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Analgesia for rib fractures: a narrative review

Analgésie pour les fractures des côtes : une revue narrative

  • Review Article/Brief Review
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Canadian Journal of Anesthesia/Journal canadien d'anesthésie Aims and scope Submit manuscript

Abstract

Purpose

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

Source

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

Principal findings

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

Conclusion

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Résumé

Objectif

Les fractures des côtes sont des blessures courantes et douloureuses souvent associées à une morbidité importante (p. ex., complications respiratoires) et à des taux de mortalité élevés, surtout chez les personnes âgées. La stratification des risques et la mise en œuvre rapide de voies analgésiques à l’aide d’une approche d’analgésie multimodale constituent un critère d’évaluation principal des soins visant à réduire la morbidité et la mortalité associées aux fractures des côtes. Ce compte rendu narratif a pour objectif de décrire les données probantes les plus récentes et les parcours de soins actuellement disponibles, y compris les outils de stratification des risques et les blocs analgésiques pharmacologiques et régionaux fréquemment utilisés dans le cadre de l’approche analgésique multimodale largement recommandée.

Sources

La littérature disponible a été recherchée à l’aide des bases de données PubMed et Embase pour chaque sujet abordé dans le présent compte rendu et examinée par des expert·es en contenu.

Constatations principales

Quatre outils de stratification des risques ont été identifiés, le score de l’Étude de la prise en charge des traumatismes contondants de la paroi thoracique (Study of the Management of Blunt Chest Wall Trauma) étant le plus prédictif. Les données probantes actuelles sur les techniques d’analgésie pharmacologiques (c.-à-d. acétaminophène, anti-inflammatoires non stéroïdiens, gabapentinoïdes, kétamine, lidocaïne et dexmédétomidine) et d’analgésie régionale (c.-à-d. analgésie péridurale thoracique, bloc paravertébral thoracique, bloc du plan des muscles érecteurs du rachis et bloc du plan du muscle grand dentelé) ont été examinées, de même que la physiopathologie de la ou des fractures des côtes et de leurs complications associées, y compris l’apparition de douleurs chroniques et d’incapacités.

Conclusion

Les fractures des côtes continuent d’être un diagnostic grave, avec des taux élevés de mortalité, de développement de douleurs chroniques et d’invalidité. Il a été démontré qu’une approche multidisciplinaire de la prise en charge, combinée à une analgésie appropriée et à l’adhésion aux ensembles et protocoles de soins, réduit la morbidité et la mortalité. La plupart des parcours de soins de stratification des risques identifiés sont peu performants pour prédire la mortalité et les complications après une ou plusieurs fractures de côtes.

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Author contributions

Theunis van Zyl, Anthony M.-H. Ho, and Glenio B. Mizubuti conceived the research idea and helped draft and revise the manuscript. Gregory Klar helped draft and revise the manuscript. Christopher P. Haley and Susan Vasily helped revise the manuscript. Adrienne K. Ho helped create the figure and revised the manuscript. All authors meet all authorship criteria as indicated in the journal’s instructions for authors, namely: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; and drafting the article or revising it critically for important intellectual content.

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The authors declare no competing interests.

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This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Support was provided solely by departmental and institutional resources.

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This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Correspondence to Glenio B. Mizubuti MD, MSc, FRCPC.

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van Zyl, T., Ho, A.MH., Klar, G. et al. Analgesia for rib fractures: a narrative review. Can J Anesth/J Can Anesth 71, 535–547 (2024). https://doi.org/10.1007/s12630-024-02725-1

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  • DOI: https://doi.org/10.1007/s12630-024-02725-1

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