Case of the Month #35: Analgesia for Rib Fractures by Dr Mariam Latif

Pain from fractured ribs involves a multimodal approach aimed at optimising lung function, minimising discomfort and allowing ribs to heal. A specific pathway linked to a stepwise approach to analgesia and regular input from a multi-disciplinary team of specialists, including medical, nursing, pain management and physiotherapy may reduce complications and mortality⁹.

Analgesia can include:

• Oral analgesia – paracetamol, non-steroidal anti-inflammatory drugs and weak opioids should be started unless contraindicated. Consider gabapentin.
• Local anaesthesia: lidocaine plasters 5%
• Local anaesthesia: regional catheter-based technique, many institutions are increasingly favouring this over thoracic epidurals and IV opioids. See joint RCOA/RA-UK video and pdf in recommended reading for details of all Plan A blocks. More advanced regional techniques can be considered, depending on patient and provider expertise.
• IV opioid: Morphine PCA
   

Wider scope of care

Chest wall injuries are associated with significant morbidity and mortality, particularly in elderly patients with coexisting respiratory disease. The use of supplementary oxygen to treat hypoxia in the event of compromised breathing and to facilitate the use of stronger opioid analgesics must not be forgotten. Patients developing more significant hypoxia may benefit from high-flow nasal oxygen or non-invasive ventilation. These devices, used in conjunction with early effective analgesia, including regional anaesthesia techniques, have been demonstrated to be associated with reduced ICU admission and mortality¹⁰.

Respiratory support in the form of physiotherapy directed exercises to encourage deep breathing and improve lung function is also essential. These techniques help provide patients like Mr M with sustainable practice they can continue once discharged.