Post on 21-Jul-2020
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