ASRA Pain Medicine Update

Introduction

Rib fractures are common in multitrauma patients and require effective analgesia to prevent respiratory complications. At the Penn State Health Milton S. Hershey Medical Center, all multitrauma patients with rib fractures are referred to the acute pain medicine service (APMS) once they have been assessed and stabilized by the trauma surgery service. APMS performs a detailed history and physical examination, focusing on location of fractures, medications, patient's current coagulation status, allergies, and other injuries, including trauma to internal abdominal organs, spine, pelvis, or limbs. APMS also evaluates history of prior surgeries or disease and mental status. An analgesic plan is formulated with the goals of optimizing respiratory function, minimizing opioid consumption, and preventing cognitive dysfunction. Therefore, the plan usually includes an interventional regional anesthesia procedure.

The erector spinae plane (ESP) block was described in 2016 as a novel regional anesthetic technique for acute and chronic thoracic pain.

Until recently, APMS performed mainly thoracic epidural, thoracic paravertebral, and intercostal blocks to provide rib fracture analgesia.^[1-2] In general, patients with one to two rib fractures were considered for intercostal blocks, whereas patients with three or more rib fractures were considered for thoracic epidural or paravertebral blocks. However, the latter two techniques are not always feasible because of various factors, including pre-existing anticoagulation or antiplatelet therapy, hemodynamic instability, or other associated injuries (eg, vertebral fractures).

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