FRACTURE RIBS: PAIN RELIEF PATHWAYDr Baskar Manickam

Consultant AnaesthetistDarlington Memorial Hospital

ALERT SYSTEM• Rib fractures not easy to diagnose on X-ray

• ED – Medicine – Trauma- Surgery- Acute Pain

• Inconsistent care – Delayed referrals

• Uncontrolled pain – Ventilatory insufficiency

• Enhanced recovery pathway?

• Multidisciplinary team collaboration?

• Red flags?

• Who coordinates this pathway?

DMH UHND

Diagnosis of Fractured Rib(s), admitted to hospital from A&E

Site 2014-10 2014-11 2014-12 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 Total

DMH 7 8 7 7 4 5 8 6 8 5 5 5 75

UHND 1 3 3 5 6 2 7 4 4 3 4 5 47

Grand Total 8 11 10 12 10 7 15 10 12 8 9 10 122

DMH UHND

Accident & Emergency 2 19

Diabetic Medicine 1 1

Ear Nose And Throat 1 0

General Medicine 29 13

General Surgery 33 10

Geriatric Medicine 3 0

Trauma & Ortho 6 3

Paediatrics 0 1

UHND DMH

IS IT A PROBLEM?• Unanticipated escalation of care to ICU

• Readmission to ED after discharge

• Hospital acquired pneumonia Patient experience

• Length of stay

• Patient experience

Site LOS 2014-10 2014-11 2014-12 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 Total

DMH

0-1 2 2 3 3 1 3 1 1 1 172-5 2 3 1 2 1 2 3 1 3 2 2 2 246-10 1 3 1 1 2 2 1 1 1211-20 4 1 2 1 1 1 3 1 14>20 1 1 1 1 2 1 1 8

DMH Total 7 8 7 7 4 5 8 6 8 5 5 5 75

UHND

0-1 1 2 2 2 1 2 3 132-5 2 2 1 2 1 3 2 1 1 1 166-10 0 0 0 0 2 0 1 0 1 0 1 1 611-20 1 1 2 1 1 1 1 8>20 2 1 1 4

UHND Total 1 3 3 5 6 2 7 4 4 3 4 5 47Grand Total 8 11 10 12 10 7 15 10 12 8 9 10 122

DMH UHND

Admissions directly to the ITU ward

Ward Ward Description 2014-10 2014-11 2014-12 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 Total

DT1 INTENSIVE THERAPY UNIT 1 DMH 2 1 1 1 1 6

ITU INTENSIVE THERAPY UNIT 1 1

Total 2 0 0 0 0 0 1 0 1 1 1 1 7

Transfers to the ITU ward

Ward Ward Description 2014-10 2014-11 2014-12 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 Total

DT1 INTENSIVE THERAPY UNIT 1 DMH 1 2 2 2 1 8

Total 1 0 2 2 0 0 0 2 1 0 0 0 8

CARE BUNDLE• Oxygen

• Physio (Incentive spirometry)

• Analgesia

• Respiratory care (if underlying lung disease, Lung injury, Thoracostomy, CPAP, HDU)

• Trauma care (Other injuries, Surgical fixation)

Rib Fracture Analgesic ladder: Pain management following rib fracture

M.Balasa, B.Manickam, Jambulingam. Acute Pain Service, CDDFT. May 2015

3-6 Conservative

•Oral /IV Paracetamol +/_ NSAID +/- Weak opioids (Refer WHO ladder) •Consider Lidocaine patch (max 3 patches; 12 h ON and 12 h OFF) •Seek early pain referral: In patients with COPD/Asthma, Methadone users

and Long term opioids

7 - 10 Progressive

•IV PCA (in a surgical ward) +/- adjuvants. •Refer to Physio (Incentive spirometry if stable). •If pain persists: Refer for consideration of nerve blocks

11-15 Aggressive

• If pain persists or increasing : Refer to Anaesthetic team for consideration of Epidural / nerve block catheters.

> 15 Emergency

•Refer to Cardiothoracic eg., flail segment •Consider HDU referral

Contact Anaesthetic / Acute Pain team for further management

Check coagulation

0800 till 1630 (weekdays) Contact acute pain team

Out of hours Contact 1st on call anaesthetists via bleep

Rib fracture score Pain Management Pathway

Risk score >10

Rib Fracture score breaks x sides + age factor

PHYSIOLOGICAL

INTERVENTIONS

• is multimodal systemic analgesia effective?

• Are there any contraindications to PCA, NSAIDS, regional techniques?

• is the pain limiting patient recovery?

• is the patient in high risk group?

Flowchart for selection of analgesia in multiple rib fracture:

! 1

High risk group: 1. Age>65? 2. >=4 rib fracture? 3. Cardiopulmonary disease? 4. DM?

Regional analgesia

Contraindication for iv PCA morphine?

1. Confused? 2. CVS stable? 3. Airway obstruction?

For iv PCA morphine+ oral/iv/PR medication

Head injury, intraabdominal injury, CVS instability?

Epidural analgesia

Expertise available? **

Thoracic paravertebral block

Contraindications for regional analgesia?

Oral/iv/PR medication

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

SURGICAL FIXATION

NICE interventional procedure guidance [IPG361] Published date: October 2010

SUMMARY• ALERT system and MULTIDISCIPLINARY CARE BUNDLE improves patient

pathway following rib fracture

• Pain, Inspiratory capacity and Cough are good indicators for severity SCORING and monitoring progress

• Aggressive pain control, respiratory care and early mobilisation is key to successful outcome

• Regional analgesia should be considered early in the HIGH RISK group

• PARAVERTEBRAL catheter is a safe effective method of analgesia for unilateral rib fractures

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