Pain Case of the Month: Pain Management of a Burn Patient in a Nigerian Hospital

A rare look at veterinary care in Africa, this case study examines the case of a German shepherd who was treated successfully for burn injuries sustained in a house fire in Nigeria.

by Emmanuella A. O. Sogebi, DVM, PhD, FCVSN

Introduction

Pain is an unpleasant sensory and emotional experience associated with potential or actual tissue damage or described in terms of such. There are some myths about pain in animal species, such as animals don’t feel pain, or feel pain less than humans. Evidence has, however, shown that the pain pathway in animals is very similar to that in humans and, moreover, that behavioral changes in animals experiencing pain revert when given an analgesic.

Figure 1: Rex, upon presentation at the hospital

Signalment and History

Rex, a three-year-old male German shepherd dog weighing 25 kg, was presented to the Veterinary Teaching Hospital of the College of Veterinary Medicine, Federal University of Agriculture, Abeokuta, Nigeria, with the chief complaint of anorexia.

History revealed that the dog had been off feed for about three days before presentation and that there was an incidence of fire outbreak in the house four days before presentation. The fire outbreak occurred in the absence of the owner. On clinical examination, the dog was apparently alert and active. The vital parameters were as follows: rectal temperature 38.6°C, pulse rate 104 beats/minute, and respiratory rate 20 cycles/minute. Physical evaluation revealed pink ocular mucous membrane (normal) but slightly enlarged prescapular and popliteal lymph nodes. There was flame burn of the skin of the dorsum from the cervical region (C1 spine) through the trunk, terminating at the croup [editor’s note: the rump]. There was also a thickened leathery brown-black eschar from the cervical region to the perineal area that was suspected to be infected because of the odor emanating from underneath the eschar. The burn was estimated as 27% of the total body surface area (Figure 1).

Diagnosis and Treatment

The diagnosis of pain was based on behavioral changes (Carroll, 1998) observed in the patient. These changes included a violent withdrawal with loud groaning from the patient on an attempt to debride the burnt tissue to expose the viable tissue. Furthermore, weight loss was apparent in this patient (Rex had lost weight since his last visit to the clinic), which confirmed decreased appetite, and he very slowly approached his favorite meal.

Figure 2: Rex remained calm during debridement

Figure 3: 22 days after debridement

Figure 4: 88 days after treatment

Pain treatment approach included venous access through the cephalic vein and fluid therapy institution with lactated Ringer’s solution at a flow rate of 10 mL/kg/hour. Thereafter, the patient received intravenous dexmedetomidine at 1 mg and ketamine bolus at 5 mg/kg for induction, followed by CRI ketamine at 5 mg/minute (Muir, et al., 2007) for maintenance of anesthesia. Analgesia was achieved with intravenous pentazocine [editor’s note: pentazocine is an opioid not commonly used in the United States] at 2 mg/kg and 20 mL of 2% lignocaine hydrochloride [editor’s note: Lignocaine is known as lidocaine in the United States] administered by infiltration under the viable tissue around the burns. Ketamine infusion continued for 24 hours following wound debridement. Wound debridement lasted one hour. The patient was calm throughout the period of wound debridement (Figure 2) and ate later the same day. The dog was discharged 24 hours after successful wound debridement.

Fluid was administered to maintain homeostasis and patent line. The rate of flow of fluid was considered based on the level of dehydration and degree of burn. Lignocaine was used for pre-emptive analgesic intervention to produce local analgesia, while pentazocine was administered for general analgesia. Dexmedetomidine and ketamine were used as analgesic adjunctive agents to produce neuroleptic analgesia. In addition, CRI ketamine was used to produce hypnosis and analgesia in the patient during debridement and following debridement. Dexmedetomidine was also used to potentiate the analgesic effect of pentazocine in this protocol.

Conclusion

A multimodal approach to pain management was instituted in this case to produce optimal analgesia. All the drugs used were either analgesic agents or adjuvants aimed at each of the pain pathways.

In conclusion, animals feel pain and respond positively when treated with analgesic. The protocol provided optimal analgesia that made it possible to debride the burnt wound, returned normal appetite, and restored healing process.

The donation of a syringe pump by Practivet is acknowledged; it enhanced the effectiveness of the CRI technique used in this case.

 

Emmanuella A. O. Sogebi, DVM, PhD, FCVSN, is an associate professor and researcher at the Federal University of Agriculture, College of Veterinary Medicine, Department of Veterinary Medicine and Surgery, in Abeokuta, Nigeria. Sogebi combines academic work as a lecturer and a researcher with clinical duties and veterinary extension services. She is also a consultant veterinary anesthesiologist at the Veterinary Teaching Hospital of the Federal University of Agriculture. Sogebi’s colleagues, O. E Adeleye, O. A. Makinde, and I. O. Oyenekan of the Federal University of Agriculture, contributed to this report.

 

Discussion by Mike Petty, DVM, CCRT, CVPP, DAAPM

Pain Management in Burn Patients

Burn injuries are among the most painful injuries among animals. Failure to properly treat a patient in the acute phase can lead to long-lasting changes that give rise to chronic pain states such as hyperalgesia or allodynia, affecting the animal’s quality of life for the rest of its days. In this case, every precaution was taken to treat this animal in a multimodal fashion, the best approach to treating severe acute injuries.

Mike Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty offers commentary on each Pain Case of the Month.

Photos courtesy of Emmanuella A. O. Sogebi

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