Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 24 , ISSUE 3 ( March, 2020 ) > List of Articles

RESEARCH ARTICLE

Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK

Laura Beard, Billy Holt, Catherine Snelson, Chetan Parcha, Fang Gao Smith, Tonny Veenith

Keywords : Analgesia, Critical care, Pain relief, Rib fractures, Thorax trauma

Citation Information : Beard L, Holt B, Snelson C, Parcha C, Smith FG, Veenith T. Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK. Indian J Crit Care Med 2020; 24 (3):184-189.

DOI: 10.5005/jp-journals-10071-23375

License: CC BY-NC 4.0

Published Online: 01-03-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Introduction: Good analgesia has been shown to reduce the risk of pneumonia, chronic pain, and mortality in patients with multiple rib fractures (MRFs). This survey explores the current analgesic practice in the UK, protocol use, barriers to provision, and physician preferences. Materials and methods: A web-based survey was distributed nationally to an enriched cohort of clinicians working in UK trauma units with an interest in MRF management. Results: Seventy-nine healthcare professionals responded. A third (31.4%) reported that their department had a rib fracture pain protocol, 52.9% did not, and 15.7% were unsure. Significantly more respondents reported adequate pain control when a hospital protocol was present compared to when not (χ2, p < 0.01). Inadequate analgesia, a poor cough, and inability to breathe deeply were the commonest complications reported by 81.4, 78.6, and 65.7%, respectively. Patient-controlled analgesia (PCA) was the most commonly used form of analgesia (38.6%) followed by thoracic epidural (TEA) (30.0%) and continuous opioid infusion (18.6%). However, TEA was the preferred method of analgesia among respondents (37.1%) followed by serratus block (21.4%), paravertebral block (17.1%), and PCA (14.3%). Discussion: There is considerable variation among physicians in their current use of analgesic modalities, with opiate-based methods predominating despite a physician preference for regional techniques. Thoracic epidurals are preferred by physicians but of limited use as a result of contraindications, time pressures, and staff skill mix. Pain control is reported to be better handled when protocols are present. Further research focusing on currently utilized regional techniques is required in order to produce a validated standardized national protocol that is informed by the current practice, the evidence base, and limitations to service provision. Key messages: There is considerable variation among physicians in their current use of analgesic modalities. Opiate-based methods dominate for thoracic trauma despite a physician preference for regional techniques, which can be challenging in this cohort due to contraindications, staff skill mix, and time pressures. Inadequate analgesia is common but is better managed when pain management protocols are available.


  1. Pressley CM, Fry WR, Philp AS, Berry SD, Smith RS. Predicting outcome of patients with chest wall injury. Am J Surg 2012;204(6):910–913; discussion 3–4 10.1016/j.amjsurg.2012.05.015.
  2. Lin FC, Li RY, Tung YW, Jeng KC, Tsai SC. Morbidity, mortality, associated injuries, and management of traumatic rib fractures. J Chin Med Assoc 2016;79(6):329–334. DOI: 10.1016/j.jcma.2016.01.006.
  3. Liman S, Kuzucu A, Tastepe A, Ulsan G, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003;23(3):374–378. DOI: 10.1016/s1010-7940(02)00813-8.
  4. Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017;2(1):e000064. DOI: 10.1136/tsaco-2016-000064.
  5. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004;136(2):426–430. DOI: 10.1016/j.surg.2004.05.019.
  6. Chapman BC, Herbert B, Rodil M, Salotto J, Stovall RT, Biffl W, et al. RibScore: a novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg 2016;80(1):95–101. DOI: 10.1097/TA.0000000000000867.
  7. Jensen CD, Stark JT, Jacobson LL, Powers JM, Joseph MF, Kinsella-Shaw JM, et al. Improved outcomes associated with the liberal use of thoracic epidural analgesia in patients with rib fractures. Pain Med 2017;18(9):1787–1794. DOI: 10.1093/pm/pnw199.
  8. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012;43(1):8–17. DOI: 10.1016/j.injury.2011.01.004.
  9. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000;48(6):1040–1047. DOI: 10.1097/00005373-200006000-00007.
  10. Hasenboehler EA, Bernard AC, Bottiggi AJ, Moghadamian ES, Wright RD, Chang PK, et al. Treatment of traumatic flail chest with muscular sparing open reduction and internal fixation: description of a surgical technique. J Trauma 2011;71(2):494–501. DOI: 10.1097/TA.0b013e3182255d30.
  11. May L, Hillermann C, Patil S. Rib fracture management. BJA Educ 2016;16(1):26–32. DOI: 10.1093/bjaceaccp/mkv011.
  12. Todd SR, McNally MM, Holcomb JB, Kozar RA, Kao LS, Gonzalez EA, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg 2006;192(6):806–811. DOI: 10.1016/j.amjsurg.2006.08.048.
  13. Maxwell CA, Mion LC, Dietrich MS. Hospitalized injured older adults: clinical utility of a rib fracture scoring system. J Trauma Nurs 2012;19(3):168–174. ; quiz 75–76 10.1097/JTN.0b013e318261d201.
  14. Galvagno Jr SM, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg 2016;81(5):936–951. DOI: 10.1097/TA.0000000000001209.
  15. Bulger EM, Edwards WT, de Pinto M, Klotz P, Jurkovich GJ. Indications and contraindications for thoracic epidural analgesia in multiply injured patients. Acute Pain 2008;10(1):15–22. DOI: 10.1016/j.acpain.2007.10.019.
  16. Chincholkar M, Mills J, Howarth M, Murison F, Dwyer A, Makin R. Winning abstracts from the National Acute Pain Symposium 2017. Pain management in trauma associated with rib fractures. Br J Pain 2017;11(4):210–212. DOI: 10.1177/2049463717736491.
  17. Carver TW, Milia DJ, Somberg C, Brasel K, Paul J. Vital capacity helps predict pulmonary complications after rib fractures. J Trauma Acute Care Surg 2015;79(3):413–416. DOI: 10.1097/TA.0000000000000744.
  18. Choi J, Gadsden J. Chapter 10: local anaesthetic mixtures for peripheral nerve blocks. In: Hadzic A, ed. Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed., New York: McGraw-Hill; 2017.
  19. Durant E, Dixon B, Luftig J, Mantuani D, Herring A. Ultrasound-guided serratus plane block for ED rib fracture pain control. Am J Emerg Med 2017;35(1):197.e3–197.e6. DOI: 10.1016/j.ajem.2016.07.021.
  20. Khalil AE, Abdallah NM, Bashandy GM, Kaddah TA. Ultrasound-guided serratus anterior plane block vs thoracic epidural analgesia for thoracotomy pain. J Cardiothorac Vasc Anesth 2017;31(1):152–158. DOI: 10.1053/j.jvca.2016.08.023.
  21. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96(4):418–426. DOI: 10.1093/bja/ael020.
  22. Gupta K, Srikanth K, Girdhar KK, Chan V. Analgesic efficacy of ultrasound-guided paravertebral block vs serratus plane block for modified radical mastectomy: a randomised, controlled trial. Indian J Anaesth 2017;61(5):381–386. DOI: 10.4103/ija.IJA_62_17.
  23. Kaur RP, Anwar S. Serratus anterior plane block vs thoracic epidural analgesia for post-thoracotomy pain relief. J Cardiothorac Vasc Anesth 2018;32(6):11–12. DOI: 10.1053/j.jvca.2018.05.046.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.