title: Acute pain management of patients with multiple fractured ribs: a focus on regional techniques.
abstract: OBJECTIVE
  Thoracic trauma leading to multiple fractured ribs (MFR) remains very common. Good analgesia may help to improve a patient's respiratory mechanics and to avoid intubation of the trachea for ventilatory support and therefore may dramatically alter the course of recovery. We herein review the analgesia options for patients with MFR.
  
  
  RESULTS
  For healthy patients with one to two fractured ribs, systemic analgesics may suffice. For more than three to four fractured ribs, studies and experience have reaffirmed the superior analgesia made possible with thoracic epidural, thoracic paravertebral, and intercostal blocks. From experience, interpleural block has significant drawbacks. Catheterization allows the continuation of analgesia for 2 or more days with just one block. Use of the landmark technique is usually satisfactory for accurate block placement but ultrasound and nerve stimulation are showing promise in further improving needle and catheter placement accuracy, especially in the presence of difficult anatomy.
  
  
  CONCLUSIONS
  Thoracic epidural, thoracic paravertebral, and intercostal blocks are the top choices for patients with MFR and they are of equivalent efficacy. Each has unique advantages and disadvantages. Our preference tends to be the thoracic paravertebral approach.
authors.affiliation: Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, NT, Hong Kong. hoamh@hotmail.com
authors.forename: Anthony M-H
authors.initials: AM
authors.lastname: Ho
authors.forename: Manoj K
authors.initials: MK
authors.lastname: Karmakar
authors.forename: Lester A H
authors.initials: LA
authors.lastname: Critchley
mesh_terms: D000208:Acute Disease; D000765:Anesthesia, Conduction / Q000379:methods*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D006801:Humans; D009407:Nerve Block / Q000379:methods; D010146:Pain / Q000188:drug therapy*; D059408:Pain Management; D010147:Pain Measurement / Q000379:methods; D012253:Rib Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D013898:Thoracic Injuries / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D014463:Ultrasonography
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal