None listed
Conditions
Brief summary
Pain management of the acutely injured patient with rib fractures in the Emergency Department (ED) can be difficult. Severe pain from multiple rib fractures can splint the chest wall, decreasing the ability to clear respiratory secretions and increasing rates of pneumonia. The older person is at increased risk of these complications as well as in-hospital death. At present, pain relief options include simple analgesics (paracetamol, ibuprofen), opiates (including morphine and fentanyl) or ketamine. In the elderly, many of these medications contribute to in-hospital falls, delirium and constipation and are addictive. Thoracic epidurals are utilised by specialist pain teams however these are contraindicated in anticoagulated patients and not typically available in the ED. The serratus anterior block is an ultrasound-guided, regional anaesthesia technique utilising a single-injection method to anaesthetise the chest wall in patients with multiple rib fractures. They are being utilised at increasing rates across emergency departments worldwide. The limited evidence available on these blocks suggests they reduce pain scores and may improve respiratory function. The block has not specifically been investigated in an older population. This study aims to evaluate the effectiveness of an ED-administered, serratus anterior plane block at reducing pain scores in patients with multiple rib fractures following blunt thoracic trauma who are also receiving protocolised rib fracture care (the current standard at participating hospitals).
Interventions
The intervention itself is a serratus anterior plane block (SAPB).
The SAPB is an ultrasound-guided, regional anaesthesia technique that provides analgesia to most of the hemithorax by the use of a once-only, local anaesthetic (ropivacaine) injection performed in the axillary region. Local anaesthetic inserted into the serratus anterior plane spreads throughout the lateral chest wall, resulting in paraesthesia of the T2 through T9 dermatomes of the anterolateral thorax by blocking the lateral c
The intervention itself is a serratus anterior plane block (SAPB). The SAPB is an ultrasound-guided, regional anaesthesia technique that provides analgesia to most of the hemithorax by the use of a once-only, local anaesthetic (ropivacaine) injection performed in the axillary region. Local anaesthetic inserted into the serratus anterior plane spreads throughout the lateral chest wall, resulting in paraesthesia of the T2 through T9 dermatomes of the anterolateral thorax by blocking the lateral cutaneous branches of the thoracic intercostal nerves. It will be performed by senior clinicians (specialists or advanced trainees) in the Emergency Department. This intervention (including risks & benefits) has been described in more detail under "Interventions" on pages 8 & 9 as well as Appendix B of the Study Protocol which includes a weight-based ropivacaine dosing guide (Table 1) consistent with current NSW guidelines for fascia iliaca blocks. Blocks will be recorded in the electronic medical record and in the standardised case reporting form (on REDCap) in which clinicians must report type and dose of anaesthetic administered, volume of the diluent and which serratus plane was utilised (superficial vs deep). This will allow investigators to monitor for protocol adherence. Patients in the intervention arm also receive the "local protocolised, rib-fracture bundle of care" described below.
Sponsors
Liverpool Hospital
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
16 Years to No maximum
Healthy volunteers
No
Inclusion criteria
All patients aged 16 years or older with clinical or radiologically proven rib fractures, and a clinician qualified to perform SAPB available at time of enrolment
Exclusion criteria
- Intubated patients - Patients who have a prehospital SAPB - Pregnant women - Patients transferred for urgent surgical intervention - Moderate-severe traumatic brain injury (GCS less than or equal to 13) - Major concomitant injury identified on imaging (including Femoral fracture, Pelvic fracture, Spinal fracture, Intra-abdominal visceral injury ± free fluid)
Outcome results
None listed