Initial Management of Rib Fractures
Initiate multimodal analgesia immediately with scheduled acetaminophen 1000mg every 6 hours as first-line therapy, add NSAIDs (ketorolac or ibuprofen) for moderate-to-severe pain, reserve opioids only for breakthrough pain, and implement aggressive pulmonary hygiene with incentive spirometry to prevent respiratory complications. 1, 2
Immediate Pain Control Strategy
The foundation of rib fracture management is aggressive multimodal analgesia to prevent splinting and subsequent respiratory complications:
Administer acetaminophen 1000mg every 6 hours routinely (intravenous and oral formulations are equivalent in efficacy). 1, 2
Add NSAIDs as second-line for severe pain:
Reserve opioids strictly for breakthrough pain only at the lowest effective dose for the shortest duration to avoid respiratory depression, which is particularly dangerous in elderly patients. 1, 2
Consider low-dose ketamine (0.3 mg/kg IV over 15 minutes) as an opioid-sparing alternative, though it carries more psycho-perceptual side effects. 2
Aggressive Respiratory Care Protocol
Preventing atelectasis and pneumonia is critical, as each rib fracture increases pneumonia risk by 27% and mortality by 19% in elderly patients:
Implement incentive spirometry immediately with the patient sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling. 1
Continue incentive spirometry for at least 2-4 weeks to prevent respiratory complications. 1
Encourage regular deep breathing exercises and gentle coughing to clear secretions. 1
Monitor oxygen saturation closely and provide supplemental oxygen to maintain SpO2 >90%, as desaturation is a significant risk factor for complications. 2, 4
Initial Imaging and Assessment
Obtain standard PA chest radiograph to detect pneumothorax, hemothorax, or flail chest, though this may miss up to 50% of rib fractures. 2
Perform CT chest with 3D reconstruction if considering surgical stabilization or if multiple/displaced fractures are suspected, as this is essential for surgical planning. 1, 2
Risk Stratification for Intensive Monitoring
Identify high-risk patients requiring more aggressive management or consideration for advanced analgesia/surgical intervention:
- Age >60 years (significantly higher morbidity and mortality). 1, 2
- SpO2 <90% on presentation. 2
- ≥3 rib fractures, flail segment, or pulmonary contusion. 2
- Obesity, malnutrition, smoking, or chronic respiratory disease. 2
- Anticoagulation therapy or major trauma mechanism. 2
Consider Regional Anesthesia for High-Risk or Severe Pain
For patients with severe pain despite multimodal analgesia or multiple risk factors:
Thoracic epidural analgesia (TEA) or paravertebral block (PVB) are considered gold standard for severe pain or high-risk patients. 2, 5
Erector spinae plane block (ESPB) or serratus anterior plane block (SAPB) are practical alternatives with lower complication rates and can be performed by trained emergency physicians. 5
Intercostal nerve blocks are less effective and typically require concurrent IV medications. 5
Surgical Stabilization Indications
Consider surgical stabilization of rib fractures (SSRF) within 48-72 hours for:
- Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical movement). 1, 2
- ≥3 ipsilateral severely displaced fractures (>50% displacement) in ribs 3-10 with respiratory failure or at least two pulmonary derangements despite adequate pain control. 1, 2
- Intractable pain despite optimal medical management. 1
- Respiratory failure requiring mechanical ventilation. 1
SSRF reduces pneumonia, chest deformity, tracheostomy rates, and improves long-term outcomes including return to work at 3-6 months, though mortality benefit is not clearly established. 2
Monitoring for Complications
Assess daily for worsening respiratory status: increasing shortness of breath, declining SpO2, or increased work of breathing. 1, 4
Monitor for fever >100.4°F (38°C), productive cough with colored sputum, or chest pain different from rib pain as signs of developing pneumonia. 1
Evaluate for delayed pneumothorax if desaturation occurs after initial presentation. 4
Critical Pitfalls to Avoid
Undertreatment of pain leads to splinting, shallow breathing, atelectasis, and pneumonia—this is the most common pathway to respiratory failure. 1, 6
Overreliance on opioids causes respiratory depression, especially in elderly patients—use multimodal analgesia aggressively to minimize opioid requirements. 1, 2
Delayed consideration of SSRF in appropriate candidates (particularly elderly patients with flail chest or multiple displaced fractures) leads to prolonged pain and worse outcomes. 1, 2
Failure to reduce opioid doses in elderly patients increases risk of accumulation and respiratory depression. 1