From the Guidelines
Multimodal pain management for patients with rib fractures should prioritize a combination of systemic analgesics, regional anesthesia, and supportive measures to minimize opioid use and improve respiratory outcomes, as recommended by the 2023 WSES guidelines 1. The approach to multimodal pain management in patients with rib fractures involves several key components:
- Systemic analgesics: Scheduled administration of intravenous acetaminophen every 6 hours as first-line treatment, with consideration of adding NSAIDs for severe pain, taking into account potential adverse events and pharmacological interactions 1.
- Regional anesthesia: Thoracic epidural and paravertebral blocks are recommended for elderly patients with rib fractures to offer adequate pain control with limited contraindications and improvement in respiratory function, reducing opioid consumption, infections, and delirium, if skills are available 1.
- Supportive measures: Non-pharmacological measures such as immobilizing limbs and applying dressings or ice packs may be considered in conjunction with drug therapy to control acute pain in elderly patients in the trauma setting, although the evidence for this is very low 1. Key regional anesthesia techniques include:
- Intercostal nerve blocks
- Thoracic epidural analgesia
- Erector spinae plane blocks These techniques can significantly reduce opioid requirements and improve respiratory mechanics, which is crucial for patients with rib fractures to prevent complications such as atelectasis, pneumonia, and respiratory failure. In addition to these measures, surgical stabilization of rib fractures (SSRF) may be considered in certain patients, such as those with flail chest or multiple severely displaced rib fractures, as outlined in the WSES and CWIS position paper 1.
From the Research
Multimodal Pain Management Options
The following options are available for multimodal pain management in patients with rib fractures:
- Pharmacologic analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine 2
- Regional analgesia techniques, such as:
Benefits of Multimodal Pain Management
Multimodal pain management has been shown to:
- Reduce morbidity and mortality associated with rib fractures 2, 4
- Decrease opioid requirements in trauma patients with rib fractures 5
- Improve pain scores and expedite recovery in patients with rib fractures 3
Implementation of Multimodal Pain Management
A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, is recommended for patients with rib fractures 2, 4, 6 Implementation of a multimodal pain regimen (MMPR) has been shown to reduce inpatient opioid consumption and the quantity of opiates prescribed at discharge 5