Rib fracture management in trauma - Raigmore (Guidelines)

For all patients: if pain uncontrolled titrate iv strong opioid to effect; calculate the rib fracture score to determine initial management; consider if early regional anaesthesia is indicated (injury severity or pain yellow flags)

Please see below for:

• 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 less than 94% with O₂ requirement 40% or more

AND at least one of the following

• High frailty index (including age over 80) for active management
• Multiple other injuries
• Indicated in the flowchart above

Analgesia in renal impairment or frailty

• Avoid NSAIDs
• Oxycodone immediate release 2mg 4 times daily + 2mg prn (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 – Fri 08.00 – 17.00 or anaesthetic registrar (bleep 5000) out of hours. Please have the following information when you contact them.

• 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.
• 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  tablet -Sevredol)
• 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.

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 = (Breaks x Sides) + Age Factor

Breaks: Number of Fractures
Sides: Unilateral = 1 Bilateral = 2
Age Factor:

A score of:
3 to 6 = Step 1
7 to 10 = Step 2
11 to 15 = Step 3
over 15 = Step 4

See Rib Fracture Pathway above

• 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 (if not contra-indicated) and opioids. Morphine should be prescribed both regularly and for breakthrough (PRN).
• In patients aged 65 years or older, consideration should be given to avoiding ibuprofen and the regular opioid changed to oxycodone, which has a better pharmacokinetic profile for elderly patients. In patients with renal impairment, defined as eGFR less than 30mls/min, ibuprofen should be omitted and the oxycodone dose reduced. Acute pain management in renal impairment
• 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 referred to the acute pain team.
• 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 opioids, 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

• The first line epidural infusion should be mixed levobupivacaine 0.125% with diamorphine 5mg or 10mg.
• 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 72-96 hours.

Note max dose levobupivicaine is 2mg/kg every 4 hours.

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 under 65 and 4 or more fractured ribs
• Age 65 or over and 3 or more fractured ribs
• Presence of a flail 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 opioids)

At Raigmore our aim is:

1. for patients to leave the emergency department with a pain score of less than 4.
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 4/10.

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.

Criteria for referral for regional anaesthesia for rib fractures
Click here

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.

Referral to ICU should be either through the senior trainee, or consultant (phone 3030) if any of the following apply:
SpO₂ less than 94% on FiO₂ more than 40% and one of:

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

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

• High frailty index (including age over 80 years) and for active management
• Multiple other injuries
• RFS more than 10 severe
• RFS more than 6 moderate with evidence of lung contusion, flail chest
• RFS 3-6 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 physiotherapy. 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 support.

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 retention. 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 patients.

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.scot

david.boddie@nhs.scot

Louisemccullough@nhs.scot

gareth.medlock@nhs.scot

Erector spinae plane (ESP) catheters for analgesia for rib fractures (Raigmore only)

ESP catheters can be used as part of a multi-modal analgesic approach in the management of patients with acute pain from rib fractures. Please see “Rib fracture pathway” section for advice on assessing, scoring and referral of patients for consideration of an ESP catheter.

The catheters are inserted in theatres by the anaesthetists. Patients will return to the ward with the catheter secure over one shoulder and connected to an On-Q elastometric pump. Infusions are started when the patient leaves theatre.

The prescription should be documented in the Kardex with a box to indicate the time when a new pump will need attached. This should be at 36 hours from the time of commencing the infusion to enable time to prepare and attach a new filled On-Q pump.

These pumps should not run out overnight - If this is likely to be the case please mark an earlier time in daytime hours to facilitate obtaining a new infusion pump.

Monitoring of patients and nursing care

• The On-Q pump will be started by the anaesthetist inserting the catheter. The volume of the On-Q pump is 400 mL. These run a fixed rate of 10 mL/hr of 0.125% levobupivacaine
• A blue wound catheter chart must be completed
• All observations should be carried out as per routine practice
• Intravenous access must be maintained at all times.
• In addition to the ESP catheter infusion, regular analgesia should be administered

When the pump is empty

The pump will last for 40 hours; however, most catheters are usually in for a minimum of 48 to 72 hours and so the pump will usually need to be replaced at least once. The replacement pumps can be obtained from main theatres and filled by a member of the anaesthetic team. Catheters can remain in for up to 5 days, however, if the catheter site is healthy and the patient is still getting significant benefit, a decision will be made by the anaesthetist or pain team to continue for another 24 hours.

Removal of ESP catheters

• Daily reviews by Acute Pain Team and decision for removal will be decided by the team.
• Catheters can remain in place for up to 5 days if still effective and no signs of local infection
• Catheters will be removed by ward nurse and must be documented
• Please make decisions to step down from regional analgesia at the beginning of a day. The catheter can be clamped off for 2 to 4 hours before removal.
  If patient is still managing pain well, the catheter can be removed.
  If the patient is in sufficient pain to interfere with coughing, deep breathing or mobilizing, then the catheter should be continued for at least a further 24 hours and may require a bolus on restarting the infusion.
• Patients should not be sent home on the same day the infusion is stopped and catheter removed. This is to allow time to exclude complications and ensure oral analgesia is optimised.

Trouble shooting On-Q pumps

If called in to see patient in pain:
Always make sure patient is on multimodal analgesia (providing no contraindications) ie: paracetamol / NSAID / PCA / when required opiate

ESP catheter

• Check pump connected and not empty.
• Check catheter site to exclude malposition or gross leakage.
• Patient habitus, height, and position / number of rib fractures may mean that some patients experience breakthrough pain after the initial local anaesthetic bolus. Some patients may require additional boluses down the ESP catheter to re-establish the block.
• If catheter site healthy and intact, bolus 20 mL of 0.125% Levobupivacaine in a sterile fashion (similar standard of sterility to epidural top-up required). Re-connect the On-Q Infusion. You must be available for the next 15 minutes for the unlikely occurrence of local anaesthetic toxicity.
• Boluses should only given by an anaesthetist or member of the acute pain team.
• Please document the bolus dose on the front of the Kardex. Re-connect the On-Q Infusion.
• Maximum number / frequency of top-ups:
  Two per day of 20mL 0.125% levobupivacaine at least 8 hours apart.
• If no improvement:
  • In hours: refer to emergency anaesthetist for consideration of catheter re-site
  • Out of hours:Abandon catheter and optimise oral / IV / PCA analgesia

GLOSSARY

ESP: Erector spinae plane
IV: Intravenous
NSAID: Non-steroidal anti-inflammatory drug
PCA: Patient controlled analgesia