2023.1 Day 1 VIVA 6

You are the on-call rural generalist for the Scenarioville hospital. Your rural generalist colleague calls you at 11pm from the emergency department to ask for your assistance with analgesic management of a case.

A 25 year old, otherwise fit and well male has presented with bilateral foot and lower leg burns after walking in a campfire after a couple of beers.

He has been given 5mg of IV morphine by the paramedics during the 1 hour retrieval time from his campsite. On your assessment, he is writhing in pain, slurring his words, and appears to have an altered level of consciousness.

What are your considerations with respect to his analgesic management in the Emergency Department?

• Severe acute pain with relatively low dose (5 mg) IV morphine.

• Altered level of consciousness (LOC) – consider:

  • Opioid toxicity (unlikely with 5 mg morphine but consider accumulation).

  • Alcohol intoxication (most likely).

  • Head injury or associated trauma (exclude clinically).

• Risk of opioid-induced respiratory depression vs. need for adequate analgesia.

What is your multimodal analgesic strategy in ED? 📃(Notes)

• Non-opioids:

  • Paracetamol (1g IV/PO) + NSAID (if no contraindications, e.g., IV ketorolac 15-30 mg).

• Opioid escalation cautiously:

  • Titrate IV fentanyl or morphine in small doses (e.g., fentanyl 25-50 mcg IV).

• Ketamine infusion (analgesic dose):

  • 0.1–0.3 mg/kg/hr IV (reduces opioid use, maintains airway reflexes).

• Burn-specific adjuncts:

  • Cooling with saline-soaked dressings.

  • Anxiolysis (low-dose midazolam if anxious/agitated).

• Monitor LOC & respiratory rate closely

The patient will require recurrent burns dressing changes. How do you plan sedation?

• Discuss with surgeon:

  • Frequency & extent of debridement.

  • Setting: Minor procedure room, ward, or theatre.

• Sedation options based on pain severity & setting:

  • Ward/procedure room:

    • Ketamine 0.5–1 mg/kg IV bolus + infusion 0.2–0.5 mg/kg/hr.

    • Fentanyl 1 mcg/kg IV.

    • Midazolam 0.5–1 mg IV (if needed for anxiolysis).

  • Theatre (severe cases):

    • GA with LMA or ETT if significant surgical debridement required.

What are the safety considerations for procedural sedation?

• Full monitoring: SpO₂, EtCO₂, ECG, BP.

• Airway readiness: Suction, bag-mask, airway adjuncts, emergency drugs.

• Reversal agents available: Naloxone for opioids, flumazenil for benzodiazepines.

• Post-sedation monitoring: Recovery criteria before discharge from sedation.

Neuropathic Pain Management

Three months later, the patient complains of burning pain, hyperalgesia, and allodynia. What is your diagnosis?

• Neuropathic pain due to burn injury nerve damage.

• Features: Burning pain, electric shock sensations, allodynia, hyperalgesia.

Q: What are your pharmacological treatment options?

• First-line:

  • Gabapentinoids (Pregabalin 25-75 mg BD or Gabapentin 100-300 mg TDS).

  • Tricyclic antidepressants (TCAs) (Amitriptyline 10-25 mg nocte).

  • SNRIs (Duloxetine 30-60 mg daily).

• Adjuncts:

  • Lidocaine patches, capsaicin cream for localised pain.

  • IV lignocaine infusion (for severe refractory pain).

Q: Would you use opioids for neuropathic pain?

• Not first-line due to poor efficacy & risk of dependence.

• If already on opioids → wean gradually while introducing neuropathic agents.

• Consider low-dose tramadol (if needed) as a transition strategy.

What are non-pharmacological strategies for managing chronic pain?

• Physiotherapy – functional recovery, pain desensitisation.

• Psychological support – CBT, pain education, coping strategies.

• Desensitisation techniques – graded exposure to touch, heat, cold.

• TENS (Transcutaneous Electrical Nerve Stimulation).

Bonus Question

What if the patient develops opioid dependence after prolonged opioid use?

• Gradual tapering plan – reduce dose by 10-20% per week.

• Transition to non-opioid analgesics.

• Consider referral to pain specialist if withdrawal symptoms or high-dose dependency.