Blunt Thoracic Trauma (BTT), Pain Management in

Level 1

 Epidural analgesia is the optimal modality of pain relief for blunt chest wall injury and is the preferred technique after severe blunt thoracic trauma.

Level 2

Patients with 4 or more rib fractures who are > 65 years of age should be provided with epidural analgesia unless this treatment is contraindicated.

Younger patients with 4 or more rib fractures or patients aged > 65 with lesser injuries should also be considered for epidural analgesia.

Level 3

1. The approach for pain management  in BCT requires individualization for each patient. Clinical performance measures (pain scale, pulmonary exam / function, ABG) should be measured as judged appropriate at regular intervals.
2. Presence in elderly patients of cardiopulmonary disease or diabetes should provide additional impetus for epidural analgesia as these co¬morbidities may increase mortality once respiratory complications have occurred.
3. Intravenous narcotics, by divided doses or demand modalities may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved.
4. High-risk patients who are not candidates for epidural analgesia should be considered for paravertebral (extrapleural) analgesia commensurate with institutional experience.
5. A specific recommendation cannot be made for intrapleural or intercostal analgesia based on the available evidence but its’ apparent safety and efficacy in the setting of thoracic trauma has been  reported.

Level 1

1. Use of epidural analgesia (EA) for pain control after severe blunt injury and non-traumatic surgical thoracic pain significantly improves subjective pain perception and critical pulmonary function tests  compared to intravenous narcotics. EA is associated with less respiratory depression, somnolence and  gastrointestinal symptoms than IV narcotics. EA is safe with permanent disability being extremely rare and negligible mortality attributable to treatment.

Level 2

1. Epidural analgesia may improve outcome  as measured by ventilator days, ICU length of stay and hospital lengths of stay.
2. There is some class I and adequate class II evidence to indicate that paravertebral or extrapleural infusions are effective in improving subjective pain perception and may improve pulmonary function.

Level 3

1. Though paravertebral or extrapleural analgesia  is effective, there is an inadequate quantity of comparative evidence or information regarding safety  to establish any recommendation with regard to overall efficacy.
2. The information regarding both the effectiveness and safety of intrapleural and intercostal analgesia is contradictory and experience with trauma patients is minimal. Consequently no recommendation can be made regarding overall efficacy of this modality.

Level 1

There is insufficient Class I and Class II evidence to establish any specific techniques of epidural  analgesia as a standard of care.

Level 2

Combinations of a narcotic ( i.e. – fentanyl ) and a local anesthetic (i.e.-bupivicaine) provide the most effective epidural analgesia and are the preferred drug combinations for use by this route. Use of such combinations allows decreased doses of each agent  and may decrease the incidence of side effects attributable to each.

Level 3

1. While reliable literature describes the safe use of epidural analgesia  on regular surgical floors, most victims of blunt thoracic trauma receiving this modality of treatment will have other primary indications for a higher level of care. Consequently, such patients in general, should be nursed in a monitored setting with cardiac monitoring and continuous pulse oximetry.
2. There is insufficient evidence at this time to make a recommendation regarding the use of continuous epidural infusion vs. intermittent injection in trauma patients.