Blunt chest trauma with multiple rib fractures has reappeared recently in the CICM Part II exam, after a prolonged hiatius.
- Question 2 from the second paper of 2018 asked the trainees to "discuss the available options for analgesia"
- Question 13 from the second paper of 2002 asked specifically to compare PCA and thoracic epidural in the setting of rib fractures.
- Question 26 from the first paper of 2010 also asked to compare PCA and epidural
Such resurgence of attention is surely owed to the recognition that chest injury analgesia is poorly managed in general, and the resulting introduction of the 2012 Chest Injury Pathway (ChIP) into the local repertoire of trauma management guidelines The protocolised care bundle directs the attention of a multidisciplinary team, which includes pain specialists; the focus is on preventing pneumonia, which this thing apparently does (Curtis et al in 2016 found a 4.8% decrease in the rate of pneumonia). Others have not been able to find much of a difference in outcomes, except the increase in the rate of ICU admission (Carrie et al, 2018).
The CICM PArt II questions about this topic usually require the trainees to make a comparison of analgesic techniques, discussing their advantages and disadvantages. In order to better structure this sort of response, one may recommend a tabulated answer. Advantages and disadvantages of analgesia techniques in blunt chest injury are never again brought together as well as in the old 2003 article by Karmakar et al, where there's an actual table of advantages and disadvantages, and this has formed the basis for what is offered below.
Technique | Advantages | Disadvantages |
Systemic opiates +paracetamol |
|
Adverse effects from opiates, especially:
|
NSAIDs |
|
|
Gabapentin and pregabalin |
|
|
Ketamine |
|
|
Epidural |
Analgesia is better than with PCA
|
|
Regional techniques (paraveretebral, intrapleural) |
|
|
Ventilation |
|
|
Surgical fixation |
|
|
A couple of meta-analysis papers from 2009 both discovered the following key features:
- There was no mortality difference
- There was no ICU length of stay difference
- There was no hospital length of stay difference
- Epidural was associated with more hypotension
- PCA was associated with more pneumonia
- Pain control was better with epidural.
In terms of evidence-based society recommendations, important to acknowledge that the leading publication for this topic at the moment is probably the EAST/TAS Guidelines (Galvagno et al, 2016). The time-poor trainee needs to look no further, especially as the guidelines are available for free from semanticscholar.org. Their recommendations were:
- Epidural is better than systemic analgesia, and the more ribs are fractured, the...betterer it is. Other epidural-favouring effect modifiers included age and severity of injury.
- Paravertebral block is probably equivalent to epidural but there are too few studies to make a firm recommendation
- Intrapleural block is even less explored than the paravertebral, and literally nothing can be said about it because "few studies that were identified were of very poor methodological quality". However, those few studies were highly supportive of the use of intrapleural pain catheters
- Adding "multimodal" strategies to opiates (gabepentin, NSAIDs, et cetera) is supported by "limited evidence of very low quality"; but because that's as good as it gets, multimodal analgesia has made it into the final EAST/TSA recommendations, along with epidural.
References
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.