18. 4 Rib Fractures + Pain Assessment

Question 1

You are called to the emergency department to assess a 63-year-old man with known chronic respiratory
disease.

He has sustained unilateral fractures to his 9th, 10th and 11th ribs but has no other injuries.
Paracetamol and codeine phosphate have not provided adequate pain relief.

a) What respiratory problems could result from inadequate pain relief in this patient? (5 marks)

Answer 1

1. > > Respiratory depression due to pain.
2. > > Basal atelectasis.
3. > > V/Q mismatch.
4. > > Poor oxygenation.
5. > > Respiratory failure.
6. > > Failure of secretion clearance.
7. > > Pneumonia.

Question 2

b) How can the effectiveness of his pain relief be assessed? (8 marks)

Answer 2

1. > > Pain scores, either VAS (visual analogue scores)
   or matching face to pain.
2. > > Intervals between assessment **
   should be as short as 15 minutes until
   good pain control has been achieved
   and then less frequently.
3. > > Assess pain at rest, on movement,
   deep breathing, coughing, on
   incentive spirometry, and
   ability to comply with
   respiratory physiotherapy.
4. > > Other physiological parameters: **
   heart rate, respiratory rate, blood pressure.
5. > > Frequency of use of breakthrough pain medication.
6. > > Involvement of pain team to facilitate regular assessment.

Question 3

c) What other methods are available to improve management of this patient’s pain? (7 marks)

Answer 3

Oral analgesia:
» Ensure paracetamol and codeine
are administered regularly with the
maximum appropriate codeine dose for the patient.

> > Consider NSAIDs: must actively seek contraindications, limit duration and
consider gastrointestinal protection.

> > If codeine insufficient,
change to a stronger opioid,
e.g. oral morphine sulfate solution as required,
and then to modified release oral morphine
once total daily dose required is known.

Intravenous analgesia:
» PCA, either morphine or fentanyl. However, if the patient already
has compromised respiratory function, beware of causing further
deterioration.

Topical analgesia:
» Local anaesthesia patches.

Regional analgesia:
» Thoracic epidural:
offers excellent analgesia
without causing respiratory
depression.
However, might be limited by
hypotensive effect and can
usually only be managed in specific wards.

> > Thoracic paravertebral block or catheter:
requires anaesthetist skilled in
such techniques.
Catheter offers longer-lasting solution to pain.
Avoids the hypotensive effect of epidural.

> > Intercostal block or catheter: as above.

> > Serratus anterior block or
catheter: as above.

Surgical intervention:
» Operative fixation.