Analgesic techniques for multiple rib fractures

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.

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.