Alternative Rib Fracture Management in the ED

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Alternative Rib Fracture Management in the ED – A Medical Student Clinical Pearl

Victoria Mercer, Clinical Clerk 3, DMNB

Reviewed and Copyedited by Dr. Mandy Peach

Rib fractures are a frequent presentation in the ED, occuring in approximately 10% of all injured patients with the primary causes being blunt chest trauma and MVAs(1,2).  The mainstay of treatment for rib fractures is analgesic control(1). When pain cannot be adequately managed, the patient is at a heightened risk of hypoventilation due to decreased thoracic mobility and secretion clearance, predisposing the patient to significant atelectasis(1,2).

Historically the pain from rib fractures has been managed with acetaminophen or NSAIDS and if these do not sufficiently alleviate the pain, opioids are used(1,3). Unfortunately, these methods often do not provide adequate pain control or in the case of opioids, come with a myriad of side effects such as nausea, vomiting, constipation, respiratory depression and the potential for dependency and abuse (1,4).

An alternative to traditional methods include regional techniques such as paravertebral or epidural nerve blocks. These interventions have been shown to effectively control pain in rib fractures(3,4). The downside to these interventions include being technically challenging and time consuming with significant complication risks and contraindications such as coagulation disorders (1,3).

The solution? A serratus anterior block 

An ultrasound guided blockade of the lateral cutaneous branches of the thoracic intercostal nerves was first described by Blanco et al. in 2013 for patients following breast surgery to manage their postoperative pain(5). This procedure has been adopted by many emergency departments for its convenience and practicality compared to epidural or paravertebral nerve blocks(3).

Serratus anterior blocks are less invasive and considerably more practical in the ED setting, providing paresthesia to the ipsilateral hemithorax for 12-36 hours (6).

The only absolute contraindications are patient refusal, allergy to local anesthetic and local infection(1).

Complications of a serratus anterior block include pneumothorax, vascular puncture, nerve damage, failure/inadequate block, local anesthetic toxicity and infection(1).

Serratus anterior blocks are only effective for the anterior two-thirds of the chest wall (3).

 

Figure 1. Ultrasound image of serratus anterior muscle and surrounding tissues with superficial or deep needle guides. Image from Thiruvenkatarajan V, Cruz Eng H, Adhikary SD. An update on regional analgesia for rib fractures. Current Opinion in Anaesthesiology. 2018;31(5):601–607.

How do you do it?

The procedure is usually performed with the patient laying supine however the patient could also lay in a lateral decubitus position (1,3). Using a high frequency linear ultrasound probe (6-13MHz), identify the serratus anterior and latissimus dorsi muscles over the fifth rib in the mid-axillary line(1,3). Using an in-plane approach, insert the needle either superficial or deep to the serratus anterior and confirm correct needle placement by visualizing anaesthetic spread via ultrasound(1,3). According to May et al., superficial spreading tends to have a longer lasting analgesic effect(1). Place and secure a catheter to infuse the remainder of the bolus(1,3). Thiruvenkatarajan et al. recommend a bolus of 40ml of 0.25% levobupivacaine and a 50mm 18G Tuohy catheter needle(3).

See this excellent review by Dr. David Lewis on identifying rib fractures and their complications using ultrasound (start 3:08) as well as a review of the block and procedure (start 8:00)

Rib Fractures and Serratus Anterior Plane Block

References

  1.         May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2016 Jan 1;16(1):26–32.
  2.         Malekpour M, Hashmi A, Dove J, Torres D, Wild J. Analgesic choice in management of rib fractures: Paravertebral block or epidural analgesia? Anesthesia and Analgesia. 2017 Jun 1;124(6):1906–11.
  3.         Thiruvenkatarajan V, Cruz Eng H, Adhikary S das. An update on regional analgesia for rib fractures. Vol. 31, Current opinion in anaesthesiology. 2018. p. 601–7.
  4.         Tekşen Ş, Öksüz G, Öksüz H, Sayan M, Arslan M, Urfalıoğlu A, et al. Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial. American Journal of Emergency Medicine. 2021 Mar 1;41:16–20.
  5.         Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013 Nov;68(11):1107–13.
  6.         Mayes J, Davison E, Panahi P, Patten D, Eljelani F, Womack J, et al. An anatomical evaluation of the serratus anterior plane block. Anaesthesia [Internet]. 2016 Sep 1 [cited 2021 Apr 18];71(9):1064–9. Available from: http://doi.wiley.com/10.1111/anae.13549

 

 

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