Introduction
Traumatic rib fractures are a common injury in the trauma population and may cause severe pain in cases of both isolated rib fractures and chest injuries (1,2). Rib fractures are clinically important and even isolated fractures are associated with significant consequences such as long-term pain and disability (3). The number of rib fractures is indicative of the severity of the trauma, and 90% of patients with multiple rib fractures have injuries involving the head, abdomen, and/or extremities (1). Multiple traumas with an increasing number of fractures, advanced age, and rib fractures are associated with increased morbidity and mortality rates (1,4,5). Thoracic pain caused by rib fractures or chest contusion limits patients’ coughing and deep breathing, which may cause atelectasis and pneumonia. Patients may also suffer from pulmonary contusion due to injuries and this situation may cause acute respiratory distress syndrome and/or respiratory failure; mechanical ventilation may be needed (6,7).
A combination of adequate pain control, respiratory assistance, and physiotherapy is considered key in the management of patients with rib fractures (4,8). Approaches used in treatment include epidural catheters; intravenous (patient-controlled) narcotics; intercostal, paravertebral, or interpleural blocks; oral opioids; and different analgesic treatments (9,10).
The literature on the use of different analgesic treatments is insufficient. Epidural analgesia or multimodal approaches was recommended for patients with blunt chest trauma compared to opioids (9). In the systematic reviews of Duch and Møller (10) and Carrier et al. (11), it was reported that evidence for the use of epidural analgesia as the preferred method is insufficient.
However, comprehensive studies comparing modalities independently, including both observational studies and randomized controlled trials, were not analyzed. Therefore, the aim of our study was to compare the early pain control of intercostal block with that of intravenous analgesia + intercostal block in patients with rib fractures admitted to the emergency department due to blunt thoracic trauma.
Materials and Methods
Ethics committee approval of the study was obtained from the local ethics committee (Ankara City Hospital, decision no: E1-20-363, date: 27.02.2020). Patients admitted to the emergency department due to blunt thoracic trauma in a tertiary medical facility were retrospectively evaluated. A total of 48 patients were included in the study. The patients were divided into two groups as those receiving only intercostal block and those receiving intravenous analgesia + intercostal block. Patients were evaluated for early pain control parameters in terms of age, gender, trauma type, number of rib fractures, and method of treatment.
Patients with major trauma to the head and abdomen in addition to blunt thoracic trauma were excluded from the study. Patients with severe hemorrhagic trauma were also excluded. Patient groups were analyzed comparatively primarily in terms of age, gender, and number of rib fractures. According to the treatment method applied in both patient groups, results were compared according to pain levels at 0th, 15th, 30th, and 120th minutes.
Statistical Analysis
The chi-square test or Fisher’s exact test was used to show the relationships between categorical data and demographic and clinical data of patients and descriptive statistics. Student’s t-test and Mann-Whitney U analysis were used for continuous variables. Values of p<0.05 were considered significant in the study. SPSS 22 (IBM Corp., Armonk, NY, USA) was used for calculations.
Results
Of the 48 patients included in the study, 30 (62.5%) were male and 18 (37.5%) were female. The mean age was 46.08±20.01 years (range: 15-91). Thirty-seven patients were under 65 years of age, while 11 patients were 65 years of age or older. Eighteen (37.5%) patients had experienced traffic accidents, 11 (22.9%) assault, 14 (29.2%) falling, 2 (4.2%) rib fractures due to animal attacks, and 3 (6.3%) motorcycle accidents. Twenty-two patients (45.8%) had fractures on the right side and 26 patients (54.2%) on the left side. Nine patients (18.7%) were administered only intercostal block, while 39 patients (81.3%) were administered intravenous analgesia + intercostal block (Table 1).
The patient groups were compared according to the pain levels at 0th, 15th, 30th, and 120th minutes according to the treatment method applied, including only intercostal block and intravenous analgesia + intercostal block. Considering the early pain results of group A and group B, a significant improvement was observed in Group B in terms of pain results after the first 15 minutes (p<0.05) (Table 2).
Discussion
The most important problem of rib fractures is pain. It is known that pain causes ineffective coughing, atelectasis with a decrease in the depth of respiratory capacity, hypoxemia, postoperative lung infection, and many other complications such as respiratory distress. These complications increase with age, smoking, obesity, and additional diseases. For this reason, various methods such as intravenous analgesia, intercostal block, epidural analgesia, and patient-controlled analgesia are used in pain control (12,13).
Intravenous narcotic analgesia is one of the most commonly used treatment modalities in patients with chest trauma. Patient comfort and treatment of respiratory depression should be carefully considered, especially in elderly patients (14). In the study of Bayouth et al. (15), it was noted that intravenous treatment with NSAI medications was very effective in reducing pain in patients with rib fractures. In the study of Kieninger et al. (16), it was reported that intravenous analgesic treatment was a more effective and reliable method with a low complication rate compared to epidural pain control.
One of the most effective methods of relieving acute pain is local anesthesia. Intercostal block is a simple and effective method that provides analgesia after upper abdominal and thoracic surgery. With this method, adequate analgesia may be provided and the ability to cough and breathe deeply may be increased. It is especially useful in the early stages of trauma and provides eight hours of analgesia. Since the drugs are used locally, the rates of side effects and morbidity are very low. In some articles, it has been stated that intercostal blocks provide pain control close to that of thoracic epidural analgesia (17). In the study of Sheets et al. (18), where intercostal nerve block was compared with epidural analgesia, the pain scores were the same in the two groups and the incidence of side effects was higher in the epidural analgesia group. In the study of Osinowo et al. (19), it was stated that intercostal block with 0.5% bupivacaine was very effective in pain control in patients with rib fractures and it may be applied safely. In the studies of Hwang and Lee (20) and Britt et al. (21), the intercostal block method applied for pain control in cases of rib fractures caused by blunt thoracic trauma increased the respiratory efficiency of the patients and significantly reduced the duration of hospital stay. In our study, considering the early pain results of the group with only intercostal block and the group with intercostal block + intravenous analgesia, a significant improvement was observed in the intercostal block + intravenous analgesia group in terms of pain results after the first 15 minutes (p<0.05). For this reason, we concluded that the combined use of intravenous analgesia and intercostal block is more effective than other methods in pain control.
Study Limitations
The main limitation of the study that it was retrospective, the number of patients was insufficient. It could have been done by more than one center.
Conclusion
In our study, we found that the combination of intravenous NSAIDs or opioid derivatives and intercostal nerve block is an effective combination in pain control in patients with rib fractures. In addition, we think that intercostal nerve block will be beneficial in pain control and increase respiratory efficiency in patients with rib fractures, since it is both easy to apply and accelerates healing by providing effective analgesia. Due to these positive effects, we think that it may reduce the duration of hospital stay and be very beneficial in terms of efficiency and cost.
Ethics
Ethics Committee Approval: This study was approved by the Ethics Committee of Ankara City Hospital, decision no: E1-20-363, date: 27.02.2020.
Informed Consent: Retrospective study.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: E.Ç., A.G., Ö.Ö.Y., Design: E.Ç., A.G., Ö.Ö.Y., Data Collection or Processing: E.Ç., A.G., Ö.Ö.Y., Analysis or Interpretation: E.Ç., A.G., Ö.Ö.Y., Literature Search: E.Ç., A.G., Ö.Ö.Y., Writing: E.Ç., A.G., Ö.Ö.Y.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.