What are the recommendations for managing bruised rib pain?

Management of Bruised Rib Pain

For bruised rib pain, a multimodal analgesic approach with regular acetaminophen administration every 6 hours as first-line treatment, combined with non-pharmacological measures such as ice packs and proper positioning, is strongly recommended. 1, 2

First-Line Pharmacological Management

• Regular administration of acetaminophen (oral or intravenous) every 6 hours is the cornerstone of pain management for bruised ribs, with evidence showing oral acetaminophen is equally effective as intravenous for pain control 1, 3
• NSAIDs may be added for severe pain, but should be used cautiously while considering potential adverse events and drug interactions, especially in elderly patients 1, 4
• For breakthrough pain, opioids may be used for the shortest period at the lowest effective dose as part of a multimodal approach 1, 2

Regional Anesthetic Techniques (For Moderate to Severe Pain)

• Thoracic epidural analgesia (TEA) and paravertebral blocks (PVB) are considered gold standard for rib fracture pain control, offering superior analgesia while reducing opioid consumption, infections, and delirium 1, 2
• Newer myofascial techniques such as erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB) can be effective alternatives with fewer side effects 1, 2
• Low-dose ketamine (0.3 mg/kg IV over 15 minutes) provides analgesic efficacy comparable to morphine for short-term treatment with fewer cardiovascular side effects, though it may cause more psycho-perceptual effects 1

Non-Pharmacological Approaches

• Application of ice packs to the affected area helps reduce pain and inflammation 1
• Proper positioning and immobilization techniques can significantly reduce pain during movement 1, 2
• A rib belt or tape may provide support and reduce pain, though care must be taken not to restrict breathing 4

Risk Assessment and Monitoring

• Assess for risk factors that may predict increased complications: age >60, SpO2 <90%, obesity/malnutrition, multiple rib fractures, smoking/chronic respiratory disease, anticoagulation, or major trauma 1
• Regular monitoring of respiratory function is essential as inadequate pain control can lead to shallow breathing, atelectasis, and pneumonia 2, 5
• For elderly patients, pain management is particularly crucial as each rib fracture increases the risk of developing pneumonia by 27% and mortality by 19% 6

Special Considerations

• Surgical rib fixation may be considered for severe cases with flail chest or persistent severe pain, though evidence for its benefit specifically for pain control is mixed 1
• In elderly patients, evidence suggests conservative management may be more beneficial than surgical fixation in terms of hospital stay and mechanical ventilation duration 1
• When using acetaminophen, monitor for signs of toxicity, particularly in patients with underlying liver or kidney disease 2

Algorithm for Pain Management

1. Begin with regular acetaminophen (1000 mg every 6 hours) 1, 2
2. Add NSAIDs if no contraindications and pain persists 1, 7
3. For moderate to severe pain or if risk factors present, consider regional anesthetic techniques 1
4. Use opioids only for breakthrough pain at lowest effective dose 1, 2
5. Implement non-pharmacological measures throughout treatment 1