Medicating the cage: Pain management of rib fractures

Common practice in the management of rib fractures is a combination of pain control and pulmonary hygiene. Morbidity and mortality caused by rib fractures is the result of three main problems: altered breathing mechanics secondary to splinting, hypoventilation caused by uncontrolled pain, and impaired gas exchange as a result of underlying lung parenchyma damage. The chest pain caused by a patient’s rib fractures often significantly limits the patient’s ability to cough and breathe deeply, leading to pulmonary complications. This splinting contributes to an increased risk of pneumonia, acute respiratory distress syndrome, and respiratory failure, which can lead to a longer hospital length of stay and even death. The morbidity and mortality rates associated with rib fractures have been found to be greater in patients older than 65 years of age, patients with more than three rib fractures, and in those individuals who have premorbid cardiopulmonary disease.1

Recent recommendations

In 2016, the Eastern Association for the Surgery of Trauma (EAST) and the Trauma Anesthesiology Society conditionally recommended multimodal analgesia and regional anesthesia for the management of pain in blunt thoracic trauma.2 Traditionally, physicians have used an escalating pain control modality, starting with oral nonnarcotic medications (acetaminophen/ibuprofen) paired with as-needed oral opioids. The addition of nonsteroidal anti-inflammatory drugs also known as NSAIDs have been found to decrease overall opioid requirements, risk of pneumonia, ventilator days, and intensive care unit (ICU) stays.3,4

When oral management fails, escalation to intravenous opioids on an as-needed basis or via patient-controlled analgesia is recommended. Some physicians have advocated for regional anesthesia in the form of intercostal nerve blocks, paravertebral blocks, or epidural placement for those patients who have failed to get relief from oral and intravenous pain management. The Western Trauma Association developed a treatment algorithm that recommends admitting to a monitored unit patients with more than two rib fractures who are older than age 65, who are particularly frail or have comorbid respiratory disease, or who have severe rib fractures. These severely injured patients also should be considered for epidural anesthesia and early rib fixation.5 Cited in the EAST guidelines, a study by Moon and colleagues found the use of epidural anesthesia had a significant pain reduction when compared with systemic opioids, leading to their recommendation for the use of regional anesthesia.6

Patient needs vary

To examine the occurrence of patients with multiple rib fractures in the National Trauma Data Bank® (NTDB®) research admission year 2016, medical records were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records that contained a diagnosis code of S22.4 (multiple fractures of ribs). A total of 92,159 records were found, 83,815 of which contained a discharge status, including 52,472 patients discharged to home, 14,945 to acute care/rehab, and 11,700 to skilled nursing facilities; 4,698 died (see Figure 1). Of these patients, 66 percent were male, on average 55.9 years of age, had an average hospital length of stay of 7.7 days, an ICU length of stay of 7.8 days, an average injury severity score of 17.8, and were on the ventilator for an average of 7.9 days. Of those tested, 28 percent (14,235 out of 50,634) tested positive for alcohol.

Figure 1. Hospital Discharge Status

Figure 1. Hospital Discharge Status

Many patients are able to have their pain controlled with the previously described modalities; however, in a select patient population, medicating the cage is inadequate, and surgical rib fixation has been beneficial. The data behind operative fixation are under further investigation.

Throughout the year, NTDB data are highlighted in brief monthly reports in the Bulletin. The NTDB Annual Report can be found as a PDF file on the ACS website. In addition, the website contains information about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB.

Acknowledgment

Statistical support for this article was provided by Ryan Murphy, Data Analyst, NTDB.


References

  1. 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.
  2. Galvagno SM Jr, Smith CE, Varon AJ, 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.
  3. Bayouth L, Safcsak K, Cheatham ML, Smith CP, Birrer KL, Promes JT. Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture. Am Surg. 2013;79(11):1207-1212.
  4. Yang Y, Young JB, Schermer CR, Utter GH. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg. 2014;207(4):566-572.
  5. Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association critical decisions in trauma: Management of rib fractures. J Trauma Acute Care Surg. 2016;82(1):200-203.
  6. Moon M, Luchette FA, Gibson SW, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg. 1999;229(5):684-691.

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