Outline your approach to the pain management of a pedestrian (hit by a car) who has significant chest injuries.
It may be very difficult to obtain adequate analgesia in patients with significant chest injuries. The various options available may be limited by associated injuries, in particular the presence of a closed head injury, an uncleared cervical or thoraco-lumbar spine, a coagulopathy or renal injury. The options available may also be limited by the area in which the patient will be managed, though these patients should be managed in at least a high dependency unit. Patient sensitivities or allergies, and past illnesses (eg. bleeding ulcer) may also restrict choices.
The options available which should be discussed are multiple and include combinations of:
• simple parenteral opioids (infusion, boluses, PCA), with the use of adjuvant agents
(tramadol, NSAIDs, paracetamol, codeine)
• regional techniques (including epidural analgesia with local anaesthetics and/or opioids, interpleural local anaesthetics or intercostal blocks).
Pain management in chest injuries is touched upon in the answer to Question 26 from the first paper of 2010, "Outline the relative advantages and disadvantages of thoracic epidural analgesia compared to systemic opioid analgesia via a PCA (Patient Controlled Analgesia)"
To simplify revision, that comparison table is reproduced below.
Additionally, an excellent resource on acute pain management in chest injury is available from theJournal of Trauma, Injury, Infection and Critical Care.
Systemic opiates via PCA
Staff very familiar with use
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness
Additional issues can be brought up.
Regional analgesic techniques are gaining in popularity:
- Paravertebral block
- Intercostal nerve block
Opiate-sparing analgesic agents can be used:
Agents to manage a neuropathic component of the pain can be used:
Non-pharmacological methods may be employed:
- PEEP to splint the rib fractures
- Early removal of chest drains
Karmakar, Manoj K., and Anthony M-H. Ho. "Acute pain management of patients with multiple fractured ribs." Journal of Trauma-Injury, Infection, and Critical Care 54.3 (2003): 615-625.