Burn Pain Engine Rules Reference

1. Required Baseline Classes

The engine prefers filling missing baseline classes before maximizing a single medication.

2. Pain-Band Rules

3. Hydromorphone Rules

HM CR rebalance rule

• Triggered when total hydromorphone dose is more than 10 mg/day.
• Triggered only if PO route is available.
• Triggered only if current HM CR is less than 50% of the total hydromorphone daily dose.
• Suggested HM CR target is approximately 50% of total hydromorphone dose.
• Target is rounded to the HM CR step size of 3 mg/day.
• Target is bounded to the HM CR reference range of 3-36 mg/day.
• When this rule fires, the engine adds the remark: consider lowering HM IR as HM CR is increased.
• This exact >10 mg/day and 50% CR conversion threshold is treated as a local protocol rule.

Severe-pain opioid escalation

• If pain is in the severe range (6-10/10), the engine can suggest increasing HM IR or HM CR by one step.
• HM IR is formatted as q6h PRN equivalents in the output.
• HM CR is formatted as daily, BID, or TID depending on the computed total. Doses up to 6 mg/day display as daily.

4. Non-Opioid Escalation Rules

• If pain is above 4/10, the engine suggests adding or increasing selected non-opioid medications.
• If pain is in the severe range (6-10/10), the engine suggests both non-opioid and opioid escalation.
• Venlafaxine is the default antidepressant-class adjunct, but it opens only when all three baseline classes are already active.
• If venlafaxine is already active and pain remains above 4/10 with all baseline classes in place, the engine suggests titrating toward 150 mg/day before switching to a different antidepressant-class adjunct.
• Ketamine is suggested when pain is in the severe range, or when pain is above 4/10 with elevated hydromorphone IR requirement (>= 6 mg/day) or 4+ PRN doses in 12 hours.
• Ketamine add-dosing starts at 0.2 mg/kg/hr for non-severe qualifying cases and 0.4 mg/kg/hr for severe pain in this model.
• An alpha-2 adjunct pathway opens when pain is above 4/10 or agitation is present.
• Clonidine is suggested when that alpha-2 pathway is open, enteral route is available, and there is no hemodynamic contraindication.
• Dexmedetomidine is used instead of clonidine when the alpha-2 pathway is open but PO/NGT is unavailable, IV is available, and hemodynamics allow. This should be treated as a monitored-setting/local-protocol recommendation.
• Ketorolac IV is preferred over celecoxib when pain is in the high/severe range and IV is available, even if PO/NGT is also available.
• The engine prefers lower-dose additions from different classes over pushing one existing medication to its maximum dose.
• For existing baseline medications, optimization uses the next step, not an immediate jump to the maximum documented dose.

Literature basis: ABA burn pain guideline supports ketamine as an opioid-sparing adjunct and alpha-2 agonists for anxiety/withdrawal contexts. The exact hydromorphone trigger and the 0.4 mg/kg/hr severe-pain ketamine start are implemented here as local protocol choices within the subanesthetic infusion range.

5. Renal Adjustment Rules

If the Renal checkbox is selected, the engine applies a conservative renal adjustment consistent with roughly GFR/CrCl 30 or lower for gabapentinoids.

Because the UI uses a yes/no renal checkbox rather than numeric eGFR, the engine uses one conservative renal bucket.

6. Exclusion and Penalty Rules

• Acetaminophen is excluded if hepatic impairment is selected.
• NSAIDs are excluded if renal impairment is selected.
• Alpha-2 agonists are avoided with bradycardia or hypotension risk.
• Medications with sedative or cognitive burden are down-ranked with delirium and respiratory risk.
• Agitation can partially offset that penalty for sedating medications.
• Ketamine is down-ranked if significant psychiatric history is selected.
• Only one medication per duplicate-sensitive class is preferred: NSAID, GABA, Alpha-2 agonist, SSRI/TCA.

7. Age > 65 Toggle

The engine now applies conservative geriatric ranking penalties when Age > 65 is checked. These are ranking and warning adjustments, not hard age-based dose caps.

Active age-based rules

• Opioids are down-ranked in older adults, with an additional penalty when respiratory risk or delirium is also present.
• Gabapentin and pregabalin are down-ranked in older adults, especially when opioids, respiratory risk, or delirium are also present.
• When a GABA agent is still needed in that context, pregabalin is preferred over gabapentin.
• Clonidine is down-ranked in older adults, but agitation partially offsets that penalty.
• Dexmedetomidine is down-ranked in older adults, but severe pain with agitation partially offsets that penalty.
• Nortriptyline is strongly down-ranked in older adults because of anticholinergic, cognitive, and fall-related burden.
• Older-adult warnings are added to the output for opioids, gabapentinoids, clonidine, dexmedetomidine, and nortriptyline.

Evidence basis used for these conservative penalties: hydromorphone geriatric sensitivity from DailyMed labeling, FDA gabapentinoid respiratory warning, dexmedetomidine geriatric bradycardia/hypotension labeling, and the 2023 AGS Beers Criteria for nortriptyline caution.

8. Output Rules

• Ranked outputs show one medication per option.
• The summary block at the top can contain multiple actions when the pain-band logic requires a combined plan.
• The top suggestion is selectable in the UI and is toggled on by default.
• Output dosing is shown as dose plus interval, for example q6h, BID, TID, daily, or continuous.
• The engine returns up to 5 ranked options.
• The top ranked option is preselected in the UI.

9. Current Medication Dose Steps

When the engine recommends starting a medication, it uses the configured default dose for that medication, adjusted to the active renal range when needed.

10. Medication Reference From Burn_Pain_Drugs_Table_from_v1_v4

This section mirrors the source spreadsheet fields and adds the active engine min/max range where the web model currently uses a dose slider. Source file: /Users/noamgoder/Documents/QI/Burn_Pain_Drugs_Table_from_v1_v4.xlsx.

11. Source Files

• /Users/noamgoder/Documents/QI/heliohost-root/httpdocs/assets/decision-engine.js
• /Users/noamgoder/Documents/QI/heliohost-root/httpdocs/data/medications.json
• /Users/noamgoder/Documents/QI/heliohost-root/httpdocs/assets/app.js