Question 24

A patient was admitted to ICU with multiple rib fractures due to chest trauma.
a) Outline your approach to analgesia for this patient.    (6 marks)
b) Discuss the role of surgical rib fixation. Your headings should include:
i. The rationale for fixation.    (1 mark)
ii. Indications for surgical referral.    (2 marks)
iii. Potential disadvantages.    (1 mark)

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College Answer

Syllabus topic/section:
2.1.13    Trauma Intensive Care – L1.

Aim:

To demonstrate a stepwise approach to multimodal analgesia, tailored to the individual patient and their pattern of injury.
To assess candidates’ understanding of the controversies, indications and potential disadvantages of surgical rib fixation, an area of increasing interest and emerging evidence in treatment of chest trauma patients in ICU.
Discussion:

Very few candidates included a patient assessment as part of their answer to part a) “outline your approach” which made it difficult for them to pass this question as it was worth 6 of the marks. However nearly all who did attempt some assessment received 5 marks or greater. A section that is worth 6/10 marks requires a detailed response, and this would have aided more candidates to structure their answer for success. Analgesia in traumatic chest injuries is complex and individually tailored to both the pathology and the patient co-morbidities. This is a core facet of trauma ICU and given its importance a high level of competency is required.

Many candidates did not include non-pharmacological strategies as part of their approach to analgesia. Candidates need to approach the question as they would a real patient to make the answer more patient centred and less generic. More detail for all sections was required in answering this question.

Part (B) – Indications for surgical referral include but are not limited to respiratory failure, intractable pain, failure to wean 2’ to chest wall instability and symptomatic non-union. A knowledge of surgical management indications and referral patterns to our surgical colleagues as we advocate for our patients is expected for this common problem post thoracic trauma in the ICU.
 

Discussion

a)  An "outline" answer is in essence a point-form list which is organised into a logical structure and decorated with some qualifying statements to give the impression that it is being synthesised as an organic and individualised response to the SAQ, rather than being regurgitated verbatim from a textbook or website. 

An approach to analgesia in blunt chest trauma with multiple rib fractures:

  • Systemic analgesia
    • First line: opioid PCA, eg. fentanyl, plus paracetamol
    • Adjunctive: opioid-sparing agents
      • NSAIDs
      • Ketamine
      • Clonidine
    • Anti-neuropathic
      • Gabapentin
      • Pregabalin
      • Amitryptiline or venlafaxine
    • Third line: refractory pain
      • Lignocaine infusion or local patch
  • Regional analgesia in addition to systemic
    • ​​​​​​​Epidural if there is not any additional thoracic vertebral injury; and if there is, or if the fractures are unilateral,
      • Serratus anterior block
      • Paravertebral block
      • Intrapleural block
  • Mechanical reinforcement
    • ​​​​​​​PEEP, even if provided via NIV or HFNP
    • Surgical fixation if appropriate 
    • Brace techniques to support the chest wall while repositioning or coughing

b) The following answer is based on the 2018 EAST rib fracture ORIF guidelines and the 2020 Chest Wall Injury Society rib fracture ORIF guidelines, which mostly agree on the following points:

The rationale for surgical fixation of rib fractures:

  • Improved pain control because of limited fracture edge excursion, and therefore fewer adverse effects from analgesia (eg. opioids and NSAIDs)
  • Improved chest wall stability and therefore optimal respiratory effort, facilitating rapid weaning from the ventilator, as well as:
    • Reduced incidence of pneumonia
    • Reduced mortality, in select groups
    • Shorter ICU stay
    • Reduced need for tracheostomy
  • Concurrent placement of regional analgesia catheters and evacuation of haemothoraces

Indications for surgical referral

  • Chest wall instability:
    • Three rib flail chest
    • Three bi-cortically displaced/offset ribs
    • Clinical finding of paradoxical motion
    • Instability or “clicking” on palpation or as reported by the patient 2
    • Failure to wean from mechanical ventilation
  • Three or more displaced rib fractures (≥ 50% of the rib width) with two or more pulmonary physiologic derangements:
    • Respiratory rate ≥ 20
    • Measured volumes on incentive spirometry < 50% of predicted
    • Numerical pain score > 5/10
    • Poor cough 

Potential disadvantages of rib fixation:

  • May not speed the liberation from the ventilator if there is other limiting trauma (eg. severe traumatic brain injury)
  • Increases risk of localised infection and empyema
  • Nonunion
  • Irritation by the implant, eg. neuropathic pain (in 50% of patients among one prospective cohort)
  • Risk of iatrogenic lung injury
  • Risk of pneumonia is not abolished, and remains around 30%

References

Koushik, Sarang S., et al. "Analgesic Techniques for Rib Fractures—A Comprehensive Review Article." Current pain and headache reports 27.11 (2023): 747-755.

Forrester, Joseph D., et al. "Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma." Journal of Trauma and Acute Care Surgery 95.6 (2023): 943-950.

Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.

MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.

Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.

Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.

Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.

Galvagno Jr, Samuel Michael, 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." Journal of Trauma and Acute Care Surgery 81.5 (2016): 936-951.

Curtis, Kate, et al. "ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study." Australasian Emergency Nursing Journal 19.3 (2016): 127-132.

Carrie, Cédric, et al. "Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study." Anaesthesia Critical Care & Pain Medicine 37.3 (2018): 211-215.

Galvagno Jr, Samuel Michael, 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." Journal of Trauma and Acute Care Surgery 81.5 (2016): 936-951.

Zaw, Andrea A., et al. "Epidural analgesia after rib fractures." The American Surgeon 81.10 (2015): 950-954.

Peek, Jesse, et al. "Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis." European Journal of Trauma and Emergency Surgery (2018): 1-26.

Karmakar, Manoj K., and Anthony M-H. Ho. "Acute pain management of patients with multiple fractured ribs." Journal of Trauma and Acute Care Surgery 54.3 (2003): 615-625.

Beks, Reinier B., et al. "Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis." European Journal of Trauma and Emergency Surgery (2018): 1-14.

Beks, Reinier B., et al. "Long-term follow-up after rib fixation for flail chest and multiple rib fractures." European Journal of Trauma and Emergency Surgery 45 (2019): 645-654.