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172 Chest wall trauma
n Summary and recommendations
First line: morphine (initial dose 4–6 mg IV, then titrate)
Reasonable:
n opioid agonists such as hydromorphone (initial dose 1 mg IV, then titrate)
n 1–3 rib fractures: intercostal nerve block (bupivacaine with epinephrine)
Pregnancy:
n morphine (initial dose 4–6 mg IV, then titrate)
n intercostal nerve block (bupivacaine with epinephrine)
Pediatric:
n morphine (initial dose 0.05–0.1 mg/kg IV, then titrate)
n intercostal nerve block (bupivacaine with epinephrine)
Special cases:
n multiple trauma or risk of hypotension: fentanyl (initial dose 50–100 μg IV,
then titrate)
n multiple rib fractures (especially if four or more): epidural (first choice) or
regional anesthesia (e.g. with bupivacaine) after adequate fluid resuscitation
References
1. Sirmali M, Turut H, Topcu S, et al. A comprehensive analysis of traumatic rib
fractures: morbidity, mortality and management. Eur J Cardiothorac Surg.
2003;24(1):133–138.
2. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures.
J Trauma. 1994;37(6):975–979.
3. Shorr RM, Rodriguez A, Indeck MC, et al. Blunt chest trauma in the elderly.
J Trauma. 1989;29(2):234–237.
4. Bulger EM, Arneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma.
2000;48(6):1040–1046; discussion 1046–1047.
5. Moon MR, Luchette FA, Gibson SW, et al. Prospective, randomized comparison
of epidural versus parenteral opioid analgesia in thoracic trauma. Ann
Surg. 1999;229(5):684–691; discussion 691–692.