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It takes a village and a multimodal toolbox: pain control after multiple rib fractures
  1. Kaushik Mukherjee1,
  2. George Kasotakis2,
  3. Suresh Agarwal, Jr3
  1. 1 Division of Acute Care Surgery, Loma Linda University Health, Loma Linda, California, USA
  2. 2 Division of Trauma and Acute Care Surgery, Inova Fairfax Hospital, Falls Church, Virginia, USA
  3. 3 Division of Trauma, Acute, and Critical Care Surgery, Duke University Medical Center, Durham, North Carolina, USA
  1. Correspondence to Dr Kaushik Mukherjee; kmukherjee{at}

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The article by Sadauskas et al is a prospective observational cohort study comparing adults with multiple unilateral rib fractures receiving multimodal pain management with or without ultrasound-guided serratus anterior plane block (SAPB) by emergency physicians.1 SAPB patients had more fractures (4.2±1.7 vs. 3.2±1.2, p=0.05), higher baseline pain scores (8.5±1.1 vs. 5.6±2.6, p=0.0001), more reduction in pain scores (3.7 vs. 0.9 at 3 hours, p=0.003, 5.1 vs. 2.0 at 24 hours, p=0.02), and improved incentive spirometry volume (+11% (95% CI 1.5%, 17% vs. −3% (−9.1%, +2.7%), p=0.008). These benefits dissipated after 24 hours. There was no difference in morphine equivalents, length of stay, need for intensive care unit (ICU) admission, or adverse events.

This study offers promise of a new, rapidly available tool in our toolbox of rib fracture management. However, it is also a reminder that the whole toolbox is necessary. For example, the authors note that SAPB has not been validated for bilateral or posterior rib fractures.1 A recent practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society on non-operative rib fracture management in elderly patients could not recommend for or against ketamine, epidural catheters, or other locoregional analgesia modalities as compared with multimodal pain management, instead advocating ‘a multifaceted pain management strategy based on multimodal analgesia and other techniques according to provider judgment and institutional resources.’2

This study also reminds us that emergency physicians, with their ultrasound expertise, have a critical role to play in rib fracture management along with trauma surgeons, intensivists, anesthesiologists, internists and geriatricians, respiratory and physical therapists, and others. Emergency physicians, as demonstrated here, are the first to see chest trauma patients in many centers and may be able to offer advanced therapies; a separate emergency physician-directed randomized trial demonstrated reduction of pain and morphine equivalents when ultrasound-guided erector spinae blocks were used for rescue analgesia.1 3 Locoregional analgesia also has critical care implications due to potential reduction of delirium in elderly patients with rib fractures.4

The true optimization of non-operative rib fracture care, therefore, must be both multispecialty and multimodal. Reducing pain must go hand in hand with incentive spirometry assessment and modalities such as the Pain, Inspiratory Effort, and Cough score.5 Institutional protocols should incorporate frailty measures such as the five-item Modified Frailty Index, and appropriately triage respiratory interventions such as ICU admissions, high-flow nasal cannula, bilevel positive airway pressure, and mechanical ventilation.2 6 7

It takes a village—and a multimodal toolbox.

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  • Contributors KM—origination and primary writing of the article. GK and SAJ—critical review of the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KM has consulting relationships with Intuitive Surgical and AcuMed.

  • Provenance and peer review Commissioned; internally peer reviewed.

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