From the Guidelines
Ultrasound-guided nerve blocks, particularly serratus anterior plane blocks (SAPB), offer significant clinical utility for acute pain management in patients with rib fractures, as evidenced by a recent randomized controlled trial 1.
Key Points
- The use of SAPB as part of a multimodal analgesia approach has been shown to be safe and effective in reducing acute pain in patients with rib fractures 1.
- Thoracic epidural (TE) and paravertebral blocks (PVB) are also considered gold standard for analgesia in rib fractures, offering adequate pain control and reducing opioid consumption and delirium in older patients 1.
- Novel myofascial techniques such as erector spinae plane (ESPB) and SAPB blocks have been implemented in multimodal analgesia (MMA) for older patients, providing an alternative to traditional methods 1.
- A multimodal analgesic approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain, is recommended for trauma settings in elderly injured patients 2.
Recommendations
- Implement ultrasound-guided SAPB as part of a multimodal analgesia approach for patients with rib fractures, particularly those with multiple fractures or significant pain.
- Consider the use of TE and PVB in patients with rib fractures, taking into account potential contraindications and side effects 1.
- Use a multimodal analgesic approach, including regular administration of intravenous acetaminophen and consideration of NSAIDs, gabapentinoids, and lidocaine patches, to manage acute trauma pain in elderly patients 2.
Benefits
- Ultrasound-guided nerve blocks reduce opioid requirements, improve respiratory mechanics, and may prevent complications like pneumonia and respiratory failure 1, 2.
- Early implementation of these blocks can facilitate earlier mobilization, reduce hospital length of stay, and improve overall outcomes in patients with rib fractures 1, 2.
From the Research
Clinical Utility of Ultrasound-Guided Nerve Blocks
The clinical utility of ultrasound-guided nerve blocks for acute pain management in patients with rib fractures is supported by several studies 3, 4, 5, 6, 7.
- The use of ultrasound-guided thoracic nerve blocks, such as the erector spinae block (ESP), serratus anterior plane nerve block (SANB), and intercostal nerve block (ICNB), has been shown to provide adequate anesthesia and can be performed safely in an emergency department setting 3.
- Regional analgesic techniques, including intercostal nerve block, epidural analgesia, and thoracic paravertebral block, have been used effectively to manage pain in patients with multiple fractured ribs 4, 5.
- The serratus anterior plane block (SAPB) has been shown to be an effective and safe alternative to traditional analgesic techniques, with lower incidences of adverse effects and similar levels of analgesia 6, 7.
- The use of ultrasound-guided nerve blocks has been associated with improved patient outcomes, including reduced complications and decreased opioid consumption 3, 6, 7.
Types of Nerve Blocks
Different types of nerve blocks have been used to manage pain in patients with rib fractures, including:
- Erector spinae block (ESP) 3, 6
- Serratus anterior plane nerve block (SANB) 3, 6, 7
- Intercostal nerve block (ICNB) 3, 4, 5, 6
- Thoracic epidural analgesia (TEA) 4, 5, 6
- Paravertebral block (PVB) 4, 5, 6
Advantages and Disadvantages
The advantages and disadvantages of each type of nerve block vary, but overall, ultrasound-guided nerve blocks have been shown to be a safe and effective alternative to traditional analgesic techniques 3, 6, 7.