Tweet

Professor of Psychiatry, Internal Medicine and Surgery; Vice-Chair, Department of Psychiatry; Chair, Division of Consultation/Liaison Psychiatry, Virginia Commonwealth University School of Medicine, Richmond, Va.

First published in Primary Psychiatry, Volume 2, Issue 29, July 30, 2007

Introduction

Preexisting substance-use disorders are common among burn patients and often play a causal role in the burn. Estimates of alcohol abuse or dependence in burn patients based on blood-alcohol assay or chart review range from 6%–30%, but rates >0% have been identified with screening instruments like the CAGE test or Michigan Alcoholism Screening Test.¹ Abuse of other drugs is also very common. Alcohol use has been found to be associated with more extensive burns, higher morbidity and mortality, longer length of hospital stay, and increased medical costs.¹

Alcohol withdrawal syndromes are common during the first few days in the burn unit but may be difficult to distinguish from other causes of vital-sign elevations and delirium. The best approach in a burn unit may be a standard withdrawal protocol with the long-acting barbiturate phenobarbital, although many units will be more familiar with lorazepam. Because delirium tremens can be particularly dangerous in a burn patient, it is prudent to err on the side of a liberal withdrawal regimen in patients suspected of alcohol dependence. Burn patients with preexisting opioid dependence require higher doses of narcotics for pain; the burn unit is not the time, nor the place, to preach opioid abstinence.

PTSD in Burn Patients

Posttraumatic stress disorder (PTSD) has been estimated to occur in 21%–43% of patients who have been burned, and many more have subsyndromal traumatic stress symptoms.² Posttraumatic stress reactions occur to the experience of being burned, frightening delirium, and/or treatment itself in the burn unit, particularly the extremely painful debridement. Viewing oneself, especially with disfiguring facial burns, is in itself very traumatic for many patients. Treatment of PTSD in burn patients is similar in most respects to treatment of PTSD in others, including psychotherapy and medication, but is unlikely to help until delirium has abated and pain is adequately treated.

Delirium and Psychosis in Burn Patients

Delirium during the acute care of severely burned patients is very common, related to rapid massive fluid shifts and electrolyte imbalance, hypoxia from smoke inhalation or shock lung, sepsis, medication side effects, and other organic factors. It is very difficult to determine how much of a burn patient’s agitation is due to delirium versus pain versus acute anxiety, especially since most patients will have all three to varying degrees during hospitalization in the burn unit.

---

Disclosure: Levenson has served as a consultant to Lilly.

References:

1. Powers PS, Santana CA. Surgery. In: Levenson JL, ed. American Psychiatric Publishing Textbook of Psychosomatic Medicine. Washington, DC: American Psychiatric Publishing; 2005:647-674.

2. Ehde DM, Patterson DR, Wiechman SA, Wilson LG. Post-traumatic stress symptoms and distress 1 year after burn injury. J Burn Care Rehabil. 2000;21(2):105-111.

Tweet