LOADING AWESOME
RIB FRACTURES
www.propofology.com
Dr. David Lyness
@Gas_Craic
SERIOUS, MULTIDISCIPLINARY, MUTI-SPECIALTY ISSUE. RELATIVE HIGH MORBIDITY & MORTALITY (33%).
PTX occurs in about 14% to 35% of rib fractures - ALWAYS exclude!
HaemoPTX in 20% to 25%, pulmonary contusions in 17%
Flail chest in 5.8%; increasing incidence correlates with an increased number of #'s
Traumatic injuries to the first rib have a 3% risk of great-vessel injury
ANALGESIA, NURSING & PHYSIOTHERAPY ARE KEY
RAPIDLY GAIN CONTROL OF PAIN FROM THE MOMENT OF ADMISSION
- CHEST PHYSIO ASAP WITH BREATHING EXERCISES
- HUMIDIFIED OXYGEN AT THE LOWEST % TO MAINTAIN SATURATIONS
- ABG'S CAN PROVIDE INFORMATION ON pO2 and pCO2
NON-OPIOID
- Regular IV Paracetamol
- Regular IV NSAID's (like Parecoxib 40mg loading then 20-40mg BD-TDS for 2-3 days)
- Lidocaine Patch 5% at the site of fracture
- Gabapentin 300mg STAT (then see BNF) or Pregabalin 75mg STAT (then see BNF)
- Consider IV Ketamine bolus in analgesic doses (such as 0.3mg / kg) in severe cases
WITH FRACTURES COME THE CHANCE OF ATELECTASIS
OF THE LUNGS, INFECTION AND DETERIORATION VIA THE
INABILITY TO ADEQUATELY INSPIRE & EXPECTORATE (31%)
With increasing number of fractures/Flail Chest, advancing age, chest/CVS and other co-morbidities;
should raise the question of whether the patient would benefit from a thoracic epidural for pain relief
EARLY COMMENCEMENT OF INTERVENTION WILL HELP REDUCE CHEST COMPLICATIONS AND RISK OF INTUBATION AND ICU
OPIOID OPTIONS
- IV Morphine- IV Morphine PCA (with bolus if needed, prior to starting)
- Longtec (Oxycodone MR) 10mg BD
- Shortec/Oxynorm doses between 2.5-10mg for breakthrough
- Codeine Phosphate (when de-escalating)
- Opioid patches (when de-escalating)
Check RENAL & HEPATIC issues of patient
and consult the BNF for these drugs.
Caution with some drugs in the elderly.
INCREASED MONITORING BY NURSING STAFF
SHOULD BE COMMENCED
WHEN ON OPIOID MEDICATIONS,
PARTICULARLY PCA's
These are ward-based managements -
we realise that most wards do not routinely
run IV infusions of ketamine or lignocaine.
MONITOR OXYGEN SATS
AND REQUIREMENTS
ICU/ANAESTHETICS REFERRAL
IF DETERIORATING CHEST OR
UNABLE TO CONTROL PAIN
1. DOES THE PATIENT NEED A CT CHEST?
2. DO THE SURGEONS NEED TO OPERATE?
Ask patient to demonstrate deep inspiration & cough - these need to be good!
TREATMENT STARTS IN THE ED
Not all patients are admitted to hospital - this is an suggestion of medications for those who are.
Shallow Tachypnoea & Tachycardia can indicate problems
Exclude pneumothorax - ? need for chest drain
See www.propofology.com/resources for RA advice, scoring, analgesia algorithm & sources
TITRATE ANALGESIA TO PAIN SCORE
Please see the website for more on regional anaesthetic techniques.
www.propofology.com/resources --> Rib Fracture Management
