Rib fracture management in trauma (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP
  • Raigmore, Emergency Department, Theatres, Anaesthesia, Intensive Care, Surgical High Dependency, Trauma Ward and other wards receiving trauma patients

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Aim, Scope, Background

Aim 

This guideline provides a framework for pain management for patients sustaining rib fractures whether sustained as a result of polytrauma or as a single injury. It acts as a reference for all parties involved in the care of these patients at Raigmore. It includes clinical strategies to reduce morbidity, including multimodal pain management, catheter-based analgesia, pulmonary hygiene, and discusses referral for operative stabilization.

Scope

These guidelines are for all staff involved in the care of adult trauma patients with rib fractures but are of particular relevance to those working in the Emergency Department, Theatres, Anaesthesia, Intensive Care, Surgical High Dependancy, Trauma Ward and other wards receiving trauma patients.

Background

In 2019, Raigmore received 98 patients with rib fractures; 52 of which had >3 fractures (STAG data).

10% of patients admitted following blunt chest trauma have multiple rib fractures1. The fractures themselves are rarely life threatening where pain is managed appropriately, but are often used as a marker of more severe visceral injuries inside the abdomen and the chest. The general causes of injury for rib fractures include a fall from height or standing, road collisions, recreational / athletic activities, as well as non-accidental trauma. Rib fractures may also be pathologic in cause.

Rib fractures may compromise ventilation by a variety of mechanisms:

  • The pain from the rib fractures will cause respiratory splinting and, if not controlled, will result in atelectasis (the collapse of lung tissue leading to the absence of air from part of the lungs), and pneumonia
  • Although adequate analgesia helps towards preventing atelectasis by facilitating adequate breathing, the very systemic opiates themselves can compound the downward spiral, particularly in the elderly.
  • Where the patient has a flail chest (a life-threatening medical condition that occurs when a segment of the rib cage breaks and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, so a part of the chest wall moves paradoxically, interfering with normal respiratory movement)
  • Fragments of fractured ribs can also act as penetrating objects leading to the formation of a haemothorax (blood in the pleural cavity) or a pneumothorax (air in the pleural cavity).

 

 

Rib fracture pathway

For all patients:

If pain uncontrolled titrate iv strong opioid to effect; calculate the rib fracture score to determine initial management; consider early regional anaesthesia if unable to do all three of: take a deep breath, cough and mobilise.  

Have low threshold for regional analgesia for patients who smoke or who have underlying lung disease. 

Please inform acute pain team, bleep 1003, of all patients with rib fractures

Please see:

  • Analgesia starting doses, including in frailty and renal impairment 
  • Pain yellow flags 
  • Information required when referring for consideration of regional anaesthesia

Discuss with ITU, ext 3030, if: 

  • SpO2 <94% with O2 requirements ≥40%

And at least of of the following

  • High frailty index (including age >80) for active management
Class  Drugs  Notes 
Paracetamol  Paracetamol 1g four times daily Reduce dose to 15mg/kg if under 50kg 
NSAIDs  Ibuprofen 400mg three times daily  Avoid in renal impairment, current or previous GI ulceration, active bleeding, severe liver disease or heart failure. 
Weak opioids 

Dihydrocodeine 30mg four times daily

If age <65: Tramadol, immediate release 50mg four times daily 

  
Strong opioids 

Oramorph 10 to 20mg when required (max hourly) 

Morphine PCA 1mg/5 min 

 Avoid in frailty or renal impairment (see below for prescribing for frail/renal impaired patients) 

Analgesia in renal impairment or frailty

  • Avoid NSAIDs
  • Oxycodone immediate release 2mg four times daily + 2mg when required (max 4hrly)
  • If ineffective or not tolerated please refer to acute pain team (bleep 1003) or anaesthetic registrar out of hours (bleep 5000)

Pain yellow flags: factors that increase acute pain and predispose to chronic pain

  • History of chronic pain of more than three months duration
  • History of long term opioids ≥60mg oral morphine equivalent daily, includes patches and lozenges
  • History of long term intake of neuropathic pain agents including gabapentinoids (eg gabapentin, pregabalin), TCAs (eg amitriptyline, nortriptyline) and SNRIs (eg duloxetine, venlafaxine)
  • History of severe anxiety, depression, adverse childhood experiences
  • History of substance misuse, including opioids or benzodiazepines, or participation in opioid replacement programmes such as methadone or buprenorphine.

Referral for consideration of regional anaesthesia

Contact duty anaesthetist (via switchboard) Mon to Fri, 08.00 to 17.00 or anaesthetic registrar (bleep 5000) out of hours. Please have the following information when you contact them.

Mortality risk

Rib fractures are the most common injury in elderly blunt chest trauma patients, and each additional rib fracture increases the odds of dying by 19% and of developing pneumonia by 27%.

Another study found patients (not standardised for age) with single rib fractures had 5.8% mortality, 5 fractured ribs conferred 10% mortality, 6 with 11.4%, 7 with 15%, and 8 or more with 34.4% mortality. Likewise, each additional rib fractured was associated with increased risk of death, pneumonia, ARDS, pneumothorax, aspiration pneumonia, empyema, intensive care unit (ICU) length of stay (LOS), and hospital LOS2.

The associated costs to healthcare from rib fractures have not been fully evaluated, but can be considered in terms of length of inpatient stay, ‘ICU bed days’ and ‘ventilator days’ and are likely to be significant5,7,9.

Studies evaluating longer term outcomes have demonstrated high rates of chronic disability and

chronic pain3,6,7,10, and intervention during the acute phase could reduce this.

Definitions

  • Rib fracture: a break in a bone making up the rib cage.
  • Flail chest: at least 2 fractures per rib in at least 2 adjacent ribs are needed to produce a flail segment. Flail segments cause paradoxical inspiratory movements, compromise breathing and may be life threatening.
  • Verbal Rating Scale: a method for assessing pain on an alphanumeric scale. At NHSH the numerical scale 0-10 is used.
  • Thoracic Epidural (TE): a fine bore catheter placed into the thoracic epidural space which is used to give analgesic drugs.
  • Paravertebral block (PVB): regional anaesthetic technique providing analgesia to a segment of one hemithorax.
  • Erector Spinae Plane Block (ESPB): an interfascial plane block where local anaesthetic is injected in a plane below the erector spinae muscle along the transverse processes. It is suitable for unilateral fractures of up to 4 adjacent ribs.
  • Serratus Anterior Plane Block: targets the lateral cutaneous branches of T2-T9. This block can be useful if accessing the patient’s back is contraindicated by unstable pelvic or vertebral body fractures.
  • Patient Controlled Analgesia (PCA): a method of allowing a patient to administer their own analgesia intravenously, usually opioid based.
  • Non-invasive ventilation (NIV): facial Continuous Positive Airways Pressure (CPAP) or Bi-level
  • Positive Airways Pressure (BIPAP) ventilation
  • Morphine Immediate Release (IR): a morphine immediate release preparation (available as a liquid - commonly known as Oramorph - and tablets)
  • Oxycodone Immediate Release (IR): a oxycodone immediate release preparation (available as a liquid and capsules)
  • Gabapentinoids: anti-epileptics used to modulate GABA receptors and useful in prevention of chronic or neuropathic pain.

Identifying the high-risk patient

Multiple risk factors have been identified for poor outcomes in rib fractures, but the most sensitive are number of ribs fractured and age, resulting in a rib fracture score:

Rib Fracture Score

Rib Fracture Score = (Breaks x Sides) + Age Factor

Breaks: Number of Fractures

Sides: Unilateral = 1  Bilateral = 2

Age Factor:

Age  Score 
<50 years  0 
51 - 60  1 
61 - 70  2 
71 - 80  3 
>80  4 

A score of 

3 - 6      = Step 1 
7 - 10    = Step 2 
11 - 15  = Step 3 
>15       = Step 4 

(See Rib fracture pathway) 

Analgesic options

  • As pain is a significant contributor to the morbidity arising from rib fractures, optimisation of analgesia is key to preventing complications.
  • There are many options for managing pain from rib fractures including multimodal oral therapy, intravenous analgesia, topical treatments and a variety of regional anaesthetic blocks.
  • Multimodal oral analgesia should be started on admission and include regular paracetamol, ibuprofen and opioids. Morphine should be prescribed both regularly and for breakthrough (PRN).
  • In patients aged 65 years or older, ibuprofen should be omitted and the regular opioid changed to oxycodone, which has a better pharmacokinetic profile for elderly patients. In patients with renal impairment, defined as eGFR <30mls/min, ibuprofen should be omitted and the oxycodone dose reduced.
  • All patients should receive adjunctive treatments for opioid analgesia including laxatives and anti-emetics.
  • Opioids may be administered via a patient controlled analgesia (PCA) device if the pain requires more frequent opioid dosing than the standard prescription allows.
  • Patients with features of neuropathic pain such as burning, tingling, electric shock like sensations or numbness should be prescribed a gabapentinoid.
  • In any patient with pain that is difficult to control using conventional measures, whether due to chronic pain, ‘yellow flags’ or who may have significant sequelae from systemic opiates, regional anaesthesia should be considered. All regional anaesthetic techniques for rib fracture analgesia interrupt pain transmission at various points along the intercostal nerve.

Contra-indications to epidural analgesia. Starred items apply to regional blocks

Absolute  Relative 
1. Patient refusal* 1. Unable to position patient*
2. Spinal cord injury or haematoma 2. Traumatic Brain Injury with uncontrolled Intracranial Pressure
3. Epidural haematoma 3. Incomplete spinal evaluation

4. Thoracic vertebral body fracture at

level of insertion		 4. Previous thoracic spinal surgery
5. Local or generalised sepsis*

5. Coagulopathy: INR >1.4 or platelets

<80 x 109/L*
6. Open wound at site of insertion*

6. Active Anticoagulant therapy.

AAGBI RAPAC guide.12
 

7. Extubation not anticipated within 5

days (ICU patients)*
  • The first line epidural infusion should be mixed levobupivacaine 0.125% with fentanyl 2micrograms/mL.
  • In patients with other significant injuries arising from the same incident, a plain 0.125% levobupivacaine epidural pump can be started in conjunction with an opioid PCA.
  • For fascial plane blocks, attach an elastomeric pump. It is important to calculate when this will run out and write this on the prescription so as to ensure the patient receives sustained analgesia for 72 to 96 hours.

Who and how to refer for regional anaesthesia

Patient can be pre-assesed using the Criteria for referral for regional anaesthesia for rib fractures  

Referral to the on-call anaesthetist (Duty anaesthetist during the day, bleep 5000 out of hours) for consideration of regional anaesthesia should be made when:

Age <65 and ≥4 fractured ribs

Age ≥65 and ≥3 fractured ribs 

Presence of a flair segment 

Uncontrolled pain not responding to conventional analgesia or unacceptable side effects from systemic analgesia and/or worsening respiratory function (this includes patients in whom the co-morbidities preclude systemic opiates)

At Raigmore our aim is: 

  1. for patients to leave the emergency department with a pain score of less than 5.
  2. to instate regional analgesia within 6 hours of referral either from ED or from the ward, if conventional analgesic techniques did not reduce the pain score to less than 5/10.

Any catheter based technique (epidural/paravertebral block/serratus anterior block/erector spinae plane block) should be conducted in theatre with strict asepsis by an anaesthetist of any grade competent in the technique, with an anaesthetic assistant as per AAGBI recommendations.

Destination

Destination

Epidural catheters need to be observed for 1 hour post insertion in order to trouble shoot any sequelae, most commonly hypotension. A patient can go straight to sHDU or intensive care after having an epidural placed. Other regional techniques (PVB, ESPB, SAPB) can be observed for 20 minutes before returning to the ward.

Most patients will require ward level based care and can safely be returned to 6A, 4A or 3A.

Ventilatory management

Referral to ICU should be either through the senior trainee, or consultant (phone 3030) if any of the following apply:

SpO2 <94% on FiO2 >40% and one of:

  • High frailty index (including age>80 years) and for active management
  • Multiple other injuries
  • RFS > 10 (severe)
  • RFS > 6 (moderate) with evidence of lung contusion, flail chest or poorly controlled pain
  • RFS 3 to 6 (mild) with significant other injury or significantly poorly controlled pain

Physiotherapy

Referral to physiotherapy should be through the senior trainee, or consultant if any of the following apply:

  • High frailty index (including age >80 years) and for active management
  • Multiple other injuries
  • RFS > 10 severe
  • RFS >6 moderate with evidence of lung contusion, flail chest
  • RFS 3 to 6 mild with significant other injury

As pain is a significant contributor to the morbidity arising from rib fractures, optimisation of analgesia prior to physiotherapy treatment is key to ensuring compliance with chest physiotherapy6. Enabling deep breathing and adequate coughing with clearance of pulmonary secretions reduces secondary pulmonary complications, including atelectasis, pneumonia, respiratory failure and the need for respiratory support6.

The use of an incentive spirometer may be encouraged to prevent pulmonary atelectasis and splinting, alongside the use of a supported cough. Nebulised saline may also help reduce sputum retention6. Humidified oxygen, or high flow oxygen may also be indicated.

Early mobilisation is also associated with reduction in complications and is key to managing these patients6.

Surgery

Surgical fixation and stabilisation of flail chest injuries is associated with reductions in duration of mechanical ventilation, ICU stay, total hospital stay, hospital acquired pneumonia and mortality rates. In the long term patients return to work sooner and have a reduced incidence of chronic pain and analgesic dependence. The National Institute of Clinical Health and Excellence has approved and issued guidance on surgical fixation of flail chest injuries. A multidisciplinary approach to patient selection for surgery is essential and necessitates referral to Aberdeen Royal Infirmary.

Who to refer:

  • Flail chest with paradoxical breathing
  • Multiple ribs (3 or more) displaced 100% or more
  • Ventilated patients who have multiple rib fractures
  • Thoracic spinal fractures with associated rib fractures (so called thoracic ring injury)
  • Failure of conservative / regional management for any number of rib fractures 

And any that warrant discussion.

How to refer:

To refer to ARI for consideration of rib fixation email the group of ARI orthopaedic surgeons (pending group email):

  • iainstevenson@nhs.net
  • david.boddie@nhs.net
  • Louisemccullough@nhs.net
  • gareth.medlock@nhs.net

References

  1. EAST Practice Management Guidelines Work Group. Pain management in Blunt Thoracic Trauma. J Trauma 2005; 59(5):1256-1267.
  2. Battle C et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care 2014, 18:R98.
  3. Witt C & Bulger E. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017; 2:1–7.
  4. Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg 2016; 81:936–51.
  5. Jones KM, Reed RL, 2nd, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg. 2011; 202(5):598Y604
  6. May L, Hillermann C & Patil S. Rib Fracture Management. BJA Education 2016; 16(1):26-32
  7. Unsworth A, Curtis K & Asha SE. Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine,2015; 23:17
  8. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975–9. doi:10.1097/00005373-199412000-00018
  9. Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half-a-dozen ribs: the breakpoint for mortality. Surgery 2005;138:717–23; discussion 723–5. doi:10.1016/j.surg.2005.07.022
  10. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000;48:1040–6; discussion 1046–7. doi:10.1097/00005373-200006000-00007
  11. National Institute for Health and Care Excellence (NICE). Interventional procedure guidance 361: Insertion of metal rib reinforcements to stabilise a flail chest wall. 2010. NICE: London. Available from: https://www.nice.org.uk/guidance/ipg361
  12. https://anaesthetists.org/Home/Resources-publications/Guidelines/Regional-anaesthesia-and-patients-with-abnormalities-of-coagulation

Editorial Information

Last reviewed: 08/01/2024

Next review date: 30/11/2025

Author(s): Acute Pain Department .

Version: 1.2

Reviewer name(s): C Wright, Acute Pain Nurse Specialist .

Document Id: TAM463

References

Further information for Patients