Pain Management Guidelines for Blunt Thoracic Trauma

Abstract

I. STATEMENT OF THE PROBLEM AND QUESTIONS TO BE ADDRESSED Studies of the consequences and treatment of blunt thoracic trauma (BTT) remain hampered by a varying pathologic definition of the disease. Entities typically classified as BTT include chest wall lesions such as rib fractures, flail chest and soft-tissue contusion; intrapleural lesions such as hemothorax and pneumothorax; parenchymal lung injuries such as pulmonary contusion and lung laceration; and mediastinal lesions such as blunt cardiac injury.1,2 For purposes of this evidence-based review, we are concerned primarily with those injuries to the chest wall that produce their morbidity through pain and its associated mechanical ventilatory impairment. Thus, blunt chest trauma is defined here to include soft-tissue trauma and injuries to the bony thorax such as rib fractures and flail chest.3 Within the scope of this definition, the incidence and morbidity of BTT clearly remain significant. Rib fractures themselves are believed to be very common and have been documented in up to two thirds of cases of chest trauma.4,5 In another review, 10% of all patients admitted to one trauma center had radiographic demonstration of rib fractures.3 Isolated single or multiple rib fractures are one of the most common injuries in the elderly, at approximately 12% of all fractures, with an increasing incidence recorded as the population ages.6 The true incidence of bony thoracic injury may be underreported, as up to 50% of fractures may be undetected radiographically.7 For patients with blunt chest wall trauma, the morbidity and mortality are significant. These injuries are associated with pulmonary complications in more than one third of cases3 and pneumonia in as many as 30% of cases.3,8,9 Patients older than 65 years may be even more prone to major complications after blunt chest wall injury,3,10–12 with 38% respiratory morbidity from isolated rib fractures in another review.13 Because blunt chest wall trauma causes death indirectly, through pulmonary and nonpulmonary complications, the true mortality rate for these injuries is hard to evaluate. In one study, 6% of patients with blunt chest trauma died, and at least 54% of these deaths could be directly attributed to secondary pulmonary complications.3 An elderly group of patients suffered an 8% mortality rate from isolated rib fractures.13 Mortality of isolated flail chest has been as high as 16%.14 The incremental costs attached to pulmonary complications of blunt chest trauma have not been addressed in the literature but clearly would be measured in “intensive care unit (ICU) days” and “ventilator days,” both of which are expensive commodities. The treatment for injuries of the bony thorax has varied over the years, ranging from various forms of mechanical stabilization15,16 to obligatory ventilatory support.17–19 It is now generally recognized that pain control, chest physiotherapy, and mobilization are the preferred mode of management for BTT.9,20 Failure of this regimen and ensuing mechanical ventilation sets the stage for progressive respiratory morbidity and mortality.3,8,20 Consequently, several different strategies of pain control have been used, including intravenous narcotics, local rib blocks, pleural infusion catheters, paravertebral blocks, and epidural analgesia. Each of these modalities has its own unique advantages and disadvantages, and the overall most efficacious method has not previously been clearly identified. Subsequently, analgesic practices vary widely in this crucial setting. In one recent review, the majority of BTT patients were still managed with intravenous or oral narcotics.21 Other authors noted that epidural catheters were offered in only 22% of elderly BTT patients and 15% of a younger cohort.9 This review seeks to identify the optimal method(s) of pain control for patients with blunt chest trauma. The specific questions that are addressed using an evidence-based approach for outcome evaluation are as follows: Which patients with blunt chest trauma are at particular risk for respiratory morbidity caused by pain and deserve special attention to pain management? With consideration for safety, feasibility, and therapeutic effectiveness, what is the optimal method of pain control in blunt chest trauma? For the recommended modality/modalities, what technical recommendations can be made for the administration of analgesia in blunt chest trauma? A. Anesthetic and technology concerns. B. Nursing considerations. II. PROCESS A computerized search was conducted of the MEDLINE, EMBASE, and Cochrane Controlled Trials databases for North American and European English language literature for the period from 1966 through December 31, 2004. The initial search terms were “chest injuries,” “thoracic injuries,” “rib fractures,” and “flail chest.” These were cross-referenced for the secondary terms “analgesia,” “anesthesia,” and “pain.” This search initially yielded 213 articles. One hundred twenty-eight of these articles were excluded as being case studies, reviews, letters, or otherwise irrelevant to the questions being asked. This yielded a file of 85 articles for review. An additional 52 articles were obtained from the references of these studies, yielding a total of 137 studies for review and grading. Ninety-five of these were deemed appropriate for inclusion in the final evidentiary tables. The practice parameter workgroup for analgesia in blunt thoracic trauma consisted of five trauma surgeons, one trained as a thoracic surgeon, two anesthesiologists, and one trauma clinical nurse specialist. All studies were reviewed by two committee members and graded according to the standards recommended by the EAST Ad Hoc Committee for Guideline Development.22 Grade I evidence was also subgraded for quality of design using the Jahad Validity Scale published in Controlled Clinical Trials in 1996.23 Any studies with conflicting grading were reviewed by the committee chairperson and were all Grade I studies. Recommendations were formulated based on a committee consensus regarding the preponderance and quality of evidence. III. RECOMMENDATIONS A. Efficacy of Analgesic Modalities Level I Use of epidural analgesia (EA) for pain control after severe blunt injury and nontraumatic surgical thoracic pain significantly improves subjective pain perception and critical pulmonary function tests compared with intravenous narcotics. is associated with respiratory and than intravenous narcotics. is with being and mortality to Level analgesia may outcome as measured by of and of is I and evidence to that paravertebral or are in subjective pain perception and may pulmonary Level paravertebral or analgesia is is an of evidence or regarding to with to overall The regarding both the and of intrapleural and analgesia is and with trauma patients is Consequently, can be made regarding overall of this B. Clinical of Modalities to of Level I analgesia is the optimal of pain for blunt chest wall injury and is the preferred after severe blunt thoracic trauma. Level Patients with or more rib fractures are 65 years of be with epidural analgesia this treatment is patients with or more rib fractures or patients 65 years with injuries also be for epidural analgesia. Level The approach for pain management in BTT for Clinical pulmonary be measured as appropriate at in elderly patients of or additional for epidural as these may mortality respiratory complications have narcotics, by or may be as initial management for risk patients with and pulmonary the clinical is patients are not for epidural analgesia be for paravertebral analgesia with A specific be made for intrapleural or analgesia based on the but its and in the of thoracic trauma has been of Analgesic Level I is I and evidence to specific of epidural analgesia as a of Level of a and a local the most epidural analgesia and are the preferred for by this Use of such of and may the incidence of to Nursing care of the with an epidural of appropriate at based on These but may not be respiratory and for epidural narcotics, and and for epidural may be with but may also epidural or and appropriate It be noted that epidural may the caused by these lesions such that of function is such are be as may as a of and may The of epidural be for on the of the clinical to and therapeutic and to analgesia be and the a over The epidural be and the for the or or are of such as or The for in epidural are the scope of this and additional be Level literature the of epidural analgesia on surgical most of blunt thoracic trauma this of treatment have for a of Consequently, such patients in be in a with cardiac and is evidence at this to a regarding the of epidural infusion in trauma A. 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In the study, patients with multiple rib fractures and flail were with epidural analgesia and and mechanical ventilation were clinical to respiratory and patients were managed that of patients a than and ventilation through the of analgesia by of a thoracic epidural Other European studies clinical with epidural analgesia in blunt chest wall injuries with pulmonary and mechanical Thus, the management of blunt thoracic trauma on both the lung injury and on of through chest and optimal The critical of ventilatory function tests as an of of this analgesia was by the authors of the studies of pain management in blunt thoracic trauma patients would the and on modalities and on outcome B. 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