Analgesic techniques for multiple rib fractures

Blunt chest trauma with multiple rib fractures has appeared intermittently in the CICM Part II exam:

  • Question 24 from the second paper of 2023, where rib fixation was discussed
  • 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.

Advantages and Disadvantages of Analgesia Techniques in Blunt Chest Injury
Technique Advantages Disadvantages
Systemic opiates +paracetamol
  • Equivalent to epidural in terms of ICU length of stay and hospital length of stay.
  • Good analgesia
  • Little hypotension
  • Familiar in any ICU/HDU

Adverse effects from opiates, especially:

  • Constipation
  • Nausea
  • Delirium
  • Drowsiness
  • Cough suppression
  • Salutary analgesic effect
  • Act in synergy with opiates
  • GI haemorrhage risk
  • Platelet dysfunction
  • Little evidence in support
Gabapentin and pregabalin
  • Orally available
  • Some synergistic effect with opiates
  • Sedation
  • Delirium
  • Little evidence in support
  • Potent analgesic
  • Cheap
  • Little hypotension
  • Potent synergistic effect with opiates
  • Delirium/psychosis
  • Sedation
  • Little evidence in support

Analgesia is better than with PCA

  • Better MIP (maximum inspiratory pressure) than with PCA
  • Overall improved respiratory function
  • More rapid weaning from ventilator
  • Less delirium and sedation
  • Less risk of respiratory depression
  • If local anaesthetic used alone, possible to avoid opiate side effects
  • Lower incidence of DVT
  • No mortality benefit
  • No ICU length of stay reduction, or in hospital stay for that matter (in fact, a trend towards slightly longer hospital stay)
  • Requires skill for placement
  • Not   always   effective   (can   get patchy block)
  • Hypotension 
  • May mask other injuries
  • Risk of epidural haematoma
Regional techniques (paraveretebral, intrapleural)
  • Similar to epidural in positive effect
  • Fewer side-effects as compared to epidural
  • Less hypotension
  • Little evidence in support
  • Larger doses of local anaesthetic promote the risk of LA toxicity
  • Risk of pneumothorax
  • Satisfactory analgesia by simple mechanical effect
  • May prevent some of the risks of rib fractures (eg pneumonia developing due to hypostasis)
  • May require intubation
  • NIV may not be very well tolerated
  • Potentiates air leak in penumothorax
  • Exposes patient to risk of VAP
  • Increases length of ICU stay
Surgical fixation
  • Mechanical stability promotes good analgesia
  • Supported by the most recent evidence (Becks et al, 2018); improves short term outcomes
  • Unclear patient selection criteria (who benefits?)
  • Highly invasive
  • Expensive
  • Requires well-practiced surgical team
  • May prolong duration of ventilation and ICU stay
  • The patient needs to be able to sustain one-lung ventilation for anaesthesia

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 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.

Thus, in summary, if one were ever asked to "outline" their approach (i.e. present it as a slightly fancier list with some qualifying arguments in the margins) the appearance it might take is something like this:

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

Surgical fixation of rib fractures

There was at one stage so little evidence to support this practice that it would have become the subject of a "critically evaluate" exam question, where something questionable is weighed and measured. With years enough data has accumulated that the controversy is mostly limited to patient selection, and most people would agree that rib fixation has a well defined role. Questions about this will therefore mostly interrogate the candidates' understanding of the reasons behind referral, and the specific guidelines that define the indications (such as the 2018 EAST rib fracture ORIF guidelines and the 2020 Chest Wall Injury Society rib fracture ORIF guidelines, of which the latter is by far more comprehensive and readable):

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%


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.