Pain Management in chest trauma
Outline
Pain Management for Patients with Chest Trauma
Kieran Davis
Acute Pain Service
Clinical Bottom Line
Treat life threatening Injuries
Assess and decide early
-Less than 3, can go home
Pharmacology
-Simple analgesics
-Opiates oral or iv
Invasive techniques
-Intercostal nerve blocks
-Thoracic epidural
-Paravertebral nerve block
Back to the beginning (intro)
Hippocrates
(Hemoptysis,pleurisy,empyema)
Most commonly seen after MVC
8% of trauma admissions
Commonest chest injury
Marker of severity of injury
Increased morbidity and mortality
Morbidity
Chest trauma causes pulmonary contusions
-Ventilation Perfusion mismatch
-Decreased lung compliance
-Hypoxaemia
Pain Causes
-Decreased coughing
-Shallow hyperventilation
-Reduced FRC
-Sputum retention
The elderly (over 65)
Mortality 22% vs 10%
Pneumonia 31% vs 17%
LOS 15.4 vs 10.7
Ventilator days 4.3 vs 3.1
Intensive care days 6.1 vs 4.0
Each additional # rib increased mortality by 19% and pneumonia by 27%
Long term consequences
Average time off work is 70 days
Pain at 1 month still averages 3.6/10
Chronic pain not been assessed
What did we do?
Strapping of the chest wall
External stabilisation of chest wall
Early ventilation for all people with flail chest
So what now?
Early and effective pain control
Aggressive respiratory therapy
Avoid fluid overload
Early mobilisation
Effective pain management
Enables deep breathing and coughing
Less than 3 #s
- oral analgesics, NSAIDs paracetamol, weak opiates
- intercostal nerve blocks
More extensive
- intravenous opiates, IV protocol or PCA
- Sedation, respiratory depression, cough suprresion
- Regional techniques shown to be better
Intercostal nerve blocks Pros and Cons
Advantages
- No CNS depression
- Effective for 8-24 hrs
- Can put in a catheter
Disadvantages
- Risk of pneumothorax
- Not suitable for posterior rib fractures
- Multiple injections
- Difficult for first seven ribs
Paravertebral nerve blocks pros and cons
Advantages
- Simpler, safer,easier than an epidural
- No CNS depression
- Haemodynamically stable
- Normal bladder function
- Normal limb power
Disadvantages
- Risk of pneumothorax
- Unpredictable spread
- Few Anaesthetists confident to do it
Thoracic epidural
- Decreased mortality and pulmonary morbidity in the elderly
- Increased FRC, lung compliance, vital capacity and PaO2
- Shallow breathing becomes near normal
- Shorter ICU and hospital stays
The down side
- Difficult to do with patients in pain
- Hypotension compounding hypovolaemia
- Mask intra-abdominal trauma
- Mask delayed haemothorax
- Coagulopathy mady precipitate a haematoma
- Infectio, pruritis, nausea, urinary retention
- Motor blockade
Other options
- Intrathecal opiates
- Intrapleural block
- TENS machine
Choice of analgesic technique
- Pain relief needs to be individualised
- Less than 3 # ribs oral analgesia +/- ICNB
- Patients requiring immediate surgery are best managed with IV opiates
- Regional techniques can be added in later
- Head injury and spinal trauma are contraindication for epidural analgesia
Real World
- 94% of patients with multiple rib fractures ahve other injuries
- 55% require surgery
- Haemodynamically stable, pneumothroax/haemothorax drained
- Abdominal visceral damage excluded
- This all taks time, during which IV opiates are the treatment of choice
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Ministry of Health
