What are the guidelines for managing patients with rib fractures?

Guidelines for Managing Patients with Rib Fractures

The management of rib fractures should follow a risk-stratified approach with multimodal pain management, including regular administration of intravenous acetaminophen as first-line treatment, consideration of regional anesthesia techniques for moderate to severe pain, and admission to ICU for high-risk patients with ≥3 rib fractures (especially in elderly patients), flail chest, or significant respiratory compromise. 1

Risk Assessment and Diagnosis

Initial Evaluation

• CT scan of the chest is recommended to evaluate:
  • Number of fractured ribs
  • Displacement of fractures
  • Presence of flail chest
  • Anatomic distribution of fractures
  • First rib fractures 1

Risk Stratification Using RibScore

The following factors predict adverse pulmonary outcomes:

1. ≥6 rib fractures
2. Bilateral fractures
3. Flail chest
4. ≥3 severely displaced fractures
5. First rib fracture
6. At least 1 fracture in all 3 anatomic areas (anterior, lateral, posterior) 1

High-Risk Factors Requiring Aggressive Management

• Age >60 years
• ≥3 rib fractures
• Flail chest
• Underlying respiratory disease
• Significant respiratory compromise
• Poor functional respiratory status 1

Pain Management Algorithm

First-Line Treatment

• Regular administration of intravenous acetaminophen (1 gram every 6 hours) 1
• Ice application for 20-30 minutes, 3-4 times daily using ice and water surrounded by a damp cloth 1
• Activity modification to avoid movements that exacerbate pain 1

Second-Line Treatment

• Consider adding NSAIDs with caution, especially in elderly patients (monitor for adverse events and drug interactions) 1
• Opioids at lowest effective dose for shortest possible period (hydromorphone preferred over morphine) 1
• Ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 1

Regional Anesthesia Techniques for Moderate to Severe Pain

1. Thoracic Epidural (TE): Most established technique but has contraindications 1, 2
2. Paravertebral Blocks (PVB): Alternative for those with contraindications to TE 1, 2
3. Erector Spinae Plane Blocks (ESPB): Fewer side effects, can be performed by trained emergency physicians 1, 2, 3
4. Serratus Anterior Plane Blocks (SAPB): Fewer side effects, good alternative to neuraxial techniques 1, 2, 3

Regional anesthesia has been shown to reduce opioid consumption and decrease delirium in older patients 1. Epidural analgesia specifically has been associated with decreased rates of pneumonia and shorter duration of mechanical ventilation 4.

Admission Criteria and Monitoring

ICU Admission Criteria

Admit to ICU if any of the following:

• ≥3 rib fractures in elderly patients (>60 years)
• Flail chest
• Significant respiratory compromise
• Poor functional respiratory status (FVC <50% predicted) 1

Respiratory Support

• Consider non-invasive ventilation (NIV) for chest trauma patients with acute respiratory failure 1
• Patients with underlying respiratory disease or COVID-19 require closer monitoring 1

Monitoring for Complications

• Pneumothorax
• Hemothorax
• Pulmonary contusion
• Pneumonia
• Respiratory failure
• Vascular injuries (especially with first rib fractures)
• Abdominal organ injuries (with lower rib fractures) 1

Surgical Management

Consider surgical stabilization for rib fractures when:

• Significantly displaced
• Causing damage to blood vessels or nerves
• Fractured in an anterior or anterolateral location
• Ribs 3-8 are commonly plated based on displacement and impact on respiratory mechanics 1

Follow-up Care

• Surgical stabilization patients: Initial follow-up within 1-2 weeks of discharge
• All patients: Follow-up in clinic within 2-3 weeks after hospital discharge to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Clinical Pearls and Pitfalls

• Pitfall: Underestimating the severity of rib fractures in elderly patients

  • Solution: Use age >60 years as a risk factor requiring more aggressive management 1

• Pitfall: Overreliance on opioids leading to respiratory depression

  • Solution: Implement multimodal analgesia with regional techniques when possible 1, 2, 5

• Pitfall: Missing associated injuries

  • Solution: Thorough evaluation for pneumothorax, hemothorax, and abdominal injuries 1

• Pitfall: Delayed recognition of respiratory deterioration

  • Solution: Close monitoring of respiratory status, especially in high-risk patients 1