What is the best analgesic approach for a 95-year-old patient with rib fractures allergic to narcotics (opioids) and NSAIDs?

Analgesic Management for a 95-Year-Old with Rib Fractures and Allergies to Narcotics and NSAIDs

For a 95-year-old patient with multiple rib fractures (8-11) who is allergic to both narcotics and NSAIDs, the optimal approach is a multimodal analgesic strategy centered on acetaminophen combined with regional anesthetic techniques such as thoracic epidural or paravertebral blocks. 1

First-Line Approach

• Regular intravenous acetaminophen administration every 6 hours should be the cornerstone of pain management in this patient, given the contraindications to both opioids and NSAIDs 1
• Standard dosing is 650-1000mg of acetaminophen every 6 hours, not exceeding 3000mg in 24 hours for elderly patients 2
• Acetaminophen can be administered orally if IV access is limited, as studies show oral acetaminophen is equivalent to intravenous acetaminophen for pain control in elderly trauma patients with rib fractures 1

Regional Anesthetic Techniques

• Thoracic epidural analgesia (TEA) or paravertebral blocks (PVB) should be strongly considered as they offer superior pain control with limited contraindications and improvement in respiratory function 1
• These techniques have been shown to reduce infections, delirium, and improve respiratory mechanics in elderly patients with rib fractures 1, 3
• For this specific patient, newer myofascial techniques such as erector spinae plane blocks (ESPB) or serratus anterior plane blocks (SAPB) may be safer alternatives if there are contraindications to traditional neuraxial techniques 1, 3
• Careful evaluation of anticoagulation status is essential before performing any neuraxial or plexus blocks to avoid bleeding complications 1

Adjunctive Pharmacologic Options

• Low-dose ketamine (0.3 mg/kg IV over 15 minutes) can be considered as an alternative to opioids, providing comparable analgesic efficacy for short-term treatment of acute pain 1
• Be aware that ketamine may cause psycho-perceptual adverse effects in geriatric patients, though these are typically less severe than the respiratory depression associated with opioids 1
• Gabapentinoids may be included as part of the multimodal approach, particularly for neuropathic pain components 1
• Lidocaine patches applied to the area of pain can provide localized analgesia without systemic effects 1

Non-Pharmacologic Approaches

• Implement non-pharmacological measures such as proper positioning, immobilization techniques, and application of ice packs to the affected area 1
• These approaches should be used in conjunction with pharmacologic therapy to enhance overall pain control 1
• Consider early surgical rib fixation if the patient has severe pain that is not responding to conservative management, though benefits must be weighed against surgical risks in this very elderly patient 1

Monitoring and Follow-up

• Regular pain assessment using appropriate scales is crucial, particularly in elderly patients who may have difficulty communicating pain levels 1
• Monitor for respiratory function, as inadequate pain control can lead to shallow breathing, atelectasis, and pneumonia 1, 3
• Watch for signs of acetaminophen toxicity, particularly if the patient has underlying liver or kidney disease 1, 2

Special Considerations for Advanced Age

• At 95 years old, this patient is at extremely high risk for complications from rib fractures, with mortality rates significantly higher than younger populations 1
• Pain management must be balanced with the risk of respiratory depression, cognitive impairment, and other adverse effects 1
• Under-treated pain can lead to agitation, delirium, delayed mobilization, and development of chronic pain 1