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Chest wall trauma 171
systemically administered opioids. 19,20 The success of interpleural analgesia
can be affected by a number of factors, including catheter position, patient
position, presence of hemothorax, location of RFs, characteristics of
the local anesthetic used, and the co-administration of epinephrine. 20
Because of diaphragmatic uptake of bupivacaine after interpleural administration,
respiratory excursion may be affected. 21 Interpleural catheter
placement can be technically difficult and can result in symptomatic
pneumothorax, intrapulmonary catheter placement, or misplacement
into the chest wall or in an extrapleural plane. Local anesthetic agents
are rapidly absorbed from the intrapleural space, resulting in high plasma
concentration, with potential for systemic toxicity. Interpleural instillation
of local anesthetic can also cause phrenic nerve paralysis and Horner’s
syndrome. 16
Local anesthetics (sometimes co-administered with opioids) have also
been used by the epidural administration route. This approach is associated
with decreased pulmonary morbidity and mortality in patients older than
60 years of age with RF. 7 Used in patients with chest wall trauma, epidural
analgesia produces pain relief that is dramatic and superior to that produced
by systemic opioids or other local anesthetic approaches. 5,8,11,22–24
Even though the epidural route is not used by the ED provider, the evidence
comparing its (favorable) performance to that of systemically administered
opioids cannot be ignored. Particularly for patients with multiple RFs,
epidural regimens’ advantages of improved analgesia and decreased complication
rates warrant early consideration of this approach (usually after
the ED setting) in patients who have been adequately resuscitated for
fluid. 22
Local anesthetic administration via thoracic paravertebral block entails
injecting an agent such as bupivacaine alongside the thoracic vertebrae. This
produces multidermatomal ipsilateral somatic and sympathetic nerve blockade
in contiguous thoracic dermatomes. There are few publications describing
the use of this method in patients with blunt thoracic trauma, and there is
a lack of comparative data. 16 Paravertebral administration of local anesthetics
likely has efficacy, and low complication rates, for multiple RFs, but
the technique is outside most ED providers’ practice scope. 25–27