From the Guidelines
To help manage pain from a broken posterior 11th rib, we recommend a multimodal analgesic approach, including regular administration of intravenous acetaminophen every 6 hours as first-line treatment, and considering the association of systemic analgesic treatment with thoracic epidural and paravertebral blocks, if skills are available. This approach is based on the latest guidelines from the World Society of Emergency Surgery (WSES) 1, which provide strong recommendations for managing acute trauma pain in elderly patients.
Key Recommendations
- Regular administration of intravenous acetaminophen every 6 hours as first-line treatment in managing acute trauma pain in the elderly in a multimodal analgesic approach 1
- Consider adding NSAIDs in elderly patients presenting with severe pain, taking into account potential adverse events and pharmacological interactions 1
- Implementation of Multi-Modal-Analgesia approach (MMA) in trauma setting for elderly injured patients, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose 1
- Association of systemic analgesic treatment with thoracic epidural and paravertebral blocks to offer adequate pain control with limited contraindications and improvement in respiratory function, reducing opioid consumption, infections, and delirium, if skills are available 1
Additional Considerations
- Gentle movement and controlled breathing can help minimize rib movement and reduce pain
- Applying ice packs to the injured area for 15-20 minutes every 1-2 hours during the first 48 hours can help reduce swelling and pain
- Sleeping in a semi-upright position using pillows for support can help reduce discomfort
- Seeking immediate medical attention if experiencing severe pain, difficulty breathing, dizziness, or if pain worsens significantly, as these could indicate complications requiring professional medical intervention.
It's worth noting that the 11th rib is a floating rib and is not critical to respiration, and surgical repair is likely not necessary unless there is marked displacement or damage to surrounding organs 1. However, the primary focus should be on managing pain and preventing complications, rather than surgical intervention.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION
Dosage and Administation: 2. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] .
1 INDICATIONS AND USAGE
Oxycodone hydrochloride tablets are an opioid agonist indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate
To help with pain from a broken posterior 11th rib, oxycodone may be considered for the management of pain severe enough to require an opioid analgesic. The dosage should be individualized, taking into account the patient's severity of pain, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse.
- The initial dose of oxycodone is 5 to 15 mg every 4 to 6 hours as needed for pain.
- The dose can be titrated based on the patient's response to achieve an acceptable level of analgesia.
- It is essential to monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases.
- Alternative treatment options, such as non-opioid analgesics, should be considered before initiating oxycodone therapy 2 2.
From the Research
Management of Pain from Broken Posterior 11th Rib
To manage pain from a broken posterior 11th rib, several strategies can be employed:
- Multimodal pain management, as discussed in 3, which includes a combination of pharmacologic and non-pharmacologic interventions to reduce pain and discomfort.
- Catheter-based analgesia, as mentioned in 3, which can provide targeted pain relief.
- Pulmonary hygiene, as noted in 3, which is essential to prevent respiratory complications.
- Operative stabilization, as discussed in 3, which may be necessary in some cases to stabilize the rib fracture.
Importance of Pain Management
Pain management is crucial in preventing complications, as highlighted in 4. Adequate pain control can help prevent hypoventilation, atelectasis, pneumonia, and respiratory failure. Rapid mobilization and meticulous respiratory care are also essential in preventing complications.
Current Pain Management Guidelines
A comprehensive review of current pain management in rib fractures is provided in 5, which includes a discussion of the latest trends in pharmacologic and non-invasive means of managing rib pain. The review also includes a practical guideline for managing patients with pain from rib fractures.
Associated Complications
It is essential to be aware of potential associated complications, such as pneumothorax, hemothorax, pulmonary contusion, atelectasis, flail chest, cardiovascular injury, and injuries to solid and hollow abdominal organs, as discussed in 6 and 7. Close observation and monitoring are necessary to detect these complications early and provide appropriate treatment.
Imaging and Diagnosis
Imaging tests, such as a standard posteroanterior chest radiograph, can help diagnose rib fractures, as noted in 7. However, detailed radiographs of the ribs rarely add additional information that would change treatment. Other imaging tests, such as computed tomography or bone scan, may have increased sensitivity for detection of rib fractures but are not always necessary.