Rib fractures

 

Why this article?

Rib fracture common

·      10% of chest trauma patients

·      Probably deserves a clinical care pathway

Rib fracture bad

Preventable complications:

·      ICU admission

·      T1RF

·      T2RF (pain or flail)

·      Pneumonia

·      Expensive

Associated injuries:

·      Upper: mediastinum

·      Middle: lung

·      Lower: abdomen

Analgesia good

·      ↓Suffering

·      ↓Complications (esp if high risk)

 

Risk factors for M&M:

Patient

·      Age

·      Frailty

·      Lung disease

·      Heart disease

·      Diabetes

Injury

·      Multiple fractures

·      Bilateral fractures

·      Flail segment

·      Lung contusion

Compromise

·      Impaired oxygenation

·      Impaired ventilation

 

Systemic analgesia:

Problems

·      Opioids are respiratory depressants

·      Opioids are anti-tussive

·      Beware if sleep-disordered breathing

·      Beware if lung disease

Oral

·      Paracetamol

·      NSAID

·      Maybe tramadol

·      Maybe tapentadol

·      Not gabapentinoids

IV

·      Ketamine infusion (reduces opioid requirement)

·      Opioid PCA

 

Regional analgesia (catheters)

Benefits

Patient:

·      ↓Pain

·      ↓Delirium

·      ↓Pneumonia

·      ↓Mechanical ventilation

·      ↓Mortality

Hospital:

·      ↓Cost

·      ↓ICU stay

Problems

Not a silver bullet:

·      Phrenic nerve -> diaphragm

·      Vagus nerve -> mediastinum, visceral pleura, diaphragm

·      Other nerves -> clavicle, scapula etc

Uncertainty:

·      Lack of good evidence

·      Ideal regimen unknown (? intermittent bolus)

·      Safe daily dose of local anaesthetic unknown

Thoracic epidural

·      Gold standard

·      Bilateral nerve root block

·      Spread up and down ? levels

·      Contraindicated if anticoagulated

·      Small risk of severe neuro complications

Paravertebral

·      Unilateral nerve root block

·      Reduced complications cf. epidural (esp hypotension)

·      Spread up and down 5 levels

·      Contraindicated if anticogulated

·      Smaller risk of severe neuro complications

Erector spinae

·      Unilateral nerve root block

·      Catheter between transverse process and erector spinae

·      Spread to nerve root via costotransverse foramen

·      Spread up and down 7 levels via thoracolumbar fascial plane

·      Safe if anticoagulated

·      Safe in general

Serratus anterior

·      Unilateral block of lateral cutaneous nerve only

·      Spread up and down 3-4 levels

·      Safe if anticoagulated

·      Safe in general

 

Other treatment:

Chest physio

Aims:

·      Re-expand collapsed alveoli

·      Clear secretions

Methods:

·      Bubble positive expiratory pressure

·      Postural drainage with percussion

·      Active cycle of breathing techniques

·      Autogenic drainage

·      Oscillatory positive expiratory devices

·      Thoracic oscillating devices

HFNP

·      Warmth

·      Humidification

·      PEEP a few mmHg

Rib surgery

·      Most effective if flail segment

·      Most effective if early

 

 

Feedback welcome at ketaminenightmares@gmail.com