What is the recommended approach for analgesia during fracture reduction in a geriatric patient in the Emergency Room (ER)?

Analgesia for Fracture Reduction in Geriatric Patients in the Emergency Room

For geriatric patients undergoing fracture reduction in the emergency room, a multimodal analgesic approach with intravenous acetaminophen as the foundation, combined with regional anesthetic techniques, and opioids only for breakthrough pain is strongly recommended. 1

First-Line Approach

• Regular administration of intravenous acetaminophen every 6 hours should be the cornerstone of pain management for geriatric patients undergoing fracture reduction 1
• Oral acetaminophen can be substituted if IV access is limited, as studies show equivalent efficacy for pain control in elderly trauma patients 1
• Consider adding NSAIDs for severe pain, but carefully evaluate potential adverse effects and drug interactions in the elderly population 1

Regional Anesthetic Techniques

• Peripheral nerve blocks should be placed at the time of presentation to reduce both preoperative and postoperative opioid requirements 1
  • For lower extremity fractures: fascia iliaca compartment block is particularly effective 2
  • For upper extremity fractures: brachial plexus blocks are recommended 1
• Thoracic epidural and paravertebral blocks are strongly recommended for patients with rib fractures, as they improve respiratory function and reduce opioid consumption, infections, and delirium 1
• Carefully evaluate the use of neuraxial and plexus blocks in patients receiving anticoagulants to avoid bleeding complications 1, 2

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 with fewer cardiovascular side effects 1
• For positioning during reduction procedures, a dexmedetomidine-ketamine combination has shown superior pain control compared to dexmedetomidine-fentanyl 3
• 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

Opioid Management

• Reserve opioids only for breakthrough pain, administered for the shortest period possible at the lowest effective dose 1, 2
• When opioids are necessary, implement progressive dose reduction due to the high risk of accumulation, over-sedation, respiratory depression, and delirium in elderly patients 2
• Monitor closely for adverse effects including respiratory depression, confusion, and constipation 4

Non-Pharmacologic Approaches

• Implement non-pharmacological measures such as proper positioning, immobilization techniques, and application of ice packs to the affected area 1, 5
• These should be used in conjunction with pharmacological therapy to enhance pain control 1

Special Considerations for Geriatric Patients

• Undertreated pain can lead to delirium, functional decline, and delayed rehabilitation 4, 6
• Scheduled analgesic administration has been shown to improve functional outcomes compared to as-needed dosing in geriatric hip fracture patients 6
• Systematic pain evaluation is crucial as elderly patients often receive inadequate analgesia despite reporting moderate to high pain levels 2
• Elderly patients with cognitive impairment often receive inadequate pain management, leading to poorer mobility, quality of life, and higher mortality 2

Common Pitfalls and Caveats

• Avoid excessive reliance on opioids, as both inadequate analgesia and excessive opioid use increase the risk of postoperative delirium in elderly patients 2
• Be aware that rib fractures in elderly patients are associated with particularly high morbidity and mortality rates, requiring aggressive pain management 7
• Consider the risk of drug-drug interactions in geriatric patients who are often on multiple medications 4
• Regular reassessment of pain and analgesic efficacy is essential to optimize pain control while minimizing adverse effects 5