From the Guidelines
The primary recommendation for pain management in a patient with flail chest is thoracic epidural analgesia (TEA) when not contraindicated, as it has been suggested to be considered for patients with traumatic rib fractures [+2B] 1. Pain management in patients with flail chest is crucial to prevent complications such as atelectasis and pneumonia. The use of TEA has been shown to be effective in managing pain in patients with traumatic rib fractures.
- The placement of a catheter at the T5-T8 level with continuous infusion of local anesthetics, such as bupivacaine 0.1-0.25%, often combined with low-dose opioids, such as fentanyl 2-5 mcg/mL, is a common approach.
- If epidural placement is not feasible, alternative regional techniques, such as paravertebral blocks, erector spinae plane blocks, or intercostal nerve blocks, can be considered.
- Scheduled non-opioid analgesics, including acetaminophen (1 gram every 6 hours) and NSAIDs, if not contraindicated, should be used to supplement regional techniques.
- Opioids should be used as rescue medication rather than primary therapy, as they can have significant side effects, such as respiratory depression, which can worsen the patient's condition. The use of IV opioids, such as morphine, can be considered as the first-line drug class of choice to treat non-neuropathic pain in critically ill patients [+1C] 1. However, the primary focus should be on regional anesthesia techniques, such as TEA, to minimize the use of opioids and their associated side effects.
- Effective pain control is crucial in flail chest management, as it allows for deeper breathing, effective coughing, and improved pulmonary mechanics, which helps prevent atelectasis and pneumonia.
- This approach reduces the need for mechanical ventilation and decreases overall morbidity and mortality associated with flail chest injuries.
From the Research
Pain Management for Flail Chest
The primary recommendation for pain management in a patient with flail chest is to provide adequate analgesia, which is of paramount importance in patient recovery and may contribute to the return of normal respiratory mechanics 2.
Key Considerations
- Adequate analgesia is crucial for patient recovery and return of normal respiratory mechanics 2
- A multimodal pain management approach based on the use of synergistic drugs may provide better analgesia 3
- Epidural analgesia can play a role in reducing pulmonary complications 3
- A multimodal analgesic approach can improve postoperative pain relief and reduce opioid use 4
Recommended Approach
- A combination of acetaminophen, non-steroidal anti-inflammatory drug or cyclooxygenase-2-specific inhibitor, dexamethasone, and procedure-specific regional analgesic technique and/or surgical site local anesthetic infiltration may be used 4
- Opioids should be administered as rescue adjuncts 4
- Non-pharmacological interventions are important components of an optimal multimodal analgesic technique 4
Additional Options
- Epidural fentanyl with preventive intravenous naloxone infusion may be considered to reduce side effects while maintaining analgesia 5