Outline your approach to the pain management of a pedestrian (hit by a car) who has significant chest injuries.

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College Answer

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).

Discussion

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.

Comparison of PCA and Epidural in Management of Multiple Rib Fractures

Thoracic epidural

Systemic opiates via PCA

Advantages


• Avoidance of sedation
• Less delirium
• Less     risk     of     respiratory depression
• If local anaesthetic used alone, possible to avoid opiate side effects
• Lower incidence of DVT
  • Equivalent to epidural in terms of ICU length of stay and hospital length of stay

Staff very familiar with use
• Can provide good analgesia
• Less problem with hypotension
• Safe 
• Could be used in any ICU

Disadvantages
  • Requires skill for placement
  • Not   always   effective   (can   get patchy block)
  • Hypotension       may      require excessive fluid administration or pressor support
  • May   mask   other   associated injuries,  e.g.  ruptured  spleen  in this case
  • Risk of epidural haematoma
  • If opiate used in epidural infusion, opiate side effects such as itch, nausea, still a problem.

• Increasing  age  associated  with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness
• Delirium a major potential problem in this patient
• Respiratory depression a potential problem, particularly if background infusion utilised
• Potential for drug interactions

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:

  • paracetamol
  • NSAIDs
  • clonidine
  • dexmedetomidine

Agents to manage a neuropathic component of the pain can be used:

  • Gabapentin
  • Pregabalin
  • Amitryptilline

Non-pharmacological methods may be employed:

  • PEEP to splint the rib fractures
  • Early removal of chest drains

References

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.