From the Guidelines
Treatment for multiple broken ribs in elderly patients should prioritize a multimodal approach to pain management, including acetaminophen, NSAIDs, and regional nerve blocks, with careful consideration of surgical fixation on a case-by-case basis. The cornerstone of treatment is adequate pain control, and according to the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1, a regular administration of intravenous acetaminophen every 6 hours is recommended as first-line treatment in managing acute trauma pain in the elderly.
Some key points to consider in the treatment of multiple broken ribs in elderly patients include:
- The use of NSAIDs like ibuprofen (400-600 mg every 6-8 hours) if not contraindicated, and opioids such as oxycodone (5-10 mg every 4-6 hours) for breakthrough pain 1
- Regional nerve blocks like intercostal nerve blocks or thoracic epidural analgesia may be used for severe pain, with thoracic epidural and paravertebral blocks considered as gold standard for analgesia for rib fractures 1
- Elderly patients should perform deep breathing exercises (10 deep breaths every hour while awake) and use an incentive spirometer to prevent pneumonia
- Early mobilization is crucial but should be balanced with adequate rest
- Patients need close monitoring for complications like pneumonia, flail chest, or pneumothorax, which are more common and dangerous in the elderly
- Surgical fixation (rib plating) may be considered for patients with flail chest or severe displacement, although the evidence is unclear on its individual contribution to reducing morbidity and mortality in the elderly with multiple rib fractures 1
It is also important to note that novel myofascial techniques such as erector spinae plane (ESPB) and serratus anterior plane (SAPB) blocks have been implemented in multimodal analgesia (MMA) for older patients, and have been shown to be safe and effective in reducing acute pain 1. Additionally, ketamine has been shown to be non-inferior to morphine and can be an alternative to opioids without side effects 1.
Overall, the treatment of multiple broken ribs in elderly patients requires a careful and individualized approach, taking into account the patient's overall health, medical history, and potential risks and benefits of different treatment options.
From the Research
Treatment Options for Multiple Broken Ribs in the Elderly
- Analgesia is a crucial aspect of treatment, with a multimodal approach recommended to reduce morbidity and mortality 2
- Risk stratification tools, such as the Study of the Management of Blunt Chest Wall Trauma score, can help identify high-risk patients 2
- Pharmacologic options, including acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentinoids, can be effective in managing pain 2, 3
- Regional analgesia techniques, such as thoracic epidural analgesia and thoracic paravertebral block, can also be used to manage pain 2
- Surgical stabilization may be considered for elderly patients with multiple rib fractures, although the evidence is limited and more research is needed 4
Comparison of Treatment Modalities
- A systematic review found that operative treatment was associated with lower mortality rates compared to conservative treatment in elderly patients with multiple rib fractures 4
- However, the review also found that operative treatment was associated with longer hospital and intensive care unit stays 4
- A randomized controlled trial found that oral acetaminophen was equivalent to intravenous acetaminophen in terms of pain control and morbidity in elderly trauma patients with rib fractures 3
Importance of Pain Management and Respiratory Care
- Pain management is critical in preventing complications, such as hypoventilation, atelectasis, and pneumonia, in patients with multiple rib fractures 5, 6
- Respiratory care, including rapid mobilization and meticulous respiratory support, is also essential in preventing complications and improving outcomes 5, 6
- A comprehensive review of current pain management strategies for rib fractures highlights the importance of a multimodal approach and provides practical guidelines for clinicians 6