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Pain Control for Rib Fractures. Richard A. Malthaner MD MSc FRCSC FACS Professor Division of Thoracic Surgery LHSC Trauma Program. No Conflict of Interest. No Conflict of Interest. Rib Fracture. Most common thoracic injury Increase morbidity and mortality

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pain control for rib fractures

Pain Control for Rib Fractures

Richard A. Malthaner

MD MSc FRCSC FACS

Professor

Division of Thoracic Surgery

LHSC Trauma Program

rib fracture
Rib Fracture
  • Most common thoracic injury
  • Increase morbidity and mortality
  • Pulmonary function is compromised
  • Acute pain control is critical
principles
Principles
  • Inadequate pain control
    • Inability to cough and breath deeply
    • Sputum retention
    • Atelectasis
    • Reduction in FRC
    • Compromised lung compliance
    • Ventilation-perfusion mismatch
    • Hypoxemia
    • Respiratory failure
principle
Principle
  • Resuscitation precedes pain relief
  • Multimodal analgesia is recommended
options
Options
  • Medication
    • Oral
    • IV
  • Regional analgesia
    • Topical
    • Intercostal nerve block
    • Intrapleural
    • Paravertebral block
    • Epidural
  • Surgical Fixation
first aid
First Aid
  • Analgesia
  • Deep breathing and coughing
  • Avoid taping / bandaging / splinting
medication
Medication
  • Acetaminophen
  • NSAID
    • Ketorolac, ibuprofen, voltaren, tramadol
  • Opioids
    • Morphine, fentanyl, codeine, PCA
  • Gabapentin
  • Tricyclics
iv narcotics
IV Narcotics

Advantages

Disadvantages

Respiratory depression

RN certification

Must wean

Peaks and troughs

  • Rapid onset
  • Less painful than IM & SC
slide11
PCA

Advantages

Disadvantages

Patient must comprehend

Machine errors

Family interference

Weaning

Sedation

  • Better than IV bolus
  • Continuous baseline
  • Patient controlled
lidocaine 5 patch mechanism
Lidocaine 5% patch Mechanism
  • Penetrates the skin
  • Binds sodium channels
  • Block influx sodium
  • Reduce abnormal ectopic discharges produced by damaged nerves

www.endo.com

randomized double blind placebo controlled trial using lidocaine patch 5 in traumatic rib fractures
Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures.
  • Ingalls NK, Horton ZA, Bettendorf M, Frye I, Rosdrigues C
  • J Am Coll Surg. 2010 Feb;210(2):205-9
  • Michigan State University/Grand Rapids Medical Education and Research Center, Grand Rapids, MI, USA.
outcome comparison
Outcome Comparison

* Median (interquartile range)

# Mean + SEM

conclusions
Conclusions
  • Lidocaine patches do not decrease narcotic pain medication use
  • No difference in
    • pain scores
    • pulmonary complications
    • length of stay
  • Should not be routinely used
paravertebral block
Paravertebral Block

Advantages

Disadvantages

Vascular puncture

Pneumothorax

Inadvertent epidural anesthesia

Spread to the opposite site

Horner’s

Expertise

  • Avoids sedation and ventilation
  • Allows neuro assessment
  • Can spare lumbar and sacral nerves
  • Simple
  • Less hypotension
intercostal nerve block
Intercostal Nerve Block

Advantages

Disadvantages

Multiple injections

Painful

Time consuming

Local anesthetic toxicity

Difficult for upper ribs

Pneumothorax

  • Improved PFTs
intrapleural
Intrapleural

Advantages

Disadvantages

Loss of anesthetics via chest tube

Tension pneumothorax if tube is clamped

Impaired diffusion if hemothorax

Posture-dependent

  • Less complications
    • Hypotension
    • Urinary retention
    • Lower extremity paresthesia
epidural
Epidural

Advantages

Disadvantages

Technically difficult

May mask abdominal pathology

Hypotension

Urinary retention

Epidural hematoma

Paralysis

  • Improved PFTs
  • Reduced airway resistance
  • Improved breathing
  • Improved immune response
surgical fixation
Surgical Fixation
  • > 4 segment flail
  • Intubated
  • “Stove in” chest
  • Thoracotomy for other indications
  • Don’t:
    • Severe head injury
    • Other life threatening injuries
take home
Take Home
  • Pain control
  • Pain control
  • Pain control
slide36

CHEST is

BEST