What is the treatment for rib fractures in the emergency department?

Treatment of Rib Fractures in the Emergency Department

The optimal treatment for rib fractures in the emergency department is multimodal analgesia with early consideration of regional anesthetic techniques for patients with risk factors or inadequate pain control. 1

Risk Assessment

First, assess for risk factors that predict increased complications:

• Age > 60
• SpO2 < 90%
• Obesity/malnourished
• 2-3 rib fractures, flail segment, pulmonary contusion or other chest injury
• Smoking/chronic respiratory disease
• Anticoagulation
• Major trauma

More risk factors indicate higher likelihood of complications and need for more aggressive pain management 1.

Treatment Algorithm

Step 1: Initial Pain Management

• First-line: Oral or IV acetaminophen
  • Evidence shows oral acetaminophen is equivalent to IV for pain control in elderly trauma patients with rib fractures 1
  • No difference in morbidity or mortality between oral and IV routes

Step 2: Escalation for Moderate Pain or Risk Factors

• Add NSAIDs if no contraindications
• Consider low-dose ketamine (0.3 mg/kg over 15 min)
  • Provides analgesic efficacy comparable to morphine
  • May cause more psycho-perceptual side effects but fewer cardiovascular events than opioids 1

Step 3: Severe Pain or Multiple Risk Factors

• Consider regional anesthetic techniques:

  • Thoracic epidural (TE) or paravertebral blocks (PVB) are considered gold standard for rib fracture analgesia 1
  • Benefits: Reduced opioid consumption, decreased delirium in older patients
  • Cautions: Hypotension with TE, need for vasopressors, motor block limiting mobilization

• Newer myofascial techniques:

  • Erector spinae plane (ESPB) and serratus anterior plane (SAPB) blocks
  • Demonstrated effectiveness in reducing acute pain and opioid requirements 1
  • Particularly useful when epidural/paravertebral approaches are contraindicated (e.g., anticoagulation, vertebral fractures) 2

Step 4: Adjunctive Measures

• Chest physiotherapy
• Pulmonary hygiene
• Incentive spirometry
• Pleural drainage if needed 1

Surgical Considerations

Surgical stabilization of rib fractures (SSRF) may be considered in select cases:

• Flail chest
• Severe pain unresponsive to optimal medical management
• Chest wall deformity 1

However, the evidence for surgical fixation in elderly patients is mixed:

• Some studies show improved pain scores and shorter duration of painkiller use 1
• Others show no significant differences in mortality, ICU stay, or mechanical ventilation 1
• Patients over 60 may benefit more from conservative management in terms of hospital stay and mechanical ventilation 1

Important Considerations

1. Early intervention is critical - Inadequate pain control leads to splinting, shallow breathing, poor cough, atelectasis, and secretion accumulation, potentially resulting in respiratory failure 1

2. Opioid minimization - While effective for pain, opioids carry significant risks including respiratory depression, nausea, constipation, and delirium, particularly in elderly patients 1, 3

3. CT imaging - Required for proper evaluation of rib fractures, especially to assess for displacement or deformity that might influence management decisions 4

4. Monitoring - Close monitoring for respiratory compromise is essential, particularly in high-risk patients 1

By following this algorithmic approach and prioritizing effective analgesia while minimizing opioid use, outcomes for patients with rib fractures can be significantly improved, reducing the risk of complications such as pneumonia and respiratory failure.