Algorithm management of severe rib fractures*

HD: hemodynamically; COPD: chronic obstructive pulmonary disease; COX: cyclooxygenase.
* Admit adults with rib fractures and any of the following: ≥3 rib fractures, age >65, underlying pulmonary disease (eg, pulmonary contusion, COPD), displaced rib fracture(s), multiple trauma. Patients are typically cared for in an intensive care unit or other monitored setting.
¶ We use an escalating strategy of analgesia starting with around-the-clock acetaminophen, a COX-2 inhibitor, and a low-dose opioid delivered by using demand-only patient-controlled analgesia. Other medical adjuncts such as ketamine infusion or lidocaine infusion can be given in any combination based upon the degree of pain per hospital protocol.
Δ Supportive pulmonary care includes pain control, incentive spirometry, aggressive pulmonary toilet, and chest physiotherapy, if tolerated. Severely injured patients may require initial intubation.
◊ Patients with flail chest may benefit from earlier rather than later surgical rib fixation.
§ Options include placement of an epidural or paravertebral catheter for continuous infusion of ropivacaine. An alternative is intercostal nerve blocks.
¥ Examples include pulmonary contusion, ventilator-associated pneumonia, COPD, neurologic disease.
‡ The best supporting evidence for surgical fixation is in patients with flail chest.