Continuous Intercostal Nerve Blockade for Rib Fractures: Ready for Primetime?
ABSTRACT Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS).
Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia.
Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred.
Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.
- SourceAvailable from: Mark Christopher Fitzgerald
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- "It is possible that more aggressive pain management in the acute phase could impact on longer-term pain and functional outcomes. Although different studies have shown benefits of various analgesic regimens in the acute phase (such as intravenous ibuprofen, intercostal nerve blocks, lidocaine topical patch), none of them have followed the patients to monitor whether there is any difference in longer term pain syndromes   . A meta-analysis of epidural analgesia in patients with traumatic rib fractures showed no significant benefit on mortality, ICU or hospital length of stay . "
ABSTRACT: Introduction Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Methods Retrospective review (July 2006 - July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were Quality of Life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Results Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. Conclusions This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years.Injury 01/2014; 46(1). DOI:10.1016/j.injury.2014.06.014 · 2.46 Impact Factor
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- "In conclusion, we present a safe and successful strategy for managing a highly unstable and potentially life-threatening disruption of the chest wall, associated with a “four-column” hyperextension injury of the thoracic spine in conjunction with a displaced transverse sternal fracture. A standardized multidisciplinary resuscitation protocol , in conjunction with modern ventilatory management strategies in the SICU [2,38] and a proactive surgical fixation of the “bony disruption” of the chest wall during the physiological time-window of opportunity [11,14], likely contributed to the excellent long-term outcome of this critically injured patient. "
ABSTRACT: Severe chest wall injuries are potentially life-threatening injuries which require a standardized multidisciplinary management strategy for prevention of posttraumatic complications and adverse outcome. We report the successful management of a 55-year old man who sustained a complete "bony disruption" of the thoracic cage secondary to an "all-terrain vehicle" roll-over accident. The injury pattern consisted of a bilateral "flail chest" with serial segmental rib fractures, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, a displaced transverse sternum fracture with significant diastasis, and an unstable T9 hyperextension injury. After initial life-saving procedures, the chest wall injuries were sequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of the displaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextension injury. The patient had an excellent radiological and physiological outcome at 6 months post injury. Severe chest wall trauma with a complete "bony disruption" of the thoracic cage represents a rare, but detrimental injury pattern. Multidisciplinary management with a staged timing for addressing each of the critical injuries, represents the ideal approach for an excellent long-term outcome.World Journal of Emergency Surgery 05/2012; 7(1):14. DOI:10.1186/1749-7922-7-14 · 1.06 Impact Factor
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ABSTRACT: Regional anesthesia is not only performed in the operating room. There are indications for the use of these techniques for pain relief in the emergency department and for anesthesia support of procedures outside the operating room. In this review, we will provide an overview of the indications for the regional techniques performed in the out-of-operating room environment. In the emergency department, patients may experience significant pain, and adequate analgesia is not always provided. Regional analgesia is effective and indicated for many trauma situations including hip fracture, reduction of shoulder dislocation, treatment of upper limb fractures and multiple rib fractures.Ultrasound guidance makes the performance of regional blocks more accessible and safer for use in the emergency department setting.For therapeutic procedures outside the operating room, regional anesthesia is possible for uterine artery embolization and for postoperative analgesia after implantation of cervical brachytherapy needles. Regional anesthesia is a valuable option for analgesia in trauma patients, enabling improved pain control in the emergency department and has benefits in the anesthetic management of therapeutic procedures outside the operating room. For many blocks, ultrasound guidance is useful.Current opinion in anaesthesiology 06/2012; 25(4):501-7. DOI:10.1097/ACO.0b013e3283556f58 · 2.53 Impact Factor