidelines forDrug Dosing in Overweight and Obese Children 2 to 18 Years of Age. • Consider PPI if long term use of NSAIDs. • For all sedating medications (opioids, alpha 2 agonists, anaesthetic agents, benzodiazepines) monitor for sedation (aim for UMSS <2). • If using procedural dosing &/or multiple agents – consider appropriate fasting and 1:1 nursing special. • In neonates – refer to neonatal guidelinesSucrose monograph •Nitrous Oxide / Oxygen (50:50) Self demand Guideline
More Complex Procedures
	APS
	PO CLONIDINE	INTRANASAL DEXMEDETOMIDINE	PO MIDAZOLAM	PO KETAMINE	FENTANYL		Nitrous Oxide / Oxygen 50:50 Self Demand
	PO CLONIDINE	INTRANASAL DEXMEDETOMIDINE	PO MIDAZOLAM	PO KETAMINE	LOZENGE	INTRANASAL	INHALATION
PO Dose	ONLY PRESCRIBED BY APS
Frequency / Maximum dose	ONLY PRESCRIBED BY APS
Time to reach peak effect	60 minutes	30-45 minutes	10-30 minutes	30 minutes	1-2 minutes	1-2 minutes	1-2 minutes
Mechanism	Analgesia Anxiolytic	Sedative	Amnesia Anxiolytic Sedative	Analgesia Anxiolytic Sedative Amnesic	Analgesia	Analgesia	Analgesia Anxiolytic Amnesic
Cautions	• Bradycardia • Hypotension • Can cause somnolence	• Bradycardia •Transient hypertension • Hypotension	• Hypotension • Hallucinations • Confusion	•Hypertension • Tachycardia • Receiving Central Nervous System (CNS) depressants	• Dry Mouth • Use of serotonergic agents • Receiving CNS depressants	• Dry Mouth • Use of serotonergic agents • Receiving CNS depressants	• Refer to Guidelines • Air entrapment • Patient is uncooperative
Considerations	• Refer to PCH Guidelines forDrug Dosing in Overweight and Obese Children 2 to 18 Years of Age. • Consider PPI if long term use of NSAIDs • For all sedating medications (opioids, alpha 2 agonists, anaesthetic agents, benzodiazepines) monitor for sedation (aim for UMSS <2) • All medications should be based on IBW • If using procedural dosing &/or multiple agents – consider appropriate fasting and 1:1 nursing special. • In neonates – refer to neonatal guidelinesSucrose monograph •Nitrous Oxide / Oxygen (50:50) Self demand Guideline

Appendix 1 and 2

Appendix 1: Burns Medications in the Emergency Department

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

More Complex Procedures