Regional analgesia for patients with traumatic rib fractures - a narrative review

Abstract

Rib fractures are a common complication of trauma and a marker of internal injuries and can carry a high mortality rate. Advanced age, multiple rib fractures, flail chest, and concomitant injuries are poor prognostic risk factors. Fractured ribs and chest drains are painful which can lead to splinting and impaired respiratory mechanics, thereby exacerbating underlying lung injuries and leading to pneumonia, the need for ventilatory support, and death. Younger patients and those with ?3 rib fractures and non-severe internal injuries/comorbidities generally do not require hospitalization, and should receive multimodal analgesia according to the World Health Organization pain ladder. For the elderly and those with ?3 rib fractures, significant comorbidities, and/or associated injuries, multimodal analgesia, which includes opioids, is rarely sufficient.Regional analgesia is a safe, effective, reliable modality that can facilitate chest physiotherapy, ambulation and possibly weaning from mechanical ventilation with the advantage of avoiding the central nervous depressive effects of opioids. Regional analgesia relies mainly on low-concentration local anesthetics (with or without low-dose opioids), and can be performed as a single dose injection, or, more commonly, by placing a catheter for continuous/prolonged infusion. Regional analgesia options include epidural, paravertebral block (and its variants), intercostal block, and serratus anterior block. Newer (and theoretically safer) techniques have emerged in recent years and can be easily mastered by trauma and emergency physicians, respirologists, and intensivists using ultrasound guidance. The purpose of this review is to summarize and review the literature for commonly used analgesic strategies in patients with rib fractures, with an emphasis on regional blocks. LEVEL OF EVIDENCE: 1-3 STUDY TYPE: Review Article.