CBM Pain Management & Sedation 3 — Questions and Answers
Question 1: Which sedation scale is most commonly validated for use in burn ICU patients to assess agitation and sedation depth?
- Glasgow Coma Scale (GCS)
- Richmond Agitation-Sedation Scale (RASS) (Correct answer)
- Ramsay Scale only
- Numeric Rating Scale (NRS)
Correct answer: Richmond Agitation-Sedation Scale (RASS)
The RASS is widely validated and used in ICU settings including burn units to titrate sedation to a target level and avoid over- or under-sedation.
Question 2: A pediatric burn patient undergoing procedural sedation with ketamine should routinely receive glycopyrrolate because ketamine:
- Causes bradycardia
- Stimulates excess salivation that can obstruct the airway (Correct answer)
- Lowers blood pressure significantly
- Causes paradoxical pain sensitization
Correct answer: Stimulates excess salivation that can obstruct the airway
Ketamine's sympathomimetic effects increase secretions; glycopyrrolate (an anticholinergic) reduces hypersalivation and the risk of laryngospasm.
Question 3: Regional nerve blocks in burn patients are limited primarily by:
- Patient refusal in all cases
- Infection risk when inserting through or near burned tissue (Correct answer)
- Lack of any analgesic effect on burn pain
- Prohibition by burn care guidelines
Correct answer: Infection risk when inserting through or near burned tissue
Placing catheters through or near burned, colonized tissue carries significant infection risk, limiting the use of regional techniques in burn patients.
Question 4: Methadone's role in chronic burn pain management is primarily related to its:
- Very short half-life enabling rapid titration
- NMDA receptor antagonism in addition to opioid agonism (Correct answer)
- Reversibility with naloxone only
- Absence of respiratory depression risk
Correct answer: NMDA receptor antagonism in addition to opioid agonism
Methadone blocks NMDA receptors, which are implicated in central sensitization and neuropathic pain, giving it advantages beyond pure mu-opioid activity.
Question 5: Which pain assessment tool is most appropriate for a non-verbal, intubated burn patient in the ICU?
- Numeric Rating Scale (NRS)
- Visual Analog Scale (VAS)
- Behavioral Pain Scale (BPS) (Correct answer)
- Wong-Baker FACES scale
Correct answer: Behavioral Pain Scale (BPS)
The Behavioral Pain Scale (BPS) assesses facial expression, upper limb movements, and compliance with ventilation to estimate pain in non-verbal ICU patients.
Question 6: The primary advantage of using a multimodal analgesia approach in burn patients is to:
- Eliminate the need for nursing assessment
- Reduce total opioid consumption while achieving better pain control (Correct answer)
- Avoid all sedative medications
- Replace procedural analgesia with background infusions
Correct answer: Reduce total opioid consumption while achieving better pain control
Multimodal analgesia combines agents with different mechanisms (opioids, NSAIDs, gabapentinoids, ketamine, etc.) to achieve superior analgesia with fewer opioid-related side effects.
Question 7: A burn patient on a continuous morphine infusion develops pruritus. The most pharmacologically appropriate treatment is:
- Discontinue morphine and switch to acetaminophen only
- Administer low-dose naloxone infusion or nalbuphine (Correct answer)
- Increase the morphine dose
- Apply topical hydrocortisone to the burned area
Correct answer: Administer low-dose naloxone infusion or nalbuphine
Low-dose naloxone infusion reverses opioid-induced pruritus without significantly reducing analgesia; nalbuphine (partial agonist-antagonist) also effectively treats this side effect.
CBM Pain Management & Sedation 3
Which sedation scale is most commonly validated for use in burn ICU patients to assess agitation and sedation depth?