Department of Anaesthesia and Intensive Care
Prince of Wales Hospital
Protocol for pain management of multiple rib fracture
(fracture >=3 ribs)
Management of multiple rib fracture:
pain control+chest physio+mobilization
Principle:
1. Inadequate pain control in multiple rib fracture limit ability to cough
and breath deeply, resulting in sputum retention, atelectasis, reduction
in FRC, compromised lung compliance, ventilation-perfusion
mismatch, hypoxemia and respiratory distress.
2. Resuscitation precedes pain relief
3. frequent review of patients is required: pain score, respiratory function
(RR, SaO2, triflow spirometry), SE
4. multimodal analgesia is recommended
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Flowchart for selection of analgesia in multiple rib fracture:
High risk group:
1. Age>65?
2. >=4 rib fracture?
3. Cardiopulmonary disease?
4. DM?
Yes
Regional analgesia
No
Contraindications for
regional analgesia?
No
Expertise available? **
Yes
Yes
No
Contraindication for iv PCA
morphine?
1. Confused?
2. CVS stable?
3. Airway obstruction?
Head injury, intraabdominal
injury, CVS instability?
Yes
No
No
Yes
For iv PCA
morphine+ oral/iv/PR
medication
Oral/iv/PR
medication
Thoracic
paravertebral block
Epidural analgesia
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Options:
A. Regional analgesia:
**For epidural analgesia and thoracic paravertebral analgesia, please
check availability of pain procedure section on coming Wednesday
(preferably within 2 days of injury) and inform Dr Alice Man/ MC
Chu/ Dr Simon Chan
1. Epidural analgesia
a. The optimal modality of pain relief for blunt chest wall injury, the
preferred technique after severe blunt thoracic trauma
b. Patients with >=4 rib fractures who are >=65 years of age should
be provided with epidural analgesia unless contraindicated
c. Younger patients w/ >=4 rib fracture or patients aged >=65 with
lesser injuries should be considered for epidural analgesia
d. Advantages:
 superior analgesia with increase in FRC, dynamic lung
compliance, VC and PaO2
 reduction in airway resistance
 change shallow breathing to near normal and reduce
paradoxical chest wall movement
 modify immune response
e. Disadvantages:
 technically demanding, esp. distressed in pain
 may mask intraabdominal injury
 cause hypotension
 CVS instability
 side effect (nausea, vomiting, urinary retention, respiratory
depression, pruritis)
 complication (dural puncture, epidural haematoma, spinal cord
trauma)
2. Thoracic paravertebral block (continuous)
a. effective analgesia, resulting in improved respiratory parameters
and ABG
b. Advantages:
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 avoid need for sedation and ventilation and allows continuous
neurologic assessment (especially in patents with head injury)
 unilateral segmental blockade spare lumbar and sacral nerve
root for monitoring (especially in patients w/ concomitant
lumbar spinal injury)
 does not require palpation of rib, feasible for fractures of upper
ribs
 technically simple
 lower incidence of complication like urinary retention and
hypotension
c. Complications: hypotension, vascular puncture, pleural puncture,
pneumothorax, inadvertent epidural anaesthesia
3. Intercostal nerve block
a. Improve peak expiratory flow rate and volume
b. Disadvantages:
 Require multiple injection-painful
 Time consuming
 Predispose to local anaesthetic toxicity
 Technically difficult for upper ribs
 Complication: pneumothroax
4. Intrapleural
a. Advantages: less complication like hypotension, bladder and
lower extremity paresthesia and weakness
b. Disadvantages:
 Significant amount of anaesthetic may be lost in presence of
chest drain (may require temporary clamping which may cause
tension pneumothorax)
 Theoretically impair diffusion of anaesthetic in presence of
haemothorax
 Posture-dependent
 Complication: pneumothorax
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B. Medication (oral/iv/PR)
1. NSAID:
a. effective
b. CI: GI upset, renal dysfunction, CVS instability, bleeding
tendency, head injury, allergy
c. Oral: voltaren SR 100mg daily
d. Iv: ketorolac 15mg BD for 2/7
2. Weak opioid:
Dologesic
a. Oral: dologesic tab 2 qid
b. CI: hepatic derangement, allergy
Tramadol
a. Oral/ iv/ PR tramadol 50-100mg tds
b. SE: nausea, vomiting, dizziness
c. CI: concomitant MAOI
3. Paracetamol:
a. Oral/ PR: panadol 1g qid
b. CI: hepatic derangement
4. Opioid:
a. Improve pain score and vital capacity
b. Advantages:
 Ease of administration and monitoring by nurse
 Without risk of invasive procedure or need for specialized
personnel
c. SE: respiratory depression, sedation, cough suppression
d. Morphine: iv PCA- loading dose required or iv morphine prn
(only in ICU)
Reference:
1. Manoj K. Karmakar and Anthony M.H. Ho: Acute pain
management of patients with multiple fractured ribs. The
Journal of trauma injury, infection and critical care: vol 54,
no. 3, 2003
2. Eastern Association for the Surgery of Trauma: Pain
Management in blunt thoracic trauma. An evidence-based
outcome evaluation 2nd review-2003
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