1

COMPARATIVE STUDY OF REGIONAL AND SYSTEMIC ANALGESIA FOR PAIN

CONTROL IN MULTIPLE RIB FRACTURES IN ADULT BLUNT CHEST TRAUMA

PATIENTS

SUBMITTED BY:

DR. EKPE, EYO EFFIONG (MBBS, FWACS)

DEPARTMENT OF SURGERY

UNIVERSITY OF UYO TEACHING HOSPITAL (UUTH),

UYO, AKWA IBOM STATE, NIGERIA.

A PART II DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE

MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF THE FINAL FELLOWSHIP OF THE

MEDICAL COLLEGE OF SURGEONS (FMCS)

MAY 2015

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CERTIFICATION

This is to certify that the study in this dissertation Comparative Study Of Regional And Systemic

Analgesia For Pain Control In Multiple Rib Fractures In Adult Blunt Chest Trauma Patients At The

University Of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria was carried out under our

supervision.

SIGNATURE/DATE :......................................................................

NAME OF SUPERVISOR: Professor O. O. Bassey (MS, FMCS, FWACS, FICS)

Professor/Consultant Cardiothoracic Surgeon

Department of Surgery, University of Calabar/

Teaching Hospital, Calabar, Cross River State,

SIGNATURE/DATE: -----------------------------------------------------------

NAME OF SUPERVISOR: Professor A. U. Etiuma (MBBCh, FWACS, FMCS, FICS)

Professor/Consultant Cardiothoracic Surgeon

Department of Surgery, University of Calabar/

Teaching Hospital, Calabar, Cross River State

SIGNATURE/DATE:-----------------------------------------------------------

NAME OF SUPERVISOR: Dr. Victor Ette (MBBS, FMCS, FWACS)

Adjunct Lecturer / Chief Consultant Otorhinolaryngologist,

E.N.T. Unit, Department of Surgery,

University of Uyo / University of Uyo Teaching Hospital, Uyo,

Akwa-Ibom state, Nigeria.

DR. EYO E. EKPE:...............................................................

HEAD OF DEPARTMENT

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DECLARATION

I, Dr. Eyo Effiong EKPE, hereby declare that this work is original unless otherwise

acknowledged and the study was carried out and fully written by me. This study has not been

previously presented to the National Postgraduate Medical College of Nigeria, or any other

College, Institution, Publisher or Journal.

Signature: -----------------------------------------------------------------------

Name of Candidate: Dr. Ekpe Eyo Effiong

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TABLE OF CONTENTS

TITLE PAGE - - - - - - - - 1

CERTIFICATION - - - - - - - - 2

DECLARATION - - - - - - - - 3

TABLE OF CONTENT - - - - - - - 4-5

ABSTRACT - - - - - - - - -

CHAPTER ONE

INTRODUCTION - - - - - - - - 6-7

STATEMENT OF THE PROBLEM - - - - - - 7-8

JUSTIFICATION FOR THE STUDY - - - - - 8-9

RESEARCH QUESTIONS - - - - - - -

HYPOTHESIS - - - - - - - -

SCOPE OF THE STUDY - - - - - - - 9

OBJECTIVE OF THE STUDY - - - - - - 10

LIMITATIONS OF THE STUDY - - - - - - 10

CHAPTER TWO [LITERATURE REVIEW]

SURGICAL ANATOMY OF THE CHEST WALL - - - 11-13

EPIDEMIOLOGY OF BLUNT CHEST TRAUMA AND RIB FRACTURES - 13-16

BIOMECHANICS OF BLUNT CHEST TRAUMA - - - - 16-21

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PATHOPHYSIOLOGY OF BLUNT CHEST TRAUMA - - - 22-26

RIB FRACTURES - - - - - - - - 27

DIAGNOSIS OF BLUNT CHEST TRAUMA - - - - 28

TREATMENT OF BLUNT CHEST TRAUMA

HISTORICAL PERSPECTIVE - - - - - - 29-30

TREATMENT OF RIB FRACTURES - - - - - 30-31

MODALITIES OF ANALGESIA IN RIB FRACTURES - - - 31-35

INTRAVENOUS ANALGESIA - - - - - - 31

EPIDURAL ANALGESIA - - - - - - - 32

INTERCOSTAL NERVE BLOCK - - - - - - 33

THORACIC PARAVERTEBRAL BLOCK - - - - 34

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION - 35

ORAL ANALGESIA - - - - - - - 35

PAIN PATHWAY - - - - - - - - 36-37

METHOD OF PAIN MEASUREMENT - - - - - 37-38

MECHANISMS OF ACTION OF BUPIVACAINE - - - 38

MECHANISMS OF ACTION OF TRAMADOL - - - - 39

COMPARATIVE ANALYSIS OF DIFFERENT ANALGESIC

TECHNIQUES IN PATIENTS WITH BLUNT CHEST TRAUMA - 39-41

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CHAPTER THREE

PATIENTS AND METHODS

THE UNIVERSITY OF UYO TEACHING HOSPITAL,

UYO, AKWA IBOM STATE - - - - - - 42

THE PATIENTS - - - - - - - - 42

INCLUSION CRITERIA - - - - - - - 43

EXCLUSION CRITERIA - - - - - - - 43

METHODS - - - - - - - - - 44-45

EVALUATION OF RESPONSE - - - - - - 45-47

DATA ANALYSIS - - - - - - - - 48

CHAPTER FOUR

RESULTS - - - - - - - - - 49-67

CHAPTER FIVE

DISCUSSION - - - - - - - - 68-78

RECOMMENDATIONS - - - - - - - 79

REFERENCES - - - - - - - - 80-84

APPENDICES - - - - - - - - 85-89

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ABSTRACT

BACKGROUND: A recent survey showed that rib fractures constituted 9% of the 731,823 trauma

cases, and that 13% of the patients with rib fractures developed 13,086 complications of which 48%

were related to the chest wall trauma. Such complications as pneumonia, atelectasis, bronchiectasis,

empyema thoracis, acute respiratory distress syndrome, prolonged intensive care unit and hospital stay,

and the concomitant mortality can be prevented or reduced by good analgesic therapy which is the

subject of this study.

METHODOLOGY: Randomized prospective study of intercostal nerve block (ICNB) with 0.5%

Bupivacaine group and the intravenous Tramadol (IVT) injection group.

RESULTS: There were 64 adult patients who were studied with multiple rib fractures caused by blunt

chest trauma. Out of these, there were 54 (84.4%) men and 10 (15.6%) women. According to

mechanism of the blunt chest injury, motorcycle (popularly known as “okada”) and tricycle (popularly

known as keke napap) accidents significantly accounted for the cause of multiple rib fractures in 50

(78.1%) of the patients. Before analgesia, the 64 patients rated their chest pain as either severe (68.7%)

or moderate (31.3%) whereas at one hour after commencement of analgesic, only 6.3% and 42.2% still

rated their chest pain as severe and moderate pain respectively, while 45.3% had mild pain and 6.3%

had no pain. And at 24 hours all the 64 patients had either no pain (76.6%) or mild pain (23.4%) (p

values <0,0001 and 0.002). Comparison of efficacy based on changes in pain scores among the two

groups of intervention also showed that ICNB was more effective than IVT at both the one hour and 24

hours re-assessment periods. Improvement in respiratory function as evidenced by lung function tests

also correlated positively with the control of chest pain in both treatment arms but better in the

intercostals nerve block group.

CONCLUSION/RECOMMENDATION: This study recommends the routine use of intercostal nerve

block for chest pain control in blunt traumatic multiple rib fractures where the expertise and 0.5%

bupivacaine injection are available and there are no contraindications in the patients.

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CHAPTER ONE

1.1 INTRODUCTION

Thoracic trauma leading to multiple fractured ribs (MFR) remains common.1 While the chest

pain associated with a single rib fracture is relatively easy to control, the significant chest pain

of multiple rib fractures can be difficult to manage and can lead to decreased pulmonary

function, increased hospital stay, and increased health care expenditures.2 Patients with

traumatic rib fractures often present with varying degrees of chest pain, which in turn leads to

impairment of pulmonary mechanics, retention of trachea-bronchial secretions, and

atelectasis.3 Multiple rib fractures cause severe chest pain that can seriously compromise

respiratory mechanics and exacerbate underlying lung injury and pre-existing respiratory

disease, predisposing to respiratory failure.4 Good analgesia may help to improve the patient's

respiratory mechanics, avoid intubation of the trachea for ventilatory support and therefore may

dramatically alter the course of recovery.1 The cornerstone of chest pain management is early

institution of effective pain relief.4

Analgesia could be provided using systemic opioids, transcutaneous electrical nerve

stimulation or non steroidal anti-inflammatory drugs. Alternatively, regional analgesic

techniques such as intercostal nerve block, epidural analgesia, intrathecal opioids, intra-pleural

analgesia and thoracic paravertebral block have been used effectively. Although invasive, in

general, regional blocks tend to be more effective than systemic opioids, and produce less

systemic side effects.4 Pain relief in chest trauma patients with rib fractures includes several

modalities, such as administration of analgesics, rib belts, intercostal nerve block with

bupivacaine hydrochloride (Marcaine, Astra), continuous intercostal nerve block, intercostal

nerve block with morphine chloride, and subpleural block with 0.5% bupivacaine.3 Studies

have shown that injection into one intercostal groove blocks not only the intercostal nerve of

that groove, but at least the one above and below it because of sub-pleural tracking.3 Immediate

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pain relief after intercostal nerve block and improvement in pulmonary mechanics have been

demonstrated in several reports.3 Surgical stabilization of rib fractures in form of open

reduction and internal fixation is an alternative treatment for pain management of multiple rib

fractures.5

Thoracic epidural, thoracic paravertebral, and intercostal blocks are the top choices for patients

with MFR and they are of equivalent efficacy.1

This study is aimed at prospectively evaluating the efficacy of systemic and regional analgesia

for chest pain control in multiple rib fractures in adult blunt chest trauma patients in our centre

in terms of pain relief, improvement in ventilatory function and mitigation of pulmonary

morbidity and mortality.

1.2 STATEMENT OF THE PROBLEM

Studies of the consequences and treatment of blunt chest trauma are hampered by varying

pathologic definition of the disease. Entities typically classified as blunt chest trauma include

chest wall lesions such as rib fractures, flail chest and soft-tissue contusion; intrapleural

lesions such as haemothorax and pneumothorax; parenchymal lung injuries such as pulmonary

contusion and lung laceration; and mediastinal lesions such as blunt cardiac injury.6-8

Diaphragmatic injury and oesophageal injury can also result from blunt chest trauma.

The incidence and morbidity of blunt chest trauma clearly remain significant. Rib fractures

themselves are believed to be very common and have been documented in up to two thirds of

cases of chest trauma.4 In another review, 10% of all patients admitted to one trauma centre

had radiographic demonstration of rib fractures. Isolated single or multiple rib fractures are

one of the most common injuries in the elderly, at approximately 12% of all fractures, with an

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increasing incidence recorded as the population ages.9 The true incidence of bony thoracic

injury may be underreported, as up to 50% of fractures may be undetected radiographically.6

For patients with blunt chest wall trauma, the morbidity and mortality are significant.4,7,8

These injuries are associated with pulmonary complications in more than one third of cases

and pneumonia in as many as 30% of cases.9 Patients older than 65 years may be even more

prone to major complications after blunt chest wall injury, with 38% respiratory morbidity

from isolated rib fractures.10 In one study, 6% of patients with blunt chest trauma died, and at

least 54% of these deaths could be directly attributed to secondary pulmonary complications.6

An elderly group of patients suffered an 8% mortality rate from isolated rib fractures.10

Mortality of isolated flail chest has been as high as 16%.11 The incremental costs attached to

pulmonary complications of blunt chest trauma have not been addressed in the literature but

clearly would be measured in “intensive care unit (ICU) days” and “ventilator days,” both of

which are expensive commodities.6

1.3 JUSTIFIFATION FOR THE STUDY

Chest trauma is a common type of trauma globally occurring in about 12 persons per 1 million

population in the ratio of 70% blunt:30% penetrating. In the United States, of 50,000 traumas

in the major outcome study, 15,000 patients had chest traumas with about 71% involving the

chest wall and resulting in rib fractures in about 47%. Also of the patients dying from trauma

25% die as a direct result of the chest trauma, and an additional 25% has chest trauma as a

contributory factor to their demise.12

A recent survey by the National Trauma Data Bank of the American College of Surgeons,

Chicago showed that rib fractures constituted 9% of the 731,823 trauma cases, and that 13%

of the patients with rib fractures developed 13,086 complications of which 48% were related

11

to the chest wall trauma.13 Such complications as pneumonia, atelectasis, bronchiectasis,

empyema thoracis, acute respiratory distress syndrome, prolonged intensive care unit and

hospital stay, and the concomitant mortality can be prevented or reduced by good analgesic

therapy which is the subject of this study.

Another justification of this study is the fact that literature search has not shown comparative

study of this kind in the African continent as a whole even though the problems of blunt chest

trauma and multiple rib fractures are present in all regions of the world including our own

environment.7,8 Osinowo, a Nigerian studied blunt chest trauma patients in Saudi Arabian who

sustained rib fracture(s) where the chest pain was controlled with intercostal nerve block using

bupivacaine injection.3 There are other studies within and outside Nigeria which have shown

tramadol injection as being effective and safe for the control of moderate to severe pain

experience by patients after surgical operations14-16

1.4 RESEARCH QUESTIONS

1. Is there any difference between intercostal nerve block using 0.5% bupivacaine injection and

intravenous tramadol injection in controlling chest pain in multiple rib fractures in adult blunt

chest trauma patients?

2. Would chest pain control improve respiratory function of patients with multiple rib fractures

from blunt chest trauma?

1.5 HYPOTHESIS

I. Null hypothesis: No difference between intercostal nerve block (ICNB) and intravenous

tramadol (IVT) in controlling chest pain in adult patients with blunt chest trauma and

multiple rib fractures

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II. Alternative hypothesis: There is difference between intercostal nerve block (ICNB) and

intravenous tramadol (IVT) in controlling chest pain in adult patients with blunt chest

trauma and multiple rib fractures

1.6 SCOPE OF THE STUDY

This is a prospective, randomized study which included all our consented adult blunt chest

trauma patients with multiple rib fractures and without associated major injuries as defined in

the exclusion criteria. This study involved 64 patients as the sample size arrived at using the

formulae:17,18

N = 4(Z2P(1-P)

D2,

Where N is the total sample size, Z is the Z value for the desired significance value, P is the

pre-study prevalence of the last 12 months, (in the study centre 80 adult patients were treated

for blunt chest trauma), and D is the standardized difference.

N = 4Z2 x80(1-80)

D2

= 4x1.962 x 80-6400

102

= 5503.64

100 N= 55 (sample size)

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1.7 AIM AND OBJECTIVES OF THE STUDY

Aim

I. To compare the efficacy of intravenous tramadol injection and intercostal nerve block

with 0.5% bupivacaine injection for control of chest pain in multiple rib fractures.

Specific Objectives

I. To evaluate the efficacy of intercostal nerve block (ICNB) with 0.5% bupivacaine

(DURACAINE) for pain relief in patients with rib fractures and compare same with

intravenous tramadol injection

II. To correlate the degree of pain relief with changes in the pulmonary function test

III. To correlate the degree of pain relief with changes in the oxygen saturation

Hypothesis

I. Null hypothesis: No difference between intercostal nerve block (ICNB) and intravenous

tramadol (IVT) in controlling chest pain in adult patients with blunt chest trauma and

multiple rib fractures

II. Alternative hypothesis: There is difference between intercostal nerve block (ICNB) and

intravenous tramadol (IVT) in controlling chest pain in adult patients with blunt chest

trauma and multiple rib fractures

1.8 LIMITATIONS OF THE STUDY

1. The sample size of 64 may not have been large enough to allow generalization of the

results in the population

14

II. The possibility of missing some fractured ribs because of the less than 100% sensitivity

of plain radiograph in diagnosing rib fractures in the immediate post-trauma period may

have affected the result in the intercostal nerve block arm.

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CHAPTER TWO

LITERATURE REVIEW

2.1 ANATOMY OF THE CHEST WALL

The chest is truncated, dynamic structure with upper and lower boundaries that vary with

respiration and patient’s position.12 (Figure1). The general surgeon considers the thoracic inlet

to be zone one of the neck. Some articles define both the subclavian and axillary vessels to be

part of the thoracic inlet, and others describe these vessels as belonging to the upper extremity.

The cupola of the lungs may rise into supra-clavicular spaces of the neck. With respiration

especially in the supine position, the dome of the diaphragm may rise as high as the fourth

interspace. When the patient is standing and lungs are fully expanded, the dome of the

diaphragm may be as low as the 10th intercostal space. These variable anatomic considerations

are important when determining associated neck and abdominal injuries in a patient with a

major thoracic injury.12

Figure 2-1: Boundaries of the chest

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The chest wall consists of the bony structures (ribs, sternum and the spine) (figure 2), the related

muscles and the diaphragm. Together they function as the respiratory bellows. The carefully

regulated rigidity and mobility of the chest wall normally permit a balance between the

supportive and ventilatory functions. The ventilatory function is however impaired by chest

wall trauma with corresponding impairment of breathing.

Figure 2-2: Bony chest wall

The intercostal neuro-vascular bundle runs in the subcostal groove arranged craniocaudally as

vein, artery and nerve, which makes the intercostal nerve easily accessible with injection

needle. (Figure 3).

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Figure 2-3: Disposition of neurovascular bundle in the intercostal space

The diaphragm is the principal respiratory muscle and accounts for 60% of the total amount of

ventilated air.19

2.2 EPIDEMIOLOGY OF CHEST TRAUMA

There are approximately 12 thoracic injuries per day per 1 million populations. Of these 12,

four will require hospitalization, with one being severe.12 Although commoner in young adult

males, no age or sex is immune to chest trauma. Trauma to the chest and its structures may be

due to:12

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1. Blunt injury, including blast injuries

2. Penetrating injury

3. Pulmonary injury secondary to aspiration or infection

4. Pulmonary, vascular and cardiac alterations secondary to hormonal, immunologic and cell

mediator responses, and

5. Iatrogenic injuries.

Of patients dying from trauma, 25% die as a direct result of the chest trauma. In an additional

25%, the chest traumas contribute to their demise.12 In the United State, of 50,000 injuries in

the major outcome study, 15,000 patients had chest traumas. Of these, 70% were secondary to

blunt trauma and 30% to penetrating trauma. From 1962 to 1970, 60% of chest traumas were

from motor vehicles accidents, 14% occurring at work, 10% at home, with 18% resulting in

death. Of these, 71% involved the chest wall, 41% produced a pneumothorax or hemothorax,

7% involved the heart, and 7% involved the diaphragm (Table 1). About 4% of patients will

have injury to a great vessel, with less than 5% having injury to the tracheobronchial tree or

oesophagus. Blunt and penetrating chest trauma may involve the liver, kidney and spleen. The

many organs involved and problems produced by penetrating chest trauma influence morbidity

and mortality.12

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Table 2-1. PERCENTAGE OF ORGAN INJURY FOLLOWING BLUNT CHEST TRAUMA

Organ Kemmerer Besson

(%) (%)

Chest Wall

Rib fracture 39 47

Sternal fracture 5 22

Pleural “Space”

Hemothorax 28 24

Lung laceration 10 21

Lung contusion 6 12

Mediastinum

Great vessel 10 4

Myocardial 6 7

Trachea 1 5

Diaphragm 5 7

In civilian practice, automobile accidents are the commonest causes of chest traumas (over

70%).19 Other causes of chest traumas include stab wounds, fall from heights, gun shots, falling

objects and industrial accidents. In war, chest traumas account for about 10% of all wounds.

Penetrating wounds may be produced by a knife, piece of glass, a portion of an automobile, or

a gunshot wound. Blunt trauma most commonly produced by motor vehicle accidents causes

deceleration injuries. Blunt injuries include those produced by blasts, falls and other impacts.

20

Iatrogenic injuries may be secondary to both diagnostic and therapeutic interventions resulting

in injury to the oesophagus or trachea-bronchial tree during endoscopy, to the lungs or heart

during catheterization and percutaneous biopsies, to the chest wall, the heart or even the great

vessels during cardiopulmonary resuscitation.12

2.3 BIOMECHANICS OF BLUNT CHEST TRAUMA

The three types of blunt force that lead to thoracic injury are compression, shearing, and blast.20

Thoracic compression injuries such as rib fractures occur when the applied force exceeds the strength

of the thoracic cage. The area of maximal chest wall weakness is found at a 600 rotation from the

sternum, where the ribs are flatter and less well-supported (figure 2-2). Frequently, however, ribs

subjected to lateral or anteroposterior (AP) compression will fracture in two places: one at

approximately 600 and again posteriorly. AP compression also can create a costochondral disruption,

resulting in a sternal or anterior flail.20,21 (Figure 2-5).

Shearing forces cause soft tissue and vascular injury.20 In response to a rapid acceleration or

deceleration, soft tissue and vascular organ movement is restricted at anatomic and developmental

attachments. Ultimately, if the tensile strength of the attached tissue is exceeded, tearing or rupture

will occur. This inertial effect is responsible for one of the most lethal thoracic injuries: aortic

transection.9 Because the aorta is tethered by the ligamentum arteriosum and by the mediastinal pleura

to the vertebrae below, the junction of the more mobile aortic arch and the stationary descending aorta

is the most common site of disruption.20 Both full thickness tears with free rupture and partial

thickness injuries leading to pseudo-aneurysm formation are possible results. Shearing within the

pulmonary parenchyma can lead to laceration, hematoma, contusion, or pneumatocele.20

Blasts or explosions are especially deadly, not only because of the blast pressure wave, but also

because the victim can be launched considerable distances, and surrounding debris become missiles.

21

Primary pulmonary blast injury occurs when the pressure wave strikes the chest wall and creates a

pressure differential at the air–tissue interface. The greater the pressure differential, the more force is

transmitted to the lung.20 The severity of the pulmonary injury is related inversely to the victim’s

distance from the blast. Explosions within an enclosed space are more severe, because the pressure

waves are reflected back to the patient, intensifying the original insult.20 The characteristic pathology

of pulmonary blast injury is a contusion with oedema and alveolar hemorrhage.21 Secondary blast

injuries result from objects sent into motion by the explosion, impacting the patient. Tertiary injuries

are caused by the individual being displaced. Associated injuries caused by thermal burns, inhalation

agents, and crush secondary to structural collapse are also common.20

Although rib fractures are common, it is difficult to determine the true prevalence among seriously

injured patients, because the anteroposterior radiograph is not exceptionally sensitive for rib

fractures.20 In addition, national surveys of injured patients usually only track the three most principle

diagnoses per patient, and rib fractures, in spite of their clinical importance, may not be included in

the principle diagnoses of multiply injured patients. For example, the Health Care Cost and Use

Project’s Nationwide Inpatient Sample indicates that only 140,000 patients with rib fractures were

admitted to United States hospitals in 2000.20 The actual number of patients with rib fractures seen in

United States hospitals and ICUs may be significantly higher. Rib fractures are clinically important

for three reasons: as a marker for serious intra-thoracic and abdominal injury, as a source of

significant chest pain, and as a predictor for pulmonary deterioration, particularly in the elderly. Case

series of rib fracture patients presenting to trauma centres reveal that 84% to 94% of patients will

have associated injuries.20 The most common associated thoracic injuries are pneumothorax,

hemothorax, and pulmonary contusion. The most common abdominal organs injured are the liver and

the spleen. Patients with right-sided rib fractures, including the eighth rib and below, have a 19% to

56% probability of liver injury, while left-sided fractures have a 22% to 28% probability of splenic

injury.20 Contrary to historical beliefs, rib fractures, including those of the first and second ribs, are

22

not associated statistically with aortic injury.22 In fact, many trauma surgeons are recommending chest

computed tomography (CT) angiography as a screening tool for occult intrathoracic injury in patients

with significant blunt chest trauma irrespective of chest radiograph findings.23-25 Eight percent of

patients brought to a trauma centre following a high-speed motor vehicular crash (MVC), a fall greater

than 4.5 m, or having been struck by an automobile and thrown more than 3 m had aortic injury

revealed by chest CT angiography.23 Sixty-five percent of patients with significant blunt chest trauma

who have an admission chest CT will have significant intra-thoracic injuries that are missed by chest

radiograph alone.23 The presence of rib fractures is especially ominous in children and the elderly.

The bones of children lack calcification; consequently, their chest walls are more compliant than

adults’.26 Rib fractures in a child indicate a much higher absorption of energy than would be expected

in an adult. Correspondingly, the absence of rib fractures in a child should not diminish concern for

significant intrathoracic injury. In a study of 986 paediatric patients with blunt chest trauma, 2% had

significant thoracic injuries without evidence of any chest wall trauma.26 Thirty-eight percent of

children with pulmonary contusion do not have radiographic evidence of rib fractures. In contrast,

minimal trauma rib fractures (ie, ground level falls) comprise 12% of all skeletal fractures in the

elderly and are as common as humeral fractures.26 Osteoporosis, loss of muscle mass, and

comorbidities not only decrease the force required to cause rib fractures in the elderly, but they also

decrease the physiologic reserves present to tolerate such injuries.2 Bulger et al compared patients

who were at least 65 years old to a matched cohort of 18- to 64-year olds who sustained blunt chest

trauma with rib fractures.2 The elderly group had twice the mortality and thoracic morbidity. The risk

of pneumonia increased by 27%, and mortality increased by 19% for each additional rib fracture in

the elderly group.2

Flail chest is rare, but it is the most serious of the blunt chest wall injuries. The prevalence of flail

chest among patients with chest wall injury is estimated between 5% and 13%.27 The diagnosis of a

flail chest is established most readily by observing the paradoxical motion of the affected segment in

23

a spontaneously breathing patient. Upon inspiration, the flail segment is pulled inward by the negative

intra-thoracic pressure. With exhalation, the positive pressure forces the segment to protrude outward

(figure 4). Muscular splinting of the chest early in the immediate post-injury period, however, may

mask the paradoxical motion until the flail becomes apparent hours later with the development of

chest wall muscle fatigue. In patients who are mechanically ventilated, a high degree of suspicion

with palpation of the chest wall for crepitance and fractures and review of chest radiograph or CT are

necessary. Placement of the patient on a low level of pressure support (ie, 5 cm of water) may unmask

the flail segment.24

Fig 2-4: Chest wall excursion paradox in flail chest

24

Beyond the age of 55, the likelihood of death in cases of flail chest increases 132% for every

10-year increase in age and 30% for each unit increase in injury severity score.27 In non-

intubated patients, the disruption of chest wall mechanics will dramatically decrease tidal

volume and effective coughing with a corresponding predisposition to sputum retention,

atelectasis, and pneumonia. An associated pulmonary contusion further contributes to the

development of bronchial obstruction and intrapulmonary shunting. A low threshold for

intubation of patients with flail chest, especially those with co-morbidities and the elderly, is

warranted.27

Pulmonary contusion should be anticipated in any patient who sustains significant, high-energy

blunt chest impact. A history of the inciting event and physical findings of chest wall trauma,

especially the presence of fractures or a flail segment, increase the odds of having an underlying

lesion.28 The absence of rib fractures, however, does not eliminate the possibility of pulmonary

contusion. Focal or diffuse homogeneous opacification on chest radiograph is the mainstay of

diagnosis. Unlike aspiration pneumonitis, the opacification seen with pulmonary contusions is

irregular and does not conform to segments or lobes within the lung.28 Pulmonary contusion is

not always immediately apparent radiographically; one-third of patients fail to demonstrate a

lesion consistent with this diagnosis on the initial chest radiograph.28 Although the mean time

to opacification is 6 hours, it may take up to 48 hours for pulmonary contusion to blossom.

Tyburski et al, in an attempt to quantify the volume of the pulmonary contusion and correlate

this volume with outcome, compared the pulmonary contusion score (PCS) of the initial

radiograph to a repeat film 24 hours later.28 The mean increase in the PCS of 7.9 units was

nearly equivalent to an entire hemi–lung volume. Computed tomography scans have been

advocated as a more accurate means of detecting and quantifying pulmonary contusion. Thirty-

eight percent of anesthetized dogs sustaining blunt chest trauma showed evidence of a

pulmonary contusion on plain radiograph, compared with 100% using CT scans.28 Miller et al,

25

in a series of pulmonary contusion detected by CTscan, found that a mean of 18% of the

pulmonary parenchyma was contused, and that the contusion increased by 11% with a repeat

CT scan at 24 hours.29 Moreover, 82% of patients with a contusion of at least 20% developed

acute respiratory distress syndrome (ARDS) versus only 22% of patients with a contusion less

than 20%. There was also an increased trend in the development of pneumonia in cases of

greater contusion. Wagner reported that all patients with pulmonary contusions greater than

28% of total volume required intubation, compared with no patients with less than 18%

contusion.30 Prospective studies, however, have failed to show significant changes in

management and outcome when chest CT scans are obtained solely for the assessment of

pulmonary contusion.30

2.4 PATHOPHYSIOLOGY OF BLUNT CHEST TRAUMA

Chest injuries adversely affect pulmonary function by three separate mechanisms: altered

mechanics of breathing, ventilation/perfusion imbalance, and impairment of gas transfer.31

Altered mechanics of breathing31

The great majority of blunt injuries to the thoracic cage and those penetrating injuries that cause

haemothorax or pneumothorax impair ventilation. Even relatively minor trauma with fractured

ribs but no underlying pathology may cause pain sufficient to lead to hypoventilation,

atelectasis, failure to clear secretions, pneumonia, septicaemia, respiratory failure, and even

death in an elderly or bronchitic patient. More serious problems which cause severe impairment

of the mechanics of breathing include pneumothorax (particularly tension pneumothorax),

haemothorax, ruptured diaphragm, multiple rib fractures with unstable segments, and injuries

to the major airways. The most extensive disruption of the chest wall tends to occur with crush

injuries where multiple bilateral rib fractures, ruptured diaphragm, or fractures of the spine or

sternum coexist. Multiple fractures may cause substantial blood loss into the chest wall and

26

pleural cavity; this may be increased by laceration of the underlying lung by sharp edges. There

are two main types of chest wall derangement, a functionally important traumatic defect

(sucking chest wound) or a flail segment. The latter may be unilateral with double fractures of

three or more ribs, or anterior with fractures of three or more ribs on both sides of the sternum

(figure 5). Some fractures may occur through the costochondral junctions, and are therefore

invisible on plain chest radiographs. The unstable segment moves inwards on inspiration

(paradoxical movement) and consequently compromises ventilation by reducing tidal volume

(figure 4). Following diaphragmatic rupture, the abdominal contents are similarly sucked into

the chest on inspiration. If the pleural cavity is filled with air or blood, ventilation of partially

collapsed lung is similarly compromised. Injuries to the major airways or inhalation of foreign

material including teeth, windscreen glass, or stomach contents may physically occlude the

large or small airways, thereby obstructing air entry.

Lat. Flail Ant. Flail

27

Fig 2-5: Rib fractures resulting in anterior and lateral flail chest

Ventilation/perfusion imbalance31

Effective oxygenation of the blood and elimination of carbon dioxide (CO2) depend on a

balance between ventilation of the lung and its blood supply. Thoracic injuries compromise

ventilation perfusion/balance by a number of different mechanisms. Mechanical obstruction of

the airway is an obvious cause of impaired ventilation, but in practice other mechanisms

predominate. Distribution of ventilation in the lung is influenced by regional variations in

airways resistance and compliance. The latter is governed by gravity-dependent intrapleural

pressure gradients, and gas distribution in the lung is therefore uneven during normal resting

tidal ventilation. In the lower or more dependent pleural space the pressure is closest to

atmospheric (least negative). It becomes increasingly negative towards the apex or non-

dependent region of the lung. When a normal inspiration is taken from end-expiration

(functional residual capacity) expansion of the initially smaller dependent alveoli is governed

by the steep portion of the compliance curve. Consequently, they expand more for each unit of

pressure change than do those at the apices which are influenced by the upper, flatter portion

of the curve. These differences result in preferential distribution of inspired gases to the areas

of greater expansion in the dependent portions of the lungs. However, if terminal air spaces

have collapsed due to haemopneumothorax or adult respiratory distress syndrome, inspiration

results in preferential distribution to already expanded areas because of the influence of the

compliance curve. The maldistribution of ventilation is worsened by airflow obstruction in

terminal airways due to external compression, elevated intrapleural pressure, or interstitial

oedema fluid. When a whole lobe or lung eventually collapses, there is perfusion of non-

ventilated lung and a serious veno-arterial shunt effect. Ineffective oxygenation of the venous

28

blood is reflected by widening of the alveolar–arterial oxygen tension difference and systemic

hypoxia.

Movement of blood through the lungs is also influenced by gravity and the pressure gradient

between the pulmonary arteries and left atrium. Blood flow is normally directed preferentially

to the dependent parts of normal lung where ventilation is also most efficient. However,

perfusion is often impaired by thrombosis of vessels in contused lung or widespread pulmonary

microembolism by fat from bone marrow or platelet/neutrophil microemboli in patients with

disseminated intravascular coagulation or adult respiratory distress syndrome.

In many patients after even minor thoracic trauma, the effects of ventilation/perfusion

mismatch may lead to unsuspectedly severe hypoxia which is seldom recognized without blood

gas analysis. Pulmonary contusion, intrapulmonary haemorrhage, and haemothorax or

pneumothorax are invariably associated with serious deterioration in pulmonary function

Impairment of gas transfer31

Passive diffusion of gas across the alveolar capillary barrier is dependent on the surface area

available, the width of the membrane, certain plasma and erythrocyte enzymatic factors, and

the partial pressure gradient between the alveolar and vascular spaces. Following thoracic

trauma a number of factors, including injury to the pulmonary parenchyma by contusion,

damage to the alveolar capillary barrier by inhalation of gastric contents or smoke, impaired

cardiac output, and interstitial pulmonary oedema due to over-transfusion of crystalloid,

colloid, or blood (elevated left atrial pressure), may adversely affect gas exchange. However,

the most sinister process involved is that which begins with the pathophysiological effects of

shock and, if uninterrupted by prompt resuscitation, may progress to acute respiratory distress

syndrome. The humoral and cytological changes that culminate in this syndrome are probably

triggered by activation and interaction of the complement, coagulation, kallikrein, and

29

plasminogen cascades, and result in trapping of ‘activated' neutrophils in the pulmonary

microvasculature. Here they release protease enzymes and generate oxygen free radicals with

the potential to damage the alveolar capillary membrane. When full-blown acute respiratory

distress syndrome occurs in a patient with thoracic trauma particularly following multiple

injuries, the chances of survival decrease markedly. Gas exchange is impaired by extension of

the diffusion pathway by the presence of hyaline membrane and oedema fluid in the alveoli;

accumulation of interstitial fluid within the septum and of proliferated type II cells along its

alveolar border; reduction in the surface for diffusion because of terminal air space collapse

and closure of capillary channels; and the detrimental influence of consequent hypoxaemia,

hypercapnia, and acid–base shifts in erythrocyte enzyme kinetics. Some of the consequences

of this process precipitate further deterioration in pulmonary dysfunction. Pulmonary arterial

hypertension develops because of hypoxic arteriolar vasoconstriction. Higher flow resistance

in small vessels can be made worse by increased interstitial fluid pressure. Intravascular

coagulation may exacerbate these problems and contribute to ventilation/perfusion mismatch.

Hypoxaemia is the first objective sign of the onset of acute respiratory distress syndrome, and

is the cardinal index of its progressive severity. At a later stage CO2 retention develops, with

its consequent disturbances of acid–base balance. Unless blood gases are monitored

continuously in patients with thoracic trauma the primary effects in the lung may be

misinterpreted. The manifestations of respiratory insufficiency are reflected principally in

deterioration of cardiovascular and central nervous system dysfunction.

In conclusion, injuries to the chest often produce derangement in respiration function resulting

in pulmonary hypoventilation, inadequate oxygenation and respiratory acidosis. There may

also be associated shock from massive bleeding or cardiac dysfunction.19 Therefore the

pathophysiology of chest trauma includes three factors: hypoxia, hypercapnia, and acidosis.

Hypoxia can be caused by airway obstruction, changes in intra-thoracic pressure, ventilation-

30

perfusion mismatches, intra-pulmonary shunting and hypovolemia. Hypercarbia is caused by

inadequate ventilation resulting from the presence of a collapsed lung associated head injuries

with altered mental status, or exogenous intoxication (drugs and alcohol). Acidosis is caused

mainly by hypoperfusion from blood loss.32

2.5 RIB FRACTURES

A rib fractures at the point of impact or at its weakest point which is the angle.19 Rib fractures

are the most common injuries after blunt chest injuries. Ribs 4 through 10 are usually fractured.

One or two fractures without pleural or lung involvement are usually treated on an outpatient

basis.32 However, in the elderly, because of their decreased bone density, reduced chest wall

compliance and increased incidence of underlying parenchymal disease, rib fractures may lead

to decreased ability to cough, reduced vital capacity, and infectious complications.32 Pain on

inspiration is usually the primary clinical manifestation after rib fractures. Other clinical signs

associated with rib fractures include tenderness to palpation and bony crepitus.32

Simple fractures involve only the ribs and they are painful but not serious except in the elderly

and patients with a low pulmonary reserve in whom impairment of ventilation and coughing

may precipitate pneumonia.19 The main feature is pain with tenderness at the site of the fracture,

worst on breathing or compression of the sternum. The fractured ends of the rib may puncture

the underlying lung and cause pneumo- or haemothorax or surgical emphysema.19

Multiple rib fractures are the hallmark of a severe trauma caused by the high – energy transfer.32

Patients with multiple rib fractures should have intra-thoracic and abdominal injuries excluded

by appropriate investigations. Fractures of the lower ribs (ninth to twelfth) are associated with

an increased incidence of hepatic and splenic injuries, and fractures of the upper ribs (first to

third), clavicle, or scapula are associated with major vascular injury.32

31

2.6 DIAGNOSIS OF BLUNT CHEST TRAUMA

Diagnosis of blunt chest trauma associated with rib fracture(s) can usually be made by clinical

evaluation of the patient with relevant history, physical examination and radiological

examination. Pain on inspiration is usually the primary clinical manifestation after rib fractures.

Other clinical signs associated with rib fractures include tenderness to palpation and bony

crepitus.32

Rib fractures are confirmed by chest x-ray (CXR) in only 50% of cases.24 Screening CXRs

miss rib fractures more than 50% of the time.24 Radiology reports are often not sufficiently

descriptive or are incomplete with respect to the number and location of fracture and reliance

on these data will lead to erroneous conclusions. Using computerized tomographic (CT)

scanning only, the finding of rib fractures in multiple locations was associated with increased

incidence of respiratory failure. In contrast, the presence of any parenchymal injury or visible

rib fracture on the screening CXR significantly increases the risk for subsequent pulmonary

morbidity (odds ratio, 3.8; CI95, 2.2-6.6). Although tranquil CT (TCT) scanning markedly

improved the diagnosis and delineation of rib fractures, the screening CXR was a better

predictor of subsequent pulmonary morbidity and mortality.24 TCT is highly sensitive in

detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing

lung contusions, pneumothorax, and haemothorax. Early TCT influences therapeutic

management in a significant number of patients.25

32

2.7 TREATMENT OF BLUNT CHEST TRAUMA

2.7.1 Historical Perspective

The treatment of blunt chest trauma has undergone dramatic evolution over the twentieth

century. In the first half of the century, the primary emphasis was on mechanical stabilization

of the bony injury.6 This was first done by such external devices as sandbags or traction

systems and later by various surgical methods such as wires or screws. After 1950, the

concept of “internal pneumatic stabilization” with positive-pressure mechanical ventilation

was developed.6 This became more prevalent and obligatory mechanical ventilation became

the standard for blunt chest wall trauma.6

The management of severe, blunt chest trauma evolved into the modern era with the

publication of two studies in 1975. In a small series, Trinkle demonstrated that optimal pain

control, chest physiotherapy, and noninvasive positive-pressure ventilation could avert the

need for intubation and mechanical ventilation.33 Also in 1975, Dittman published the first

in a series of three articles on pain management in blunt chest trauma.34,35 In the first study,

19 patients with multiple rib fractures and flail segments were treated with continuous

epidural analgesia and intubation and mechanical ventilation were withheld. Using objective

clinical criteria to monitor progress (e.g., vital capacity, respiratory rate, and tidal volume),

17 patients were successfully managed without positive-pressure ventilation. Dittman

subsequently showed that 46 of 49 (94%) spontaneously breathing patients maintained a vital

capacity greater than 13 mL/kg and avoided positive-pressure ventilation through the use of

morphine analgesia by means of a thoracic epidural catheter.34,35

33

Thus, the management of blunt chest trauma today focuses on both the underlying lung injury

and on optimization of mechanics through chest physiotherapy and optimal analgesia. The

critical importance of measuring ventilatory function tests as an objective means of

monitoring adequacy of this analgesia was emphasized by the authors of the early studies.6

Subsequent studies of pain management in blunt chest trauma patients would use the same

methodology and additionally focus on comparisons between modalities and on objective

outcome parameters.

2.7.2 Treatment of rib fractures

Rib fractures are the commonest of all chest injuries and are identified in 10% of patients after

trauma.6 The overall incidence is probably higher because not all rib fractures are seen on chest

radiographs or otherwise detected.24,25 Multiple fractured ribs cause severe pain, which may

be more debilitating and harmful than the injury itself.6 Pain limits one’s ability to cough and

breathe deeply, resulting in sputum retention, atelectasis, and a reduction in functional residual

capacity (FRC). These factors in turn result in decreased lung compliance, ventilation-

perfusion mismatch, hypoxemia, and respiratory distress. Failure to control pain, compounded

by the presence of pulmonary contusion, flail segment, and other insults, can result in serious

respiratory complications and death.6

The treatment for injuries of the bony thorax has varied over the years, ranging from various

forms of mechanical stabilization to obligatory ventilatory support.6 It is now generally

recognized that pain control, chest physiotherapy, and mobilization are the preferred mode of

management for blunt chest trauma.4,6,36 Failure of this regimen and ensuing mechanical

ventilation sets the stage for progressive respiratory morbidity and mortality.6 Consequently,

several different strategies of pain control have been used, including intravenous narcotics,

34

local rib blocks, pleural infusion catheters, paravertebral blocks, and epidural analgesia. Each

of these modalities has its own unique advantages and disadvantages, and on the overall most

efficacious method has not previously been clearly identified.6 Subsequently, analgesic

practices vary widely in this crucial setting. In one recent review, the majority of blunt chest

trauma patients were still managed with intravenous or oral narcotics.6 Other authors noted

that epidural catheters were offered in only 22% of elderly blunt chest trauma patients and 15%

of a younger cohort.2 Poor pain control significantly contributes to complications such as

atelectasis and pneumonia.37

2.7.3 Modalities of Analgesia

2.6.3.1 Intravenous Narcotic

Intravenous narcotics have historically been the initial and most prevalent modality for relief

of surgical and traumatic pain of all types.6 They are administered either by intermittent

injection when pain is noted by the patient or continuous infusion. Most recently intravenous

patient-controlled analgesia (PCA) has been developed to exploit the benefits of both methods.

In this modality, a baseline intravenous infusion of morphine is provided and the patient may

elicit an additional bolus for breakthrough pain.6

The obvious advantages of intravenous narcotics are ease of administration and monitoring

by nursing without the risks of an invasive procedure or need for specialized personnel. The

efficacy of this modality for blunt chest wall trauma is controversial.6 Intravenous narcotics

have been shown to improve pain scores and vital capacity, yet some clinicians consider them

35

inadequate in this setting. The disadvantages of systemic narcotics are the tendency to cause

sedation, cough suppression, respiratory depression, and hypoxemia.6

2.7.3.2 Epidural Narcotics/Anaesthetics

Epidural analgesia is a method whereby narcotics, anaesthetic agents, or combinations thereof

are introduced into the spinal epidural space at the thoracic or lumbar level to provide regional

analgesia.6 This is accomplished by introduction of a polyvinyl catheter into the epidural space

and delivery of agents by either a bolus, continuous infusion or, more recently, a demand

system.6

The major advantage of epidural analgesia is its apparent effectiveness in the absence of

sedation. Epidural analgesia has been shown to result in an increased functional residual

capacity, lung compliance, and vital capacity; a decreased airway resistance; and increased

PO2. Tidal volume is increased and chest wall paradox in flail segments is reduced.6 Patients

with epidural analgesia generally remain awake and can cooperate with pulmonary toilet and

chest physiotherapy.6

There are numerous real and theoretical disadvantages to epidural analgesia. Insertion may be

technically demanding. Epidural anaesthetics can cause hypotension, particularly in the face

of hypovolemia, and occasional epidural infection.6 Epidural hematoma, accidental entry into

the spinal canal, and spinal cord trauma can also occur.6 Inadvertent “high block” may lead to

respiratory insufficiency.6 By combining an epidural narcotic with the anaesthetic agent, the

dose of anaesthetic can be decreased and these effects mitigated. However, the narcotic can

36

cause nausea, vomiting, urinary retention, pruritus, and occasionally respiratory depression.6

The contraindications to epidural analgesia may prove problematic in the trauma patient.

These include fever, coagulation abnormalities of even minor degrees, and altered mental

status.6 There is some anecdotal concern that the bilateral analgesia effect may mask the

symptoms of intra-abdominal injury. Finally, nursing intensity in monitoring for the effects of

sympathetic block is somewhat more demanding than that for intravenous analgesia.6

2.7.3.3 Intercostal Nerve Block

Intercostal analgesia or “intercostal nerve block” traditionally involves individual injections

of local anaesthetic into the posterior component of the intercostal space.6 Because of

segmental overlap of intercostal nerves, it is necessary to induce block above and below any

given fractured rib. Blocks of adequate scope have been shown to relieve pain with multiple

rib fractures and improve peak expiratory flow rate and volume.6 However, the effect lasts

only approximately 6-24 hours depending on local anaesthetic agent used and whether

adrenaline has been added to the local anaesthetic agent.6

As a unilateral block, hypotension is rare, and bladder and lower extremity sensation are

preserved.6 The disadvantages of intercostals nerve block include the need to palpate the

fractured ribs for injection, and the need for multiple and repeated injections.6 Local

anaesthetic toxicity may theoretically occur because of the higher doses needed, and the

incidence of pneumothorax increases with the number of ribs blocked.6 Also, inducing block

for upper rib fractures is technically difficult because of the proximity of the scapula.6

Intercostal catheterization and continuous infusion has been successfully used and mitigates

the need for multiple injections. However, the anatomic endpoint of catheter placement,

37

piercing of the “posterior intercostal membrane,” is often unclear, raising the possibility of

misplacement.6 The full anatomic limits of the spread of intercostal drugs are unclear.6

2.7.3.4 Intra-pleural Analgesia

Intra-pleural analgesia involves placement of a local anaesthetic agent into the pleural space

by means of an indwelling catheter.6 This produces a unilateral intercostal nerve block across

multiple dermatomes by gravity-dependent retrograde diffusion of agent across the parietal

pleura.6 As a unilateral modality, it has advantages similar to intercostal block regarding

hypotension and bladder and lower extremity sensation. Successful use of this modality has

been reported in blunt chest trauma patients.6

In terms of disadvantages, a significant amount of anaesthetic may be lost if a tube

thoracostomy is in place, which is often the case with blunt chest trauma patients.6 This can

be mitigated by temporary “clamping” of the thoracostomy, which in turn evokes concerns of

tension pneumothorax. Conversely, in the absence of a tube thoracostomy, intrapleural

catheter placement may cause a pneumothorax.6 The presence of haemothorax, also common

in blunt chest trauma patients, may theoretically impair diffusion of anaesthetic.6 Because

distribution of agent is gravity-dependent, effectiveness also varies with patient position,

catheter position, and location of fractured ribs. Diffusion is most widespread in the supine

position, which is not optimal position for pulmonary function in the blunt chest trauma

patients.6 Conversely, the semi-upright position commonly adopted by chest trauma patients

may allow disproportionate diffusion inferiorly and adversely affect diaphragmatic function.6

2.7.3.5 Thoracic Paravertebral Block

38

Thoracic paravertebral block involves the administration of a local anaesthetic agent in close

proximity to the thoracic vertebrae.6 This can be achieved by intermittent injection, bolus by

means of a catheter, or continuous infusion, and produces a unilateral somatic and sympathetic

block that extended over multiple dermatomes.6

Despite the fact that little recent investigation has been performed with this modality, its

theoretical advantages are numerous.6 It does not require painful palpation of ribs, is not in

conflict with the scapula, and is felt by some to be technically easier than epidural anaesthesia.

Because there is no risk of spinal cord injury as with epidural analgesia, this modality can be

instituted on sedated or anesthetized patients.6 It has few ontraindications and requires no

special nursing management. The most common complications are vascular puncture, pleural

puncture, and pneumothorax.6 The unilateral nature of the block makes hypotension rare,

preserves bladder sensation, and allows monitoring of the lower extremity neurologic

examination when necessary.6

2.7.3.6 Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) produces pain relief by releasing

endorphins in the spinal cord.4 Sloan et al. used it in patients with multiple rib fractures and

found it provided better subjective pain relief, with improvement in peak expiratory flow rates

and arterial blood gases when compared with a group of patients receiving nonsteroidal anti-

inflammatory drugs (NSAIDs).38 The paucity of data on this mode of analgesia in patients with

multiple rib fractures suggests that it is rarely used in this group of patients.4

39

2.7.3.7 Oral Analgesic Drugs

Oral analgesic drugs such as nonsteroidal anti-inflammatory drugs (e.g., diclofenac,

indomethacin) and acetaminophen do not depress the central nervous system or the

cardiovascular system and are useful for mild to moderate pain. As with transcutaneous

electrical nerve stimulation, there is a paucity of data on the use of oral analgesics in patients

with multiple rib fractures.4 However, there may be a place for the use of NSAIDs as adjuncts to

other methods of pain relief in patients with multiple rib fractures.4 Non-steroidal anti-inflammatory

drugs can cause gastrointestinal upset and platelet and renal dysfunction. The latter would

contraindicate the use of NSAIDs in patients who are not adequately resuscitated.4

2.7 PAIN PATHWAY

Pain is described as an unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage indicating some problem, and

often causing further physiological effect(s) in the body of the sufferer.39 The physiology of

normal pain transmission involves some basic concepts that are necessary to understand the

pathophysiology of abnormal or non-physiologic pain. These include the concept of

transduction of the first-order afferent neuron nociceptors. The nociceptor neurons have

specific receptors that respond to specific stimuli if a specific degree of amplitude of the

stimulus is applied to the receptor in the periphery. If sufficient stimulation of the receptor

occurs, then there is a depolarization of the nociceptor neuron. The nociceptive axon carries

this impulse from the periphery into the dorsal horn of the spinal cord to make connections

directly, and indirectly, through spinal interneurons, with second-order afferent neurons in the

spinal cord (figure 6). The second-order neurons can transmit these impulses from the spinal

cord to the brain. Second-order neurons ascend mostly via the spinothalamic tract up the spinal

cord and terminate in higher neural structures, including the thalamus of the brain. Third-order

neurons originate from the thalamus and transmit their signals to the cerebral cortex. Evidence

40

exists that numerous supraspinal control areas—including the reticular formation, midbrain,

thalamus, hypothalamus, the limbic system of the amygdala and the cingulate cortex, basal

ganglia, and cerebral cortex—modulate pain. Neurons originating from these cerebral areas

synapse with the neuronal cells of the descending spinal pathways, which terminate in the

dorsal horn of the spinal cord.39

Fig 2-6: Ascending and descending tracts of pain pathways

2.8 METHODS OF PAIN MEASUREMENT

Pain assessment helps the clinician to imagine the intensity of pain the patient is experiencing.

If this assessment is done before, during and after a course of pain treatment, it helps the

41

clinician to know to what extent the treatment has helped his patient and therefore the efficacy

of the drug. So as pain is, most of the methods of pain assessment are also subjective, and

probably none is completely satisfactory.39 The methods of pain assessment in cognitively

intact persons include the 4-point verbal rating scales of Zubroid, the numerical rating scales,

and the visual analogue scales.39 These are the most widely used pain rating scales in both

clinical practice and research. They are simple, minimally intrusive, effective and easy to

administer and score.39

1. Verbal pain rating scales of Zubroid. This stratifies pain intensity according to levels of

severity. It employs different word descriptions to rate the patient’s pain, e.g no pain (0), mild

pain (1), moderate pain (2), and severe pain (3). These words can be translated to any language.

Numbers are assigned to each of these words for recording and comparison purposes.

2. Numerical rating scales. This asks the patient to rate their pain from “no pain” (0) to “worst

pain possible” (10). It is assumed that each number represents a proportional increase in pain

severity.

3. Visual analogue scales. This employs a 10 cm line rated from “no pain” at the left to “worst

pain” possible on the right. It requires the patients to mark their pain on the continuum. The

VAS “score” is the distance from the “no pain” point to the patient’s estimate. There should be

no markings, numbers or words along the line, as these tend to influence the results.

2.9 MECHANISM OF ACTION OF BUPIVACAINE

Bupivacaine (MARCAINE, SENSORCAINE), is an amide local anaesthetic. Bupivacaine’s

long duration of action plus its tendency to provide more sensory than motor block has made

it a popular drug for providing prolonged analgesia.40 Bupivacaine acts by blocking conduction

42

by decreasing or preventing the large transient increase in the permeability of excitable

membranes to Na+ that normally is produced by a slight depolarization of the membrane. This

action is due to direct interaction with voltage-gated Na+ channels. As the anaesthetic action

progressively develops in a nerve, the threshold for electrical excitability gradually increases,

the rate of rise of the action potential declines, impulse conduction slows, and nerve conduction

eventually fails resulting in non perception of pain from the infiltrated area.40

Compared to other local anaesthetics, bupivacaine is markedly cardiotoxic. However, adverse

drug reactions (ADRs) are rare when it is administered correctly. Most ADRs are caused by

accelerated absorption from the injection site, unintentional intravascular injection, or slow

metabolic degradation. However, allergic reactions can rarely occur. Clinically significant

adverse events result from systemic absorption of bupivacaine and primarily involve the central

nervous system (CNS) and cardiovascular system. CNS effects typically occur at lower blood

plasma concentrations. Initially, cortical inhibitory pathways are selectively inhibited, causing

symptoms of neuronal excitation. At higher plasma concentrations, both inhibitory and

excitatory pathways are inhibited, causing CNS depression and potentially coma. Higher

plasma concentrations also lead to cardiovascular effects, though cardiovascular collapse may

also occur with low concentrations. Adverse CNS effects may indicate impending

cardiotoxicity and should be carefully monitored.

CNS: circumoral numbness, facial tingling, vertigo, tinnitis, restlessness, anxiety,

dizziness, seizure, coma

Cardiovascular: hypotension, arrhythmia, bradycardia, heart block, cardiac arrest

Toxicity can also occur in the setting of subarachnoid injection during high spinal anesthesia.

These effects include: parasthesia, paralysis, apnea, hypoventilation, fecal incontinence, and

urinary incontinence. Additionally, bupivacaine can cause chondrolysis after continuous

43

infusion into a joint space. Bupivacaine has caused several deaths when the epidural anaesthetic

has been administered intravenously accidentally.

2.10 MECHANISM OF ACTION OF TRAMADOL

Tramadol is a synthetic 4-phenyl-piperidine analogue of codeine.40 It is a centrally acting

analgesic that possesses weak affinity for the µ opioid receptor and modifies transmission of

nociceptive impulses through inhibition of monoamine (norepinephrine and serotonin)

reuptake but not production. Receptor-blocking studies have demonstrated that these

mechanisms work synergistically to produce the therapeutic analgesic effects of tramadol.

Mechanism of action is mainly via µ opioid agonism, but also has spinal effect on 5HT

receptors.40 At similar analgesic doses, tramadol has less effect on the respiratory centre than

morphine and has not been associated with a high abuse potential.40

The most common adverse effects of tramadol include nausea, dizziness, dry mouth,

indigestion, abdominal pain, vertigo, vomiting, constipation, drowsiness and headache.

Compared to other opioids respiratory depression and constipation is considered less of a

problem with tramadol.

By incidence

Very common (>10% frequency) adverse effects include:

44

Dizziness, Nausea, Constipation, Vertigo, Headache, Vomiting, Somnolence

Common (1–10% frequency) adverse effects include:

Agitation, Anxiety, Emotional lability, Euphoria, Nervousness, Spasticity, Dyspepsia

(indigestion), Asthenia (weakness), Pruritus (itchiness), Dry mouth, Diarrhea, Fatigue,

Sweating, Malaise, Vasodilation (dilation (widening) of blood vessels), Confusion,

Coordination disturbance, Miosis, Sleep disorder, Rash, Hypertonia, Abdominal pain, Weight

loss, Visual disturbance, Flatulence, Menopausal symptoms, Urinary frequency, Urinary

retention (being unable to urinate)

Uncommon (0.1-1% incidence) adverse effects include:

Cardiovascular regulation anomalies (palpitation, tachycardia, postural hypotension or

cardiovascular collapse), Retching, Gastrointestinal irritation (a feeling of pressure in the

stomach, bloating), Urticaria (hives), Trembling, Flushing

Rare (0.01–0.1% incidence) adverse effects include:

Bradycardia, Hypertension (high blood pressure), Allergic reactions (e.g. dyspnoea (shortness

of breath), bronchospasm, wheezing, angioneurotic oedema), Anaphylaxis, Changes in

appetite, Paraesthesia (pins and needles), Hallucinations, Tremor, Respiratory depression,

Epileptiform convulsions, Involuntary muscle contractions, Abnormal coordination, Syncope

(fainting), Blurred vision, Dyspnoea (shortness of breath), Tinnitus (ringing in the ears),

Migraine, Stevens-Johnson syndrome/Toxic epidermal necrolysis (potentially fatal skin

reactions), Motorial weakness, Creatinine increase, Elevated liver enzymes, Hepatitis (liver

swelling), Stomatitis (mouth swelling), Liver failure, Pulmonary oedema (fluid in the lungs),

Gastrointestinal bleeding, Pulmonary embolism, Myocardial ischaemia (lack of blood supply

45

to the heart muscles), Speech disorders, Haemoglobin decrease, Proteinuria (protein in the

urine; usually indicative of kidney damage)

There are suggestions that chronic opioid administration may induce a state of immune

tolerance, although tramadol, in contrast to typical opioids may enhance immune function.40

Some have also stressed the negative effects of opioids on cognitive functioning and

personality.40

2.11 COMPARATIVE ANALYSIS OF DIFFERENT ANALGESIC TECHNIQUES IN

PATIENTS WITH BLUNT CHEST TRAUMA

There are relatively few clinical trials comparing the efficacy of the various analgesia

techniques in patients with blunt chest trauma. This may in part be because each technique has

unique strengths, weaknesses, and contraindications, and pain management is individualized

on the basis of the clinical condition and extent of injury. This makes randomized, controlled

comparisons difficult or hard to justify.4

Gabram et al. prospectively compared intrapleural bupivacaine with systemic narcotics

(morphine, meperidine, or hydromorphone) for the management of 48 patients with rib

fractures. The patients with the block statistically had more compromised pulmonary function

as measured by forced vital capacity (FVC) at admission; however, they tended toward a

greater objective improvement of FVC at discharge, although the difference did not reach

statistical significance.11 When analyzing a cohort of severely impaired patients (initial FVC

< 20% predicted), half of the systemic medication patients compared with only 10% of the

block group failed and required another mode of therapy. Catheter complications were minor

and did not contribute to overall morbidity.11

46

Luchette et al. prospectively evaluated analgesia for 72 hours in 19 blunt trauma patients with

unilateral rib fractures. They found that thoracic epidural bupivacaine 0.125%, 8 to 10 mL/h

continuous infusion, as compared with intrapleural bupivacaine 0.5% intermittent boluses of

20 mL every 8 hours, resulted in significantly lower visual analog scale pain scores, less use

of “rescue” narcotics, and greater tidal volume and negative inspiratory force. Vital capacity,

Fio2, minute ventilation, and respiratory rate were not affected. Mild hypotension was a

common complication with epidural blocks only.41 Shinohara et al. had more favourable

results with interpleural block. They studied 17 patients with unilateral multiple rib fractures

and hemopneumothorax in a randomized, crossover, before/after trial on the first and second

hospital days. An interpleural catheter was inserted along with a chest tube, and an upper

thoracic epidural catheter was also established in the same patient. They administered 10 mL

of 1% lidocaine for both blocks. The range of thermohypesthesia was unilateral and shorter

with the interpleural block, whereas it was bilateral and wider with the epidural block. The

effects of pain relief were almost the same. Respiratory rate decreased and Pao2 tended to

elevate similarly. Unlike epidural block, the systemic blood pressure with interpleural block

changed only minimally. Serum levels of lidocaine were similar and in the safe range.42

Mackersie et al. compared epidural and intravenous fentanyl for pain control and restoration

of ventilatory function after multiple rib fractures in a prospective, randomized trial involving

32 patients. Pre-fentanyl and post-fentanyl parameters were compared in both groups. Both

methods significantly improved visual analog pain scores. The epidural method produced

improvement in both maximum inspiratory pressure and vital capacity, whereas intravenous

analgesia produced improvement in only vital capacity. Intravenous fentanyl produced

increases in PaCO2 and decreases in PaO2, whereas no significant changes in arterial blood

47

gases were observed with epidural fentanyl administration. Side effects were similar between

the groups, with pruritus being more pronounced with epidural fentanyl.43

Sloan et al. compared two groups of patients with MFRs who were randomized to receive

either TENS or naproxen sodium 250 mg every 8 hours and also a mixture of paracetamol 1 g

and dihydrocodeine tartrate 20 mg on an as-required basis. The peak expiratory flow rate

change at 24 hours after the commencement of treatment, the PaO2, and the pain relief were

all significantly better in the TENS group.38

CHAPTER THREE

PATIENTS AND METHODS

3.1 The University of Uyo Teaching Hospital, Uyo, Akwa Ibom State

This is the only tertiary health care institution in Akwa Ibom State. Akwa Ibom State has an

approximate population of 3,920,208. The University of Uyo Teaching Hospital, Uyo receives

patients from the state predominantly and occasionally from the neighbouring communities of

Abia, Cross River and River States.

3.2 Sample Size

Sixty-four consented adult blunt chest trauma patients with multiple rib fractures (that is

fracture of two or more ribs) were randomised into the two arms of the study based on the

following sample size calculation:17,18

N = 4(Z2P(1-P)

48

D2,

Where N is the total sample size, Z is the Z value for the desired significance value, P is the

pre-study prevalence of the last 12 months, (in the study centre 80 adult patients were treated

for multiple rib fractures from blunt chest trauma), and D is the standardized difference.

N = 4Z2 x80(1-80)

D2

= 4x1.962 x 80-6400

102

= 5503.64

100 N= 55 (sample size)

3.3 Inclusion Criteria

1. All adult blunt chest trauma patients with unilateral multiple rib fractures. This is because

patients with bilateral rib fractures are considered to more derangement in the chest wall

biomechanics that is likely to adversely affect their respiratory function beyond what the chest

pain is causing.

2. All adult blunt chest trauma patients with unilateral multiple rib fractures with no associated

major intrathoracic or extrathoracic injury such as head injury, abdominal injury or skeletal

injury. This is simple chest injury (i.e chest wall injury). Associated major intrathoracic and

extrathoracic injuries were conclusively excluded through clinical history, clinical examination

and appropriate imaging tests including plain radiographs and abdominal ultrasonography.

3.4 Exclusion Criteria

1. Patients under 16 years of age. Sixteen years was chosen as the lowest age limit in this study,

because at that age patients enrolled in the study would be able to understand and obey

49

instructions and corporate maximally. The constitution of Nigeria however stipulates that

adulthood begins at 18years of age.

2. Patients who refuse to give consent to participate in the study.

3. Patients with history of sensitivity to either bupivacaine or tramadol hydrochloride, or in

whom adrenaline is contra-indicated. This information was obtained by taking drug history for

allergy during the initial evaluation of the patients. Patients suffering from systemic

hypertension were excluded since adrenaline is contra-indicated in them. These two drugs were

chosen because both of them have been shown in literatures to be effective in the control of

moderate and severe pain which multiple rib fractures can cause. There was also provision of

pentazocine injection on-keep for on-demand purpose for any patient developing break-

through pain during the study period.

4. Patients who sustained associated major injury needing surgical operation or affecting

consciousness level.

5. Patients with pre-existing pulmonary disease

6. Patients with bilateral rib fractures

7. Patients who have haemothorax which on its own can adversely affect pulmonary function.

8. Patients with greater than minor (15%) traumatic pneumothorax which on its own can affect

pulmonary function. This was determined by finding the percentage of the ratio of the

pneumothorax space to the hemi-thoracic diameter. Additionally the minor pneumothorax did

not cause dyspnoea and was expected to resolve spontaneously. The size of pneumothorax can

be objectively quantified by the measurement of the ratio of the lung to the hemithorax diameter

is accurate and relatively easy.44

50

9. Patients with only one rib fracture or greater than six rib fractures. One rib fracture usually

causes mild chest pain, and therefore excluded. Greater than six ribs fractures would have

require about 18 millilitres of 0.5% Bupivacaine since one extra intercostal nerve is usually

blocked above and below the fractured ribs. This high dose places the patient at a higher risk

of toxicity, notably central nervous system toxicity and cardiotoxicity.

10. Patients with flail chest or segmental rib fractures

3.5 Methods

Ethical approval to embark on this study was sought and obtained from the Hospital Research

Ethical Committee (see appendix V).

Informed consent was duly obtained from the patients after adequate explanation.

The study/data collection took place from November 2013 (after approval from NPMCN

(appendix VI) to October 2014

51

On presentation, the successive patients were clinically evaluated and resuscitated. At this point

patients with clinically discovered exclusion criterion/criteria were excluded while those

without were further evaluated with urgent chest radiogram.

Following urgent postero- lateral and oblique chest radiographs to confirm the clinical

suspicion of rib fracture(s) in the appropriate patients with blunt chest injury who met all the

inclusion criteria for the study, the radiographic films were interpreted to ascertain the number

and order of rib fracture(s). The chest x-ray also enables the calculation of abbreviated thoracic

injury severity score, and further decides patients’ eligibility for inclusion in the study.

Successive patients who met the inclusion criteria and who did not have any of the exclusion

criteria were randomised into the regional analgesia and systemic analgesia arms of the study

using computer generated randomisation table from WINPEPI software: intercostal nerve

block (ICNB) with 0.5% Bupivacaine group and the intravenous Tramadol (IVT) injection

group. With the help of WIN PEPI computer software on random allocation, the 64 patients

were allocated into the two study groups based on the serial number given at enrolment. The

randomisation table (appendix III) placed 30 subjects in group ‘A’ (ICNB) and 34 in group ‘B’

(IVT). The randomization was such that it was not possible to know the group for a particular

subject beforehand or to influence the allocation.

Those included were: 1. All adult blunt chest trauma patients with unilateral multiple rib

fractures. 2. All adult blunt chest trauma patients with unilateral multiple rib fractures with no

associated major intrathoracic or extrathoracic injury such as head injury, abdominal injury or

skeletal injury; while those excluded were: 1. Patients under 16 years of age 2. Patients who

refuse to give consent to participate in the study. 3. Patients with history of sensitivity to either

bupivacaine or tramadol, or in whom adrenaline is contra-indicated. This information was

obtained by taking drug history for allergy during the initial evaluation of the patients. Patients

52

suffering from systemic hypertension were excluded since adrenaline is contra-indicated in

them. 4. Patients who sustained associated major injury needing surgical operation or affecting

consciousness level. 5. Patients with pre-existing pulmonary disease 6. Patients with bilateral

rib fractures 7. Patients who had haemothorax which on its own can adversely affect pulmonary

function. 8. Patients with greater than minor (15%) traumatic pneumothorax which on its own

can affect pulmonary function. 9. Patients with only one rib fracture, and 10. Patients with

segmental rib fractures (flail chest).

Appropriate consented patients were then categorised into the two limbs of the study based on

the randomization table (Appendix III). Baseline respiratory rate, peripheral arterial oxygen

saturation (finger pulse oximetry) taken, and pain score on the Zubroid’s 4-point scale were

recorded in the respective patient’s profoma (Appedix I). Three readings of Lung function tests

were also done and the printed reading strip of the best test attached to the profoma. Then for

those on the intercostals nerve block group, two millilitres of 0.5% Bupivacaine injection (1-

2mg/kg body weight) pre-mixed with 1:20000 dilution of adrenaline was used to infiltrate each

intercostal nerve associated with all the fractured ribs and one rib superior and inferior to the

fractured ribs. The blocks were done in the subcostal groove a finger breath lateral to the

paraspinous (spinae erecti) muscles by rib palpation following standard aseptic protocols. For

patients on the intravenous tramadol (IVT) group, 100mg (2-4mg/kg body weight) of tramadol

hydochoride injection was administered intravenously every 8 hours for 24 hours after

swabbing the skin of the selected site with methylated spirit solution. All the patients were re-

assessed at one hour and 24 hours after commencement of analgesic, and all the parameters for

outcome measurements repeated as above and recorded into the individual’s profoma, while

the lung function test reading strips were also attached to the profoma. Patients who had

breakthrough pain and complained were given 30mg of pentazocine injection intravenously.

All patients’ data were collated and analysed using Stata version 10.

53

All patients underwent pre-therapy pain score assessment using a four-point Zubroid scale,

respiratory rate count, pulse oximetry using finger pulse oximeter probe (OHMEDA BRAND)

and bedside spirometry using spirometer (SCHILLER BRAND).

Verbal pain rating scales of Zubroid. This stratifies pain intensity according to levels of

severity. It employs different word descriptions to rate the patient’s pain, e.g no pain (0), mild

pain (1), moderate pain (2), and severe pain (3). These words can be translated to any language.

Numbers are assigned to each of these words for recording and comparison purposes.

These assessments were repeated at one hour and 24 hours after commencement of pain

therapy.

The degree of chest pain was scored by the patients on a four-point scale (no pain = 0, minimal

pain =1, moderate pain =2, and severe pain =3) at rest and during coughing.

Three readings of FVC, FEV1, FEV1/FVC, FEF2575 and PEFR were taken before, one hour

and 24 hours after commencement of analgesia, respectively, using a bedside spirometer and

the mean value calculated and recorded.

SaO2 on room air was measured using a pulse oximeter (Ohmeda) before, one hour and 24

hours after commencement of analgesia.

For all the patients on the regional analgesia arm of the study, intercostal nerve block (ICNB)

was carried out using 0.5% bupivacaine (DURACAINE manufactured by MYUNGMOON

PHARMA with Batch No: E1122 and expiration date: October 2014), to which 1:200,000

dilution of adrenaline was added to reduce the rate of absorption and risk of toxicity and

prolong the duration of action. Two millilitre of 0.5% bupivacaine was injected at each site.

Point of injection was lateral to the para-spinous muscles. The intercostal nerves blocked

included the ones associated with the fractured ribs and one above and below the fractured ribs.

54

Aseptic technique was used for the ICNB procedure. The ICNB was carried out with the patient

in sitting position.

For all the patients on the systemic analgesia arm of the study, 100mg of intravenous tramadol

injection (TRABILIN – 100 manufactured by MEPHA PHARMA with Lot No: L25900 and

expiration date: May 2016) was injected every 8 hours for 24 hours.

30mg of intravenous pentazocine injection was given to any patient on demand as rescue

analgesia for breakthrough pain.

Beyond the period of assessment, all patients continued to receive analgesic for pain control,

and other indicated treatment while on admission and on discharge appropriate treatment also

continued on outpatient basis.

3.6 Evaluation of response and outcome measures

The following outcome measures were compared before and after analgesia and among the two

groups

1. Mean age of the patients in the two arms of the study

2. Sex of the patients in the two arms of the study

3. Mean abbreviated thoracic trauma severity scores of the two groups (see appendix )

4. Mean number of rib fractures among the two groups determined on chest radiogram

5. Mean pain score of the two groups before, one hour and 24 hours after commencement of

analgesia

55

6. Mean SaO2 of the two groups before, one hour and 24 hours after commencement of

analgesia

7. Mean respiratory rate of the two groups before, one hour and 24 hours after commencement

of analgesia

8. Mean FVC of the two groups before, one hour and 24 hours after commencement of

analgesia

9. Mean FEV1 of the two groups before, one hour and 24 hours after commencement of

analgesia

10. Mean FEV1/FVC of the two groups before, one hour and 24 hours after commencement of

analgesia

11. Mean PEFR of the two groups before, one hour and 24 hours after commencement of

analgesia

12. Mean FEF of the two groups before, one hour and 24 hours after commencement of

analgesia

13. Mean FEF25%-75% of the two groups before, one hour and 24 hours after commencement

of analgesia

14. Pulmonary complication rate among the two groups

15. Mortality rate among the two groups

16. Mean need for rescue analgesia (pentazocine injection) among the two groups

17. Complication(s) (if any) of the analgesic technique of the two groups

56

3.7 DATA ANALYSIS

Data generated was entered into proforma sheets (see Appendix I below)

The data were subjected to statistical analysis using STATA Version 10 software. The t-test

was used for continuous variables and the Chi-squared or Fisher's exact tests, when appropriate,

for comparison of proportions. Responses between the two groups were compared at each

evaluation (before, one hour and 24 hours after commencement of analgesia) using the Chi-

squared test. All statistical comparisons between regional and systemic analgesia were two-

sided and carried out at the 0.05 significance level.

CHAPTER FOUR

RESULTS

Table 4-1: The socio-demographic characteristics of adult patients with blunt chest trauma and

multiple rib fractures in UUTH according to mode of pain control

Socio IVT ICNB Total

Demographic n=34 n=30 N=64(%)

Age group (yrs)

16-30 12(18.8) 10(15.6) 22(34.4)

30-50 11(17.2) 10(15.6) 21(32.8)

50-60 8(12.5) 8(12.5) 16(25.0)

Above 60 3(4.7) 2(3.1) 5(7.8)

Mean 41.4 42.2 41.5

Occupation

Commercial cyclists

(including keke napep) 21(32.8) 19(29.7) 40(62.5)

Commercial drivers 3(4.7) 2(3.1) 5(7.8)

57

Civil servants 5(7.8) 3(4.7) 8(12.5)

Schooling 3(4.7) 4(6.2) 7(10.9)

Others 2(3.1) 2(3.1) 4(6.3)

TOTAL 34(53.1) 30(46.9) 64(100)

IVT means intravenous tramadol ICNB means intercostal nerve block

Table 4-1 showed that the age distribution and the occupations of the adult patients with blunt

chest trauma and multiple rib fractures in U.U.T.H. were comparable between the two arms of

the study.

Fig 4-1: Age distribution of patients (in years) with blunt chest injury and multiple ribs fracture

in UUTH

Legend:

16-30 years = 34.4%

30-50 years = 32.8%

50-60 years = 25%

34.4

32.8

25

7.8

16-30

40-50

50-60

above 60

58

Above 60 years = 7.8%

Fig4-2: Sex distribution of the patients with blunt chest injury and multiple rib fractures in

UUTH

Legend:

Male = 54 (84.4%)

Female = 10 (15.6%)

59

Fig 4-3: Types of occupation patients with blunt chest injury and multiple ribs fracture in

UUTH

Legend:

Cyclists = 62.5%

Drivers = 7.8%

Civil servants = 12.5%

60

Students = 10.9%

Others = 6.3%

There were 64 adult patients who were studied with multiple rib fractures caused by blunt chest

trauma. Out of these, there were 54 (84.4%) men and 10 (15.6%) women. Further analysis

shows that among the male young adults and middle age male were very culpable accounting

for up to 94.4% while elderly male accounted for only 5.6%. However among the female

adult victims with multiple rib fractures, the age distribution was even from young adult to

elderly age group (table 4-1, figures 4-1 and 4-2). Table 4-1 and figure 4-3 show the

occupations of the victims of traumatic multiple rib fractures in this study; commercial

motorcyclists (including tricycles popularly called keke napep), all males, accounted for

62.5% of all patients in the study. All the five commercial drivers (7.8%) in the study were

males. This was statistically significant as commercial transportation is regarded as male’s

job. (P<0.0001). The other occupations in the study included civil service, schooling, trading,

technical work, etc, which were few and evenly distributed among both genders.

61

Table 4-2: Types of injury of the adult patients with chest trauma in UUTH according to mode

of pain control

Variables IVT

n=34

ICNB

n=30

Total

N=64

Statistical index

Mechanism of injury

Motor cycle (including

Tricycle)

Motor traffic accident

Fall from height

Others

26 (40.6)

5 (7.8)

1 (1.6)

2 (3.1)

24(37.5)

4 (6.2)

1 (1.6)

1 (1.6)

50 (78.1)

9 (14.1)

2 (3.1)

3 (4.7)

P value=0.628+

No of ribs fractured

Two

Three

Four

Five

Six

7 (10.9)

13 (20.3)

8 (12.5)

5 (7.8)

1 (1.6)

6 (9.4)

12 (18.8)

8 (12.5)

4 (6.2)

0 (0.0)

13 (20.3)

25 (39.1)

16 (25.0)

9 (14.1)

1 (1.6)

P value=0.979+

TOTAL 34(53.1) 30(46.9) 64(100)

62

IVT means intravenous tramadol ICNB means intercostal nerve block

+Fischer’s exact test not statistically significant

Table 4-2 showed that there is no significant difference in the mechanism of injury and number

of ribs involved between the arms of the study

Fig 4-4: Mechanisms of injury in patients with blunt chest injury and multiple ribs fracture in

UUTH

Legend:

Motorcycle (including tricycle) = 78.1%

Motor vehicular accident = 14.1%

Fall from height = 3.1%

Others = 4.7%

63

Table 4-2 and figure 4-4 show the characteristics of blunt chest injuries encountered in the

study. According to mechanism of the blunt chest injury, motorcycle (popularly known as

“okada”) and tricycle (popularly known as keke napap) accidents significantly accounted for

the cause of multiple rib fractures in 50 (78.1%) of the patients. The other causes of multiple

rib fractures encountered in the study were motor traffic accident in nine (14.1%), fall from

height in two (3.1%), and fall into gutter, fall in bathtub, and hit by a falling tree branch in the

remaining three (4.7%) of patients. Again multivariate analysis shows that motor cycle

(including tricycle) accident as a cause of multiple rib fractures was statistically significant

when compared to other causes. (p<0.05)

64

Fig 4-5: Number of ribs fractured in patients with blunt chest injury and multiple ribs fracture

in UUTH

Legend: Number of rib fractures among the 64 patients

Two = 20.3%

Three = 39.1%

Four =25.0%

Five = 14.1%

Six = 1.6%

65

Table 4-2 and figure 4-5 also show that the number of ribs fractured in the 64 patients in the

study which ranged from two to six (mean=3), were not significantly different among the two

sexes and among the two study groups. Also the type of analgesic use did not significantly

differ among the two arms of the study; ICNB 46.9% vs IVT 53.1%.

Figure 4-6: Chest radiograph showing rib fractures in one of the patients with blunt chest injury

and multiple ribs fracture in UUTH

66

Chest radiograph shows fractures of right ribs 5 to 8 (inclusive)

Figure 4-7: Chest radiograph showing rib fractures in one of the patients with blunt chest injury

and multiple ribs fracture in UUTH

67

Chest radiograph shows fractures of right ribs 7th and 8th

Figure 4-8: Chest radiograph showing rib fractures in one of the patients with blunt chest injury

and multiple ribs fracture in UUTH

68

Plain chest radiograph of patient showing fractures of right ribs 6 to 10

Figures 4-6 to 4-8 are chest radiographs showing rib fractures in some of the patients with blunt

chest injury and multiple ribs fracture in UUTH. Chest radiographs were routinely used in the

64 patients in the two arms of the study to confirm the diagnosis of multiple rib fractures,

69

ascertain the fractured ribs for purpose of inclusion into or exclusion from the study. Chest

radiographs also helped in calculation of the abbreviated thoracic trauma severity score and

guided intercostals nerve blocks in the patients in the ICNB arm of the study as shown in figure

4-9 below.

Figure 4-9: Intercostal nerve block procedure on one of the patients with blunt chest injury and

multiple ribs fracture in UUTH following motorcycle accident

Intercostal nerve block procedure with 0.5% Bupivacaine injection being carried out by the

investigator on one of the study subjects

Table 4-3: Respiratory rates of patients on ICNB and IVT at different period of analgesia in UUTH

Respiratory rate

ICNB

n=30 (%)

IVT

N=34 (%)

Total

N=64 (%)

Statistical indices

before analgesia

70

15- 20

21-25

26-30

Above 30

Mean

7 (23.3)

11 (36.7)

12 (40.0)

28.8

8 (23.5)

13 (38.2)

13 (38.2)

28.7

15 (23.4)

24 (37.5)

25 (39.1)

28.8

P value= =0.988

1 hour after analgesia

16-20

21-25

26-30

Above 30

Mean

14 (46.7)

12 (40.0)

3 (10.0)

1 (3.3)

21.5

7 (20.6)

14 (41.2)

7 (20.6)

6 (17.7)

24.8

21 (32.8)

26 (40.6)

10 (15.6)

7 (10.9)

23.2

P value=0.04+

24 hours into analgesia

16-20

21-25

26-30

Above 30

Mean

16 (55.2)

8 (27.6)

4 (10.3)

2 (6.9)

21.4

12 (35.3)

10 (29.4)

6 (19.9)

6 (17.7)

23.9

28 (44.4)

18 (28.6)

9 (14.3)

8 (12.7)

22.8

P value=0.347+

IVT means intravenous tramadol ICNB means intercostal nerve block

Table 4-3 showed that there is no difference in the respiratory rates between the two methods of

analgesia at baseline and at 24 hours but a significant difference at1 hour into analgesia

Table 4-3 shows the respiratory rates of the patients counted and recorded before administration

of analgesic, one hour and 24 hours after commencement of analgesia among the two analgesia

groups. Before administration of analgesic, about the same number of patients in the two arms

had the same classes of respiratory rates. No patient had normal respiratory rate which in this

71

study was taken as 12 – 20 breaths/minute. However at one hour following the administration

of analgesic, there was significant difference in respiratory rates among the two intervention

groups of patients. Firstly, 14 (46.7%) of patients in the ICNB group recorded normal

respiratory rate while only seven (20.7%) had similar response in the IVT group (p=0.04).

Again at one hour reassessment period, there was significant reduction in the number of

patients with respiratory rate >30 breaths/minute in the ICNB group compared to the IVT group

as only one (3.3%) patient in the ICNB group still had respiratory >30breaths/minute at one

hour post analgesic therapy, as opposed to six (17.7%) in the IVT group (p<0.04). At the one

hour post therapy assessment, the reduction in the number of patients recording worse classes

of respiratory rates (example 21 – 25 breaths/minute and 26 – 30 breaths/minute) though not

significantly different among the two treatment groups still showed numerical superiority of

the ICNB group over the IVT group.

Across period evaluation at one hour following commencement of analgesic is an evidence of

the benefit of analgesic in multiple rib fractures. The benefit of analgesic generally on the

normalization of respiratory rate irrespective of route of administration after one hour can be

seen in the two patients’ groups. In 21 (32%) of the 64 patients, the respiratory rate became

normal after single dose of analgesic. There was reduction of worst respiratory rate from 25

(39.1%) of the 64 patients to seven (10.9%) after first dose of analgesic.

At 24 hours following commencement of analgesic, the assessment of respiratory rate shows

continuous improvement in both treatment arms that is only numerically better in the ICNB

group than the IVT group. This therefore means that with repetition of the doses of IVT at 6 –

8 hourly basis within 24 hours, the efficacy approaches and possibly matches that of a single

administration of ICNB using 0.5% Bupivacaine combined with 1:20000 dilution of

adrenaline.

72

Table 4-4: Peripheral arterial oxygen saturation of patients on ICNB and IVT at different period

of analgesia in UUTH

Peripheral arterial

saturation

ICNB

n=30 (%)

IVT

n=34 (%)

Total

n=64 (%)

Statistical indices

Before analgesia

100

99

98

97

96

Mean

2 (6.7)

15 (50.0)

13 (43.3)

96.6

5 (14.7)

14 (41.2)

15 (44.1)

96.7

7 (10.9)

29 (45.3)

28 (43.8)

96.7

P value= 0.594+

1hour after

analgesia

100

99

98

97

Mean

8 (26.7)

12 (40.0)

8 (26.7)

2 (6.7)

98.9

4 (11.8)

8 (23.5)

7 (20.6)

15 (44.1)

98.0

12 (18.8)

20 (31.3)

15 (23.4)

17 (26.6)

98.4

P value=0.006+*

24hour into

analgesia

100

99

98

97

Mean

9 (30.0)

15 (50.0)

6 (20.0)

0 (0.0)

99.1

8 (23.5)

12 (35.3)

13 (38.2)

1 (2.9)

98.8

17 (26.6)

27 (42.2)

19 (29.7)

1 (1.6)

98.9

P value=0.287+

+ Fischer’s exact test * significant p value

IVT means intravenous tramadol ICNB means intercostal nerve block Table

4-4 showed that 1 hour into analgesia the peripheral arterial oxygen saturation of the patients was

significantly different even though it was similar at baseline and at 24 hour into analgesia

According to table 4-4 the peripheral arterial saturation of adult patients with traumatic multiple

rib fractures is adversely affected by chest pain before commencement of analgesic; and at one

hour and 24 hours into commencement of analgesic indicates improvement in respiratory

function following relief of chest pain. Before commencement of analgesic, none of the 64

73

patients recorded up to 99% of oxygen saturation, while about 43.8% recorded oximetry of

96%. However after one hour of administration of analgesic, 18.8% and 31.3% of the patients

recorded 100% and 99% of peripheral arterial saturation after a single dose of analgesic, while

none recorded less than 97% oxygen saturation. This was statistically significant (p=0.006}.

At 24 hours into commencement of analgesic, the improvement in respiratory function was

better with 26.6% and 42.2% of patients having oxygen saturation of 100% and 99% in their

blood respectively. Also no (0%) patient had had 96% while only one (1.6%) patient had 97%

compared to the respective pre-therapy figures of 28 (43.8%) and 29 (45.3%) patients.

Comparison of peripheral arterial saturation among the two intervention groups shows that at

one hour post analgesic therapy eight (26.7%) and 12 (40%) patients recorded 100% and 99%

among the ICNB group while among the IVT group the figures were lower being four (11.8%)

and eight (23.5%) patients respectively. Similarly assessment at one hour post analgesic shows

that all the 13 (43.3%) patients in ICNB group that had pre-therapy oxygen saturation of 96%

improved as well as reduction in the number of those that had oxygen saturation of 97% from

15 (50.0%) to two (6.7%). Among the IVT treatment group although all the 15 (44.1%) patients

with pre-therapy saturation of 96% improved, there was no improvement in the subset of IVT

patients who had oxygen saturation of 97%. At 24 hours post commencement of analgesic,

ICNB still exhibited superiority over IVT as 30.0% vs 23.5% and 50.0% vs 45.3% patients

recorded peripheral arterial saturation of 100% and 99% at 24 hours respectively. No patient

in the ICNB group still had saturation of 96% or 97% while one patient (2.94%) in IVT group

had saturation of 97% at 24 hours after commencement of analgesic.

Table 4-5: Chest pain score of patients on ICNB and IVT at different period of analgesia in

UUTH

Chest pain score ICNB

n=30 (%)

IVT

n=34 (%)

Total

n=64 (%)

Statistical

indices

74

(4-point Zubroid

Scale)

Before analgesia

No pain (0)

Mild (1)

Moderate (2)

Severe (3)

0 (0)

0 (0)

10 (33.3)

20 (66.7)

0 (0)

0 (0)

10 (29.4)

24 (70.6)

0 (0)

0 (0)

20 (31.3)

44 (68.7}

1 hour into analgesia

No pain (0)

Mild (1)

Moderate (2)

Severe (3)

4 (13.3)

21 (70.0)

5 (16.7)

0 (0.0)

0 (0.0)

8 (23.5)

22 (64.7)

4 (11.8)

4 (6.3)

29 (45.3)

27 (42.2)

4 (6.3)

Pvalue<0.0001+*

24 hours into analgesia

No pain (0)

Mild (1)

Moderate (2)

Severe (3)

27 (90.0)

3 (10.0)

22 (64.7)

12 (35.3)

49 (76.6)

15 (23.4)

P value=0.02+

IVT means intravenous tramadol ICNB means intercostal nerve block

Table 4-5 shows that mean pain scores were comparable between the two arms of the study

before administration of analgesic. However at one and 24 hours post analgesic assessments,

the score was significantly lower in the intercostals nerve block group.

Table 4-5 depicts the stratification of the 64 patients with traumatic multiple rib fractures

according to the severity of chest pain on the 4-point Zubroid scale across the study period.

Before the institution of analgesic, 44 (68.7%) of the patients rated their chest pain as severe,

and by one hour after the first dose of analgesic only four (6.3%) patients still had severe chest

75

pain. This was statistically significant with p-value < 0.0001. And by 24 hours of pain therapy

no patient reported severe chest pain. Also before commencement of analgesic no patient

reported zero chest pain or mild chest pain, but at one hour post analgesic assessment four

(6.3%) and 29 (45.3%) patients reported zero and mild chest pain respectively. And by 24 hours

of analgesic up to 49 (76.6%) had only mild chest pain (p=0.02).

Inter-group comparison shows similarity in the pre-therapy severity of chest pain felt by

patients in the two intervention groups. However at one hour after first dose of analgesic four

(13.3%) patients reported zero chest pain and none still had severe pain in the ICNB group.

Comparable figures in the IVT group were none for zero chest pain and four (11.8%) for severe

pain (p<0.0001). Comparing the two modes of analgesia at 24 hours shows that both were able

to mitigate severe chest pain in patients with traumatic multiple rib fractures, but no type of

analgesia studied was able to completely eradicate pain at 24th hour point. It therefore means

that the zero chest pain that was reported by 13.3% of patients one hour after ICNB could not

be sustained at 24th hour due to wearing away of effect of Bupivacaine injection used in the

ICNB. However at 24 hours a single dose of ICNB is probably more effective in controlling

chest pain in traumatic multiple rib fractures than three or four doses of intravenous tramadol

injections. This is supported by the fact that at 24 hour point of pain assessment, 27 (90%) and

three (10%) of patients in the ICNB group had mild and moderate pain respectively. The

respective figures in the IVT group were 22 (64.7%) and 12 (35.3%) patients.

Table 4-6: Percentage predicted of FVC of patients on ICNB and IVT at different period of analgesia

% predicted of FVC ICNB

n=30 (%)

IVT

n=34 (%)

Total

n=64 (%)

Statistical indices

Before analgesia

100

76

91-100

81-90

71-80

61-70

Mean

2 (6.7)

16 (53.3)

8 (26.7)

4 (13.3)

80.8

3 (8.8)

14 (41.2)

12 (35.3)

5 (14.7)

79.9

5 (7.8)

30 (46.9)

20 (31.3)

9 (14.1)

80.3

P value=0.81+

I hour into analgesia

100

91-100

81-90

71-80

Mean

4 (13.3)

24 (80.0)

2 (6.7)

0 (0.0)

96.2

0 (0.0)

20 (58.8)

12 (35.3)

2 (5.9)

90.8

4 (6.3)

44 (68.8)

14 (21.9)

2 (3.1)

93.3

P value= 0.001+*

24 hours into analgesia

91-100

81-90

71-80

61-70

Mean

20 (66.7)

8 (26.7)

2 (6.7)

91.5

22 (64.7)

10 (29.4)

2 (5.9)

91.4

42 (65.6)

18 (28.1)

4 (6.3)

91.4

P value= 1.000+

IVT means intravenous tramadol ICNB means intercostal nerve block +

fischer’s exact test * significant p value

The table 4-6 showed that 1 hour into analgesia the percentage predicted of FVC of ICNB is

significantly higher than that of the IVT, it was similar at before analgesia and 24 hour into analgesia

Table 4-7: Percentage predicted of FEV1 of patients on ICNB and IVT at different period of

analgesia in UUTH

% predicted FEV ICNB

n=30 (%)

IVT

n=34 (%)

Total

n= 64 (%)

Statistical indices

Before analgesia

100

77

91-100

81-90

71-80

61-70

Mean

2 (6.7)

14 (46.7)

9 (30.0)

5 (16.7)

79.8

2 (5.9)

15 (44.1)

12 (35.3)

5 (14.7)

79.6

4 (6.3)

29 (45.3)

21 (32.8)

10 (15.6)

79.7

P value=0.978+

1 hour into analgesia

101-110

91-100

81-90

71-80

Mean

5 (16.7)

21 (80,0)

1 (3.3)

0 (0.0)

97.0

0 (0.0)

19 (55.9)

14 (41.2)

1 (2.9)

90.8

5 (7.8)

40 (67.2)

15 (23.4)

1 (2.9)

93.5

P value<0.0001+*

24 hour into

101-110

91-100

81-90

71-80

Mean

analgesia

19 (63.3)

11 (36.7)

0 (0.0)

101.8

20 (58.8)

12 (35.3)

2 (5.9)

100.8

39 (60.9)

23 (35.9)

2 (3.1)

101.3

P value=0.644+

+ Fischer’s exact test * significant p value

IVT (intravenous tramadol) ICNB (intercostal nerve block)

The table 4-7 showed that 1 hour into analgesia the percentage predicted FEV1 was

significantly different between the two methods of analgesia but were comparable at 24 hour

into analgesia

Respiratory function is adversely affected by chest pain of traumatic rib fractures and gets

improved when the pain is controlled. According to table 6, average forced vital capacity

(FVC) of the 64 patients in the study was low (80.3% of predicted) before commencement of

analgesia. However following administration of analgesic, the FVC of all patients improved

78

with average of 93.3% of predicted at the first hour and 91.4% of predicted at 24 hours. Before

analgesic no patient had FVC prediction > 100%, only five (7.8%) patients had FVC prediction

of 91 – 100% while 29 (45.4 %) patients had <80% prediction. But at one hour, the respective

figures changed to 6.3% of patients having >100% FVC prediction, 68.8% of patients having

91 – 100% FVC prediction, while 25% of patients had <80% of FVC prediction. The increment

at the first hour was statistically significant with p-value = 0.001.

Inter-group analysis of changes in FVC across the monitoring period proved the superiority of

ICNB over IVT. For instance at one hour re-assessment, four (13.0%) patients were able to

achieve FVC prediction >100% of predicted value in the ICNB group while none could in the

IVT group. Also no patient in the ICNB still had FVC prediction <70% while 5.9% of patients

in the IVT group still did. At 24 hours, a single dose of ICNB using 0.5% Bupivacaine was

found to be equally effective in improving respiratory function test of adult patients with

traumatic multiple rib fractures. Though no patient in both treatment groups had FVC

prediction >100%, both treatment groups could boast of an approximate number of patients

with FVC predictions of 91 – 100% (66.7% vs 64,7% : ICNB vs IVT).

The forced expiratory volume at first second (FEV1) aspect of respiratory function test also

exhibited the same pattern as FVC aspect. FEV1 was moderate (mean = 79.7% predicted)

before commencement of analgesic in the population of patients with traumatic multiple rib

fractures. This section of lung function test at the pre- analgesic assessment showed that no

patient recorded >100% of predicted value, 6.3% patients recorded 91 – 100% of expected

while 15.6% patients recorded 61 – 70% of predicted value. The remaining 78.1% of patients

recorded moderate FEV1 value of 71 – 90% of predicted. With the commencement of analgesia,

FEV1 significantly improved from the one hour to the 24 hours re-assessments. At one hour re-

assessment, the mean FEV1 became 93.5% predicted characterized by 7.8% of patients

achieving FEV1 >100% predicted, 67.2% patients achieving 91 – 100% predicted while no

79

patient had low FEV1 of 61 – 70% predicted (p <0.00001). The moderate value of FEV1 (71 –

90% predicted) was recorded in only 26.3% of patients at the one hour re-assessment. The

further analysis of FEV1 component of respiratory function test at 24 hours showed a further

improvement in FEV1 with a mean value of 101.3% predicted. Almost all patients (96.8%)

recorded very high predictive value of FEV1; 91-100% predicted in 35.9% of patients and

>100% predicted in 60.9% of patients. Only 3.1% of patients recorded moderate value of 81-

90% predicted (table 4-7).

Inter-intervention group analysis of patients’ FEV1 showed superiority of ICNB with 0.5%

Bupivacaine over IVT in controlling chest pain in traumatic multiple rib fractures at all re-

assessment periods. At the one hour re-assessment 16.5% of patients in the ICNB group were

able to achieve a FEV1 value >100% of predicted value while none in the IVT group did. For

the range of 91-100% of predicted value of FEV1 the figures were 80.0% versus 55.9% for

ICNB versus IVT. At the same one hour re-assessment period, only 3.3% patients of the ICNB

group had FEV1 predictive value of 81-90%, while no patient had 71-80% of FEV1 prediction.

The respective figures among the IVT treatment group were 41.2% patients with FEV1

prediction of 81-90% and 2.9% patients with FEV1 prediction of 71-80%. This was statistically

significant. The 24th hour comparison of the two intervention groups FEV1 showed some

numerical advantage of ICNB over IVT. Among the ICNB group 63.3% of patients were able

to achieve >100% predicted value of FEV1 while the remaining 36.7% of patients had FEV1 in

the range 91-100% predicted. The equivalent figures for the IVT group were 58.8% patients

having >100% predictive FEV1 and 35.3% patients having 91-100% predictive FEV1. Table 4-

7 shows that at 24 hours following commencement of IVT doses about 5.9% of patients still

had average FEV1 (81-90% predicted).

Table 4-8: Predicted FEV1/FVC of patients on ICNB and IVT at different period of analgesia in UUTH

80

% predicted of

FEV1/FVC

ICNB

n=30 (%)

IVT

n=34 (%)

Total

n=64 (%)

Statistical indices

Before analgesia

100

91-100

81-90

71-80

61-70

Mean

2 (6.7)

17 (56.7)

6 (20.0)

5 (16.7)

80.8

1 (2.9)

16 (47.1)

11 (32.5)

6 (17.7)

79.0

3 (4.7)

33 (51.6)

17 (26.6)

11 (17.2)

79.9

P value=0.690+

1 hour into analgesia

100

91-100

81-90

71-80

Mean

5 (16.7)

20 (66.7)

5 (16.7)

0 (0.0)

95

0 (0.0)

9 (37.5)

12 (50.0)

3 (12.5)

87.5

5 (9.3)

29 (53.7)

17 (31.5)

3 (5.6)

91.7

P value=0.001+*

24 hour into analgesia

100

91-100

81-90

71-80

Mean

22 (73.3)

6 (20.0)

2 (6.7)

91.9

20 (58.8)

10 (29.4)

4 (11.8)

89.7

42 (65.6)

16 (25.0)

6 (9.4)

90.6

P value=0.489+

+ Fischer’s exact test * significant p value

IVT (intravenous tramadol) ICNB (intercostal nerve block)

Table 4-8 showed a significant difference between the FEV/FVC at 1 hour into analgesia between the

two methods of analgesia, while it was comparable at 1st and 24th hour into analgesia

Table 4-8 is the analysis of the FEV1/FVC ratio (FEV1%) of the 64 patients with traumatic

multiple rib fractures extracted from the three spirometric tests done before administration of

analgesic, one hour after administration and 24 hours after commencement of analgesic. Before

analgesic the FEV1% was low among the two arms of the study population with no patient

81

recording FEV1% value >100% predicted, only 4.7% patients recording FEV1% value of 91-

100% predicted, while the majority of patients (78.2%) recorded moderate FEV1% value of

71-90% predicted, and still 17.2% of the patients had low FEV1% value <70% predicted with

pre-anaesthetic FEV1% mean of 79.9% predicted. However one hour after commencement of

analgesia, the repeat FEV1% showed remarkable and significant improvement in both study

arms with the majority of patients (63.0%) having high FEV1% values while the remaining

37.0% of patients had moderate FEV1% values leaving no patient with low FEV1% values

with a p-value = 0.001. At 24 hour re-assessment point majority of patients (65.6%) were still

able to maintain a high FEV1% value of 90-100% predicted, while the remaining 34.4% of

patients had moderate value of 71-90% predicted FEV1%, giving a mean value of 90.6%

predicted FEV1%.

Comparison of the performance of the FEV1% among the two groups of intervention also

suggests superiority of ICNB over IVT across the re-assessment points. At the one hour re-

assessment point, 16.7% of ICNB patients were able to achieve a FEV1% value >100%

predicted whereas no patient in the IVT group did. Again 66.7% of ICNB patients were able

to achieve FEV1% value 91-100% predicted whereas only 37.5% patients in the IVT group did.

And only 16.7% of the ICNB patients had moderate value of FEV1% at that first hour re-

assessment point. These all belonged to the 81-90% predicted range. However up to 62.5% of

the IVT patients recorded moderate value of FEV1% at that first hour re-assessment point in

both 71-80% and 81-90% predicted ranges. At 24 hours re-assessment, 73.3% of the ICNB

patients still had FEV1% of 91-100% predicted while the remaining 26.7% had moderate

FEV1% values. On the other hand 58.8% of the IVT patients were able to maintain high FEV1%

of 91-100% predicted at 24 hours re-assessment, while the remaining 41.2% had moderate

FEV1% values.

82

Table 4-9: Percentage predicted of FEF 25-75% of the patients on ICNB and IVT at different period of

analgesia in UUTH

% predicted of FEF 25-

75%

ICNB

n=30 (%)

IVT

n=34 (%)

Total

n=64 (%)

Statistical indices

83

Before analgesia

100

91-100

81-90

71-80

61-70

Mean

2 (6.7)

14 (46.7)

11 (36.7)

3 (10.0)

80

1 (2.9)

16 (47.1)

13 (38.2)

4 (11.8)

79.7

3 (4.7)

30 (46.9)

24 (37.5)

7 (10.9)

79.9

P value<0.431+*

1 hour into analgesia

100

91-100

81-90

71-80

Mean

4 (13.3)

21 (70.0)

5 (16.7)

0 (0.0)

94.7

0 (0.0)

19 (55.9)

12 (35.3)

3 (8.8)

89.7

4 (6.3)

40 (62.5)

17 (26.6)

3 (4.7)

92.0

P value=0.014+

24 hour into analgesia

100

91-100

81-90

71-80

Mean

20 (66.7)

6 (20.0)

4 (13.3(

90.3

16 (50.0)

9 (28.1)

7 (21.9)

87.8

36 (58.1)

15 (24.2)

11 (17.7)

89.0

P value=.441+

+ Fischer’s exact test * significant p value; IVT (intravenous tramadol) ICNB (intercostal nerve block);

FEF25-75 means forced expiratory flow during the 25-75% interval of forced expiration

Table 4-9 shows FEF25-75 of the two arms of the study to be significantly higher among the ICNB

group only at one hour post analgesic period. The values were comparable between the two groups

before and 24 hours after commencement of analgesic

Table 4-9 depicts the forced expiratory flow during the 25 – 75% interval of forced expiration

(FEF 25-75) of the 64 patients with blunt traumatic multiple rib fractures before administration

of analgesic, one hour after commencement of analgesic and 24 hours after commencement of

analgesic. Before commencement of analgesic, only 4.7% of the patients had FEF 25-75 in the

84

range of 91-100% predicted, while the majority (84.4%) had moderate range (71-90%

predicted) value of FEF 25-75. The remaining 10.9% had low FEF 25-75 value of the range

<70% of predicted value. With commencement of analgesic, the repeated respiratory function

tests showed an improvement in the FEF 25-75 at the re-assessment points. At the first hour

re-assessment, four (6.3%) patients were able to achieve FEF 25-75 value >100% predicted,

another 57 (89.1%) patients achieved moderate range (71-90% predicted) value of FEF 25-75,

leaving 4.7% patients with low FEF 25-75 (<70% predicted) value (about 58% reduction)

which enabled the mean value to appreciate to 92.0% predicted against the pre-analgesia mean

of 79.9% predicted (P-value = 0.014). Assessment at 24 hours also shows maintenance of the

improvement over the pre-analgesia recording. Although no patient had FEF 25-75 value in

the range of >100% predicted, none also had low range (<70% predicted) value. The majority

of the patients (58.1%) still had high FEF 25-75 (91-100% predicted) while the remaining

41.9% patients had moderate (71-90% predicted) range of FEF 25-75 at the 24th hour

reassessment.

The two-prong comparison of the FEF 25-75 values of the ICNB against the IVT sub-groups

across the re-assessment points showed superiority of ICNB over IVT. At the first hour re-

assessment, all the patients that achieve >100% predicted values of FEF 25-75 were from the

ICNB group (13.3%). 70% in the ICNB group against 55.9% in the IVT group achieve a high

(91-100% predicted) FEF 25-75 value, and all the patients that still had FEF 25-75 value in the

range of 71-80% predicted were in the IVT treatment group. The effect of these was a

differential mean of 94.7% predicted FEF 25-75 value of ICNB treatment group against 89.7%

predicted FEF 25-75 value of the IVT treatment group at one hour re-assessment with a p-value

of 0.014. At the 24th hour 66.7% of the ICNB group patients still had high FEF 25-75 value of

91-100% predicted against 50% of patients in the IVT group, whereas the relatively low range

85

of 71-80% predicted FEF 25-75 had 13.3% in the ICNB group patients and 21.9% in the IVT

group patients respectively.

Table 4-10a: Percentage predicted of FEF of patients on ICNB at different period of analgesia in UUTH

%predicted ofFEF Before

analgesia(%)

1 hour into

analgesia(%)

24 hour into

analgesia(%)

Statistical indices

100

91-100

81-90

71-80

61-70

Mean

0 (0.0)

2 (6.7)

14 (46.7)

11 (36.7)

3 (10.0)

80.0

4 (13.3)

21 (70.0)

5 (16.7)

0 (0.0)

0 (0.0)

94.7

0 (0.0)

20 (66.7)

6 (20.0)

4 (13.3)

0 (0.0)

90.3

P value<0.0001+*

IVT (intravenous tramadol); ICNB (intercostal nerve block)

FEF means forced expiratory flow

Table 4-10a shows a significant change in FEF across the period of analgesia in patients receiving ICNB

particularly one hour after intercostal nerve block

Table 4-10b: Percentage predicted of FEF of patients on IVT at different period of analgesia in

UUTH

86

%predicted

ofFEF

Before

analgesia(%)

1 hour into

analgesia(%)

24 hour into

analgesia(%)

Statistical

indices

100

91-100

81-90

71-80

61-70

Mean

0 (0)

3 (8.8)

16 (47.1)

13 (38.2)

2 (5.9)

80.1

0 (0)

9 (26.5)

19(55.9)

5 (14.7)

1 (2.9)

85.7

0 (0)

16 (47.1)

16 (47.1)

2 (5.9)

0 (0.0)

89.0

P value< 0.537+

IVT (intravenous tramadol); ICNB (intercostal nerve block)

FEF means forced expiratory flow

Table 4-10b showed no statistically significant difference in the periods of analgesia among

patients on Intravenous Tramadol

Tables 4-10a and 4-10b depict the forced expiratory flow (FEF) of the 64 adult patients with

traumatic multiple rib fractures recorded before commencement of analgesia, at one hour after

commencement of analgesia and finally at 24 hours after commencement of analgesia. The two

types of analgesia used were ICNB and IVT. Before analgesia, none of the 64 patients achieved

>100% predicted FEF, 32.8% achieved 91-100% predicted, 40.6% achieved 81-90% predicted,

while 21.9% fell into 71-80% predicted and 4.7% into 61-70% predicted range. The mean FEF

of the 64 patients before analgesia was 84.8% of predicted FEF value. Following

commencement of analgesia, the first hour re-assessment showed that 6.3% of the patients

started achieving >100% predicted FEF value, while 62.5% achieved 91-100% predicted FEF,

26.6% patients achieved 81-90% predicted FEF and the remaining 4.7% of patients still had

FEF value of 71-80% predicted. The mean FEF of the 64 patients at one hour after

87

commencement of analgesia was 92.2% predicted which was statistically significant with p =

0.0003. At 24th hour re-assessment, 56.3% of patients had FEF value of 91-100% predicted,

while 34.4% had FEF value in the range of 81-90% predicted and the remaining 9.4% patient

81-90% predicted value of FEF. The mean FEF of all the patients at the 24th hour re-assessment

was 89.0% predicted which was numerically significant over the pre-analgesia mean.

A comparison of the FEF values of patients on the two arms of the study supports superiority

of ICNB over IVT both at the first and 24th hour re-assessment points. At one hour following

commencement of analgesia, a total of four (6.3%) patients achieved a FEF value >100%

predicted, all being from the ICNB treatment group giving an intra-group response rate of

13.3%. No patient in the IVT group had such a response. Another 70.0% of ICNB patients

achieved FEF value 91-100% predicted while only 55.9% of the IVT patients achieved such.

The remaining 16.7% of the ICNB treated patients had FEF value of 81-90% predicted with

no patient in this intervention arm recording lower FEF predicted values at one hour re-

assessment. Whereas at the one hour re-assessment two (5.8%) patients in the IVT treatment

group still had low (71-80% predicted) FEF value. The FEF mean values of ICNB treatment

group and IVT treatment group at the first hour re-assessment were 94.7% predicted and 89.7%

predicted respectively. At 24th hour re-assessment, 66.7%, 20.0% and 13.3% patients in the

ICNB group achieved predicted FEF values of 91-100%, 81-90% and 71-80% respectively

while the equivalent figures for the IVT treatment group were 47.1%, 47.1% and 5.8%

respectively. And the FEF mean values of ICNB treatment group and IVT treatment group at

the 24th hour re-assessment were 90.3% predicted and 87.8% predicted respectively.

Table 4-11: Percentage predicted PEFR of patients on ICNB and IVT at different period of

analgesia in UUTH

% predicted of PEFR ICNB

N=30(%)

IVT

N=34 (%)

Total

N=64 (%)

Statistical indices

88

Before analgesia

100

91-100

81-90

71-80

61-70

Mean

4 (13.3)

13 (43.3)

11 (36.7)

2 (6.7)

81.0

5 (14.7)

14 (41.2)

12 (35.3)

3 (8.8)

81.2

9 (14.1)

27 (42.2)

23 (35.9)

5 (7.8)

81.3

P value=1.00+

I hour into analgesia

100

91-100

81-90

71-80

Mean

6 (20.0)

18 (60.0)

6 (20.0)

0 (0.0)

95.0

0 (0.0)

17 (50.0)

13 (38.2)

4 (11.8)

88.8

6 (9.4)

35 (54.7)

19 (29.7)

4 (6.3)

94.7

P value=0.003+*

24 hour into analgesia

100

91-100

81-90

71-80

Mean

20 (66.7)

6 (20.0)

4 (13.3)

100.3

16 (47.1)

11 (32.4)

7 (20.6)

97.8

36 (56.3)

17 (26.6)

11 (17.2)

99.0

P value= 0.441+

+ fischer’s exact test * significant P value

IVT (intravenous tramadol); ICNB (intercostal nerve block)

Table 4-11 showed that at one hour into analgesia there was a significant difference in

percentage perceived PEFR between patients in ICNB and IVT treatment arms

Table 4-11 shows the changes in peak expiratory flow rate (PEFR) of the 64 adult patients with

traumatic multiple rib fractures before administration of analgesic, and at first hour and 24th

hour following commencement of analgesia. Before analgesia no patient was able to achieve

89

PEFR value >100% predicted while only 9 (14.1%) patients were able to achieve a PEFR value

in the range of 91-100% predicted value. Another 27 (42.2%) patients achieved PEFR value in

the range of 81-90% predicted, 23 (35.5%) patients achieved PEFR value in the range of 71-

80% predicted, while the remaining five (7.8%) patients pre-analgesic PEFR values fell in the

61-70% predicted range. The mean PEFR value of the 64 patients before analgesia was 81.5%

of predicted. At the first hour post analgesic assessment, a total of six (9.4%) patients were able

to achieve PEFR values >100% predicted, while 35 (54.7%) patients achieved PEFR values in

the range of 91-100% predicted, 19 (29.7%) patients achieved PEFR value of 81-90%

predicted, the remaining four (6.9%) patients achieved PEFR value of 71-80% predicted. There

was no more patient with low PEFR score of <70% of predicted value. The mean PEFR value

of the 64 patients one hour after commencement of analgesia was 94.7% of predicted, giving a

p-value of 0.003. At 24 hours re-assessment showed a better improvement over the first hour

performance in PEFR values. For instance 36 (56.3%) patients had PEFR value in the range

>100% predicted, another 17 (26.6%) patients had PEFR score in the range of 91-100%

predicted , the remaining 11 (17.2%) patients had PEFR score in the range of 81-90% predicted,

with a mean of 99% predicted PEFR value. When the average of PEFR value of the 64 patients

at 24th hour re-assessment and pre- analgesic PEFR mean (99.0% predicted vs 81.3% predicted)

are compared, there is statistical significance (p<0.00001).

Inter-therapy groups’ comparison showed superiority of ICNB over IVT significantly at the

first hour re-assessment. For instance the six patients that were able to achieve PEFR value in

the range >100% were all in the ICNB group (20.0%), and none in the IVT group. Again 60.0%

of ICNB group versus 50.0% of the IVT group were able to achieve PEFR value in the range

of 91-100% predicted. And no patient in the ICNB group still had low PEFR value in the range

below 80% predicted whereas up to four (6.3%) patient in the IVT group did. At the one hour

re-assessment the PEFR mean in the ICNB and IVT treatment groups were 95.0% predicted

90

versus 88.8% predicted respectively. The difference was statistically significance (p = 0.003).

The 24th hour re-assessment showed that the ICNB treatment group still had more patients in

the high PEFR range of >100% predicted than the IVT treatment group (66.7% vs 47.1%) and

less patients in the moderate PEFR range of 81-90% predicted than the IVT treatment group

(13.3% vs 20.6%). These still resulted in higher mean PEFR value of ICNB treatment group at

24 hours of treatment than the IVT group: 100.3% predicted versus 97.8% predicted. P-value

= 0.441.

Table 4-12: Mean abbreviated thoracic trauma severity scores for rib fractures of the two groups

No. of rib fracture (point)

ICNB

n=30(%)

IVT

n=34 (%)

Total

N=64 (%)

Statistical indices

2 – 3 (1) 18(28.1) 20(31.3) 38(59.4) p=0.9114

4 – 6 (2) 12(18.8) 14(21.9) 26(40.6)

Mean 1.4 1.4 1.4

IVT (intravenous tramadol); ICNB (intercostal nerve block)

Table 4-12 shows that the mean abbreviated thoracic trauma severity score for rib fractures of the two

groups was low (1.4) and comparable between the two groups of therapy.

Analysis of the two groups of adult patients with multiple rib fractures according to the

abbreviated thorax trauma severity scores (ATTSS) showed that the mean ATTSS was low and

same in the two groups. The abbreviated scoring system only considers unilateral rib fractures

because of the exclusion criteria in the study.

91

There were no complications of rib fractures in the both study groups either within the 24 hours

of study or during subsequent follow – up management. There were also no complications

related to the treatment modalities. The intercostal nerve blocks were devoid of intercostal

neurovascular bundle or lung parenchymal injury. Only one patient in each study arm

demanded for rescue analgesia, and there was no mortality in both arms of the study.

CHAPTER FIVE

DISCUSSION

92

This study involves 64 adults who presented to the Accident/Emergency Department of the

University of Uyo Teaching Hospital in Akwa Ibom State of Nigeria between November 2013

and October 2014 with multiple rib fractures following blunt chest trauma. Over the 12 months

study period there were a total of 2118 cases of trauma, and 205 cases of chest trauma. In this

study chest trauma accounted for 9.7% of all injuries. This was slightly lower than other study

with thoracic traumas comprising 10–15% of all traumas and being the direct causes of death

in 25% of all fatalities due to trauma,9 However only 64 patients with chest trauma met the

inclusion criteria for the study. This study has shown that chest trauma constitutes 9.7% of

traumas in the centre, with 82 cases of rib fractures constituting 40% of chest trauma. This is

in agreement with the Liman et al study which reported rib fractures as the most common

pathologies associated with chest trauma,45 However the 64 patients studied constituted only

31% of chest injury since some cases of rib fractures were excluded from the study. Expectedly

there were more men than women (84.4% vs 15.6%) giving male female ratio of 6.4:1. This is

because 70.3% of the patients were engaged in commercial transportation (commercial

motorcyclists including “okada and keke napep” and commercial drivers) which are

predominantly males’ occupations. Similar male preponderance has been found in other studies

because of motor vehicle accident.3,46 Although in other series analyzing chest trauma and rib

fractures males also predominate partly because of workplace injuries, involvement in crimes

and assaults which men are more likely to venture into.3,47 It can therefore be said that

commercial transportation particularly with the use of motorcycles is an important risk factor

for chest trauma in particular and all types of trauma in general. In this study this was

statistically significant when compared with all other occupation put together (p<0.0001). This

is more so where and when motorcycles are used as a mean of commercial transportation in

the city centres with high volumes of traffic. As part of the strategy to curb the prevalence of

motorcycles and motor vehicles accidents, outright legislation against and restriction on use of

93

motorcycles in the city centres which have been operational in some states in Nigeria, would

help tremendously. Also training and retraining of all motorcyclists on safe riding should be

implemented. For the same reasons alluded to above young adults and middle age men formed

the majority (92.2%) of patients with multiple rib fractures as a result of blunt chest trauma in

this study (mean age = 41.1 years) against the 7.8% elderly people. In the Sirmah et al study,

the mean age of the patients was 43 years.47 The other mechanism of chest trauma and multiple

rib fractures were few and included fall from height, fall in bath-tub, assault, and tripped and

fall. Women also bear the brunch of commercial motorcyclist when they are involved in

motorcycle accident as either passengers or pedestrians.

Studies have shown that plain chest radiographs have sensitivity of about 12-50% and may not

identify all the rib fractures in blunt chest trauma and therefore have suggested the use of chest

computerized tomography and ultrasonography (USG) to diagnose all rib fractures.24,48

However, the present study was limited to chest radiographs for confirmation of rib fractures.

USG was more sensitive in the detection of rib fractures including the chondral rib fractures

compared with chest X-rays that 40% of patients with minor blunt chest trauma had undetected

rib fractures on chest X-rays, which was revealed with USG, and its sensitivity rate reaches up

to 78% compared with 12% detected on chest X-rays.48 Although it was not specified what type

of x-ray was used in that study, it is generally known that the diagnostic yield of rib fracture is

higher with digital x-ray than analog x-ray. Likewise, USG has been shown to be more sensitive

in the detection of chondral rib fractures and cartilage separations compared with chest X-

rays.48 USG can visualize the costal cartilage as well as the osseous part of the rib, and unlike

radiography or bone scintigraphy it avoids ionizing radiation. In addition, unlike computerized

tomography, USG can examine each rib parallel to its long axis, and unlike magnetic resonance

imaging, USG is not affected by respiratory motion. As a non-invasive imaging technique,

USG is also advantageous for its easy transportation and rapid examination.48 Plain chest

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radiographs were used in the present study to show that the 64 patients with multiple rib

fractures studied in the present study had two to six unilateral rib fractures with a mean of three

rib fractures. This is understandable since the mechanism of injury in this study was motorcycle

accident in up to 78%. In motorcycle and pedestrian accidents, the body of the victim is not

protected and comes in direct impact whereas victims in motor vehicular accident have their

body protected by the housing of the vehicle. Thirty four (53.1%) patients underwent

intravenous tramadol injection while the remaining 30 (46.9%) underwent intercostals nerve

block.

Vital signs including respiratory rate and peripheral arterial oxygen saturation measured with

finger pulse oximetry, pain scores, and pulmonary function tests were identical in the two

groups before commencement of analgesics. For instance before analgesia the mean of

respiratory rate was 28.8/minute in the ICNB group and 28.7/minute in the IVT group, with no

patient having a normal respiratory rate. The reason for this is because rib fracture causes sharp

and severe chest pain which is aggravated by breathing. Therefore the patients try to get less

pain by maintaining shallow level of respiration with near - motionless chest wall, which is

compensated for by rapid breathing. Peripheral oxygen saturation of the 64 patients also

showed the same trend giving mean of 96.7% and no patient achieving >98% oximetry before

treatment. Osinowo et al also found low peripheral oxygen saturation in their 21 patients before

ICNB and increase after ICNB.3

However following commencement of analgesia, reassessment showed improvement in these

vital signs in both limbs of the study across the 24 hour assessment period. The respiratory rate

reduced towards normal, and 14 patients and seven patients respectively in the ICNB and IVT

group had normal respiratory rate with overall average of 23.2/minute at one hour, and 16 and

12 patients respectively achieved normal respiratory rate with overall mean of 22.8/minute at

24 hours. The reduction was higher in the ICNB intervention group which had mean respiratory

95

rate of 21.5/minute and 21.4/minute at one and 24 hours respectively compared with the IVT

intervention group which figures were 24.8/minute and 23.9/minute respectively. The

difference in respiratory rate between the two groups was statistically significant at the first

hour (p=0.04). This implies that ICNB is superior to IVT in the control of chest pain of multiple

rib fractures in blunt chest trauma patients. This corroborates the findings of other related

studies.46 According to the 2003 Eastern Association for the Surgery of Trauma (EAST),

regional analgesia for chest pain control after blunt chest trauma and multiple rib fractures

significantly reduces pain scores and improves pulmonary function tests compared to systemic

therapy including intravenous narcotics. Regional analgesia has been shown to result in an

increased functional residual capacity (FRC), lung compliance and vital capacity, a decreased

airway resistance and increased pO2. Regional analgesia is associated with less respiratory

depression, somnolence and gastrointestinal symptoms compared with intravenous narcotics.49

This is worthy of note since it is only one dose of ICNB that is done against three doses of IVT.

Bupivacaine used for the ICNB can act for 6 – 24 hours especially when adrenaline is co-mixed

to prevent rapid systemic absorption and prolong duration of action.6, 49

Peripheral arterial saturation also improved in both study limbs from the pre-analgesic mean

of 96.7% to 98.4% and 98.9% at one hour and 24 hours re-assessment respectively. This

difference was statistically significant (p=0.006 being lower than 0.05). Comparison also

shows superiority of ICNB over IVT in controlling chest pain and improving pulmonary

function (PaO2 of 98.9% and 99.1% vs 98.0% and 98.8%) in multiple rib fractures patients.

Gilart et al noted that pain relief in multiple rib fractures patients is transcendental, as it allows

for proper ventilation, effective cough and adequate respiratory physiotherapy, that intravenous

use of non-steroid and non-opiate anti-inflammatory drugs is quite widespread, although their

side-effects are their main drawback, and loco-regional techniques which include intercostal

nerve block, epidural analgesics vs. opiates (fentanyl, morphine and buprenorphine), local

96

anaesthetics (bupivacaine, ropivacaine) or a combination of both, thoracic paravertebral block

and, much less frequently, intrathecal opioids are some available options.50

Tramadol is of advantage here because it does not cause severe respiratory depression

associated with narcotics or gastritis associated with non-steroidal anti-inflammatory drugs and

is useful for moderate and severe pain.51 Each one has its advantages and disadvantages. The

criteria for selecting the most effective technique include:49

1. Identifying patients at risk of development of respiratory morbidity due to chest

pain from multiple rib fractures of blunt chest trauma

2. Checking the safety and feasibility of the interventional technique in the treatment

centre.

Although invasive, in general, regional blocks tend to be more effective than systemic opioids,

and produce less systemic side effects.4 With the control of chest pain in these patients, there

was improvement in pulmonary function which reflected partly as improvement in the

peripheral arterial oxygen saturation. Osinowo et al also reported same.3

Evaluation of the patients’ pain status also gave credence to pain control following the

commencement of analgesics. At the pre-analgesic stage of assessment, the 64 patients rated

their chest pain as either severe (68.7%) or moderate (31.3%) whereas at one hour after

commencement of analgesic, only 6.3% and 42.2% still rated their chest pain as severe and

moderate pain respectively, while 45.3% had mild pain and 6.3% had no pain. And at 24 hours

all the 64 patients had either no pain (76.6%) or mild pain (23.4%) (table 4-5). The pain control

measured with changes in the pain scores was statistically significant at both periods of re-

assessment (p values <0,0001 and 0.002). This has corroborated the fact that both intravenous

tramadol (IVT) injection and intercostals nerve block (ICNB) using 0.5% Bupivacaine (+

adrenaline) injection can attenuate moderate and severe chest pain of multiple rib fractures.3,51

97

Comparison of efficacy based on changes in pain scores among the two groups of intervention

also showed that ICNB was more effective than IVT at both the one hour and 24 hours re-

assessment periods. This is in support with findings from similar study in other parts of the

world.4, 49, 50, 52 Therefore after identifying patients at risk of development of respiratory

morbidity due to chest pain from multiple rib fractures of blunt chest trauma and checking the

safety and feasibility of the interventional techniques in the treatment centre, this study

advocates preference for ICNB over IVT.

The overall effect of pain control in the 64 patients reflected in the improvement in pulmonary

function measured with lung function machine (spirometer). There were positive improvement

in the various components or the parameters measured during lung function tests over the

baseline (pre-analgesic) values, (tables 4-6 to 4-11). Multiple rib fractures in blunt chest trauma

patients are associated with significant morbidity and mortality as a result of hypoventilation

leading to atelectasis, pneumonia, and respiratory failure. Pain management was first

recognized as an important factor in preventing complications in these patients. Later,

management of the respiratory system became more widely recognized as a major factor in

patients' care. It is now known that patients with multiple rib fractures benefit most from

adequate pain control, rapid mobilization, and meticulous respiratory care to prevent

complications.53

Before administration of analgesic the forced vital capacity (FVC) of the 64 patients was low

with mean of 80.3% predicted value. However at one hour and 24 hours post commencement

of analgesic re-assessment periods, there was improvement in FVC as a direct result of the

effect of relief of chest pain on pulmonary function test. The first hour mean was 93.3% of

predicted value, while the 24th hour mean was 91.4% predicted value. The 24th hour FVC was

91.4% predicted also denoted improvement over the baseline value. Comparing the

improvement in FVC among the two limbs of the study shows better performance in the ICNB

98

group over the IVT group. This is a reflection of the superiority of ICNB over IVT in relieving

chest pain in these patients with traumatic multiple rib fractures. In these patients who have

achieved optimal control of chest pain, respiration is deep enough to open alveoli in all

broncho-pulmonary segments of the lungs and thereby preclude the development of atelectasis,

pneumonia, bronchiectasis, and lung abscess which can progress to respiratory failure and

death which have been noted in a recent study.49

The next and subsequent parameters of the pulmonary function test of the 64 patients with blunt

traumatic multiple rib fractures continued to show consistent post-analgesic improvement over

the pre-analgesic values with statistical significance and better in the ICNB group than in the

IVT group. The forced expiratory volume at first second (FEV1) mean of the 64 patients before

analgesia which was 79.9% predicted became 93.5% predicted at one hour and 101.3%

predicted at 24 hours. A related Saudi Arabian study by Osinowo et al only assessed the

changes in pain score, PaO2, and peak expiratory flow rate of 21 patients with blunt traumatic

rib fractures following ICNB for pain control.3 It was neither a multi-limbs study comparing

ICNB with another mode of pain relief nor full pulmonary function test carried out on the study

subjects.3 In the present study comparison of ICNB and IVT shows that ICNB was more

effective in controlling chest pain which translate to a higher improvement in FEV1 than IVT

at both one hour (97.0% predicted vs 90.8% predicted) and (101.8% predicted vs 100.8%

predicted) 24 hours re-assessment periods respectively.

The FEV1/FVC ratio (FEV1%) also showed the same pattern of changes with the other

components of Lung function test in the study. Before administration of analgesia the mean

FEV1% of the 64 patients was 79.9% predicted which improved following commencement of

analgesia to 91.7% predicted at one hour and 90.6% predicted at 24 hours. FEV1% also

portrayed the superiority of ICNB over the IVT at both re-assessment periods. At the first post

99

analgesic hour the mean FEV1% in the ICNB intervention group was 95.0% predicted while

that of IVT intervention group was 87.5% predicted. At 24 hours the respective figures were

91.9% predicted and 89.7% predicted. The repeated dosing of IVT within the 24 hours against

a single dose of ICNB is thought to be responsible for occasional improvement that is seen in

the 24th hour re-assessment over the first hour assessment in the IVT group.

The FEF 25-75% mean of the 64 patients with blunt traumatic multiple rib fractures before

administration of analgesic was 79.9% predicted value while those at one hour and 24 hours

after commencement of analgesia were 92% predicted and 89% predicted respectively. This

improvement in the post analgesic mean of FEF 25-75% at both the first and 24th hour re-

assessments is in support of improvement in respiratory mechanics made possible by the relief

of chest pain in the patients. Intergroup evaluation of the FEF 25-75% mean also proved the

superiority of ICNB over the IVT at both first hour and 24th hour with values of 94.7%

predicted versus 89.7% predicted and 90.3% predicted versus 87.8% predicted respectively.

Forced expiratory flow (FEF) component of pulmonary function test of the 64 patients who

sustained blunt chest trauma and multiple unilateral improved significantly after administration

of analgesic on the patients when compared to the reading before administration of analgesic

to the patients. Before analgesics the FEF mean of the 64 patients was 80.0% predicted,

whereas following commencement of analgesic administration, the FEF mean was 90.2%

predicted at the first hour and 89.6% predicted at the 24th hour. The difference in the pre-

analgesia FEF mean and the one hour post-analgesia FEF mean was statistically significance

(p<0.0001). When the post analgesic FEF mean was compared in the two intervention groups,

the FEF mean in the ICNB group was unequivocally higher than that of the IVT group at two

periods of re-assessment especially at the one hour re-assessment. At one hour reassessment

the FEF mean of the two groups was 94.7% predicted versus 85.7% predicted respectively,

100

whereas at the 24 hours re-assessment the FEF mean was 90.3% predicted versus 89.0%

predicted respectively. This further supports the superiority of ICNB over IVT.

The last parameter of pulmonary function tests analysed in this study was the peak expiratory

flow rate (PEFR). PEFR is the maximal flow (or speed) achieved during the maximally forced

expiration initiated at full inspiration, measured in litres per minute or in litres per second, and

expressed as percentage of predicted value. The mean PEFR of the 64 patients with blunt chest

trauma and multiple unilateral rib fractures measured before analgesia and two times after

analgesia showed improvement in respiratory function following administration of analgesic

to control chest pain. Before analgesia, the mean PEFR of the 64 patients was 81.3% predicted

value, which got improved to 94.7% predicted at one hour post analgesic, and 99.0% predicted

at 24 hours of commencement of analgesia. The improvement was statistically significant with

p-value of 0.003. Inter-intervention group comparison of the PEFR mean shows that the ICNB

group had higher improvement than the IVT group. At one hour post-analgesic reassessment

the PEFR mean was 95.0% predicted in the ICNB group but 88,8% predicted in the IVT group,

and at 24 hours reassessment the PEFR mean was 100.3% predicted in the ICNB treatment

group but 99.0% predicted in the IVT treatment group.

The abbreviated thorax trauma severity score (ATTSS) for rib fractures used in this study was

adapted from Pape et al.54,55 The mean ATTSS in the two groups of patients was low because

of the stringent selection criteria in the study. Other factors that contribute to ATTSS include

bilateral chest involvement, flail segment, lung contusion, pleural involvement,54,55 which were

excluded in this study (Appendix IV).

Because of the stringent selection criteria adopted in this study, there were no cases of

complications either of the blunt chest trauma or of the treatment. There was also no mortality

amongst the study population. Rescue analgesia demand was also very negligible; one patient

101

each in the two groups. On the overall, the clinical outcome of treatment in both arms was

good. This was however better in the ICNB arm based on better pain control, higher peripheral

arterial oxygen saturation, normalization of abnormal respiratory rates, and higher respiratory

function parameters of the patients following commencement of analgesia.

Blunt chest trauma has been studied extensively in other parts of Nigeria.56-70 The various

studies in different parts of Nigeria have revealed the same socio-economic characteristics of

patients sustaining blunt chest trauma with rib fractures with predominance of male, young age

group and road traffic accident as the predominant cause.56-70 A particular study on blunt chest

trauma in Enugu, Nigeria, specified that intercostals nerve block was the means of pain control

in patients sustaining rib fractures.56 However none of the studies compared intercostals nerve

block with another mode of analgesia, nor assessed the degree of pain relief with analgesic and

its effect on respiratory functions. In a continuing medical education (CME) contribution on

chest injury, Kesieme et al re-emphasizes the advantages of intercostals nerve block and other

regional analgesic techniques for multiple rib fractures following blunt chest injury.68

CHAPTER SIX

CONCLUSIONS

1 The present study was set out to compare the efficacy of regional analgesia using 0.5%

bupivacaine (at a dose of 1-2mg/kg body weight) for intercostals nerve block and systemic

analgesia using intravenous tramadol injection (at a dose of 2-4mg/kg body weight) in relieving

chest pain in adult patients with multiple rib fractures following blunt chest trauma a null and

alternative hypothesis. The study has established the superiority of intercostals nerve block

using 0.5% bupivacaine (co-mixed adrenaline injection to give a dilution of 1:20000) over

102

intravenous tramadol injection in the relief of chest pain in adult patients with multiple rib

fractures following blunt chest trauma with. The relief of chest pain with analgesic was

evaluated with the Zubroid 4-point pain scoring system before and after administration of

analgesic.

2 The study also shows positive correlate between the degree of pain relief and

improvement in respiratory functions including respiratory rate and spirometric parameters in

the two arms of the study. The abnormally high respiratory rates in the multiple rib fractures

patients following blunt chest trauma progressively normalised following commencement of

analgesics. The degree of improvement was also better in the intercostals nerve block group

than in the intravenous tramadol group. Following commencement of analgesics, the various

parameters of lung function tests also improved over the pre-analgesic values measured as %

predicted values. These included forced vital capacity (FVC), forced expiratory volume at one

second (FEV1), ratio forced expiratory volume at one second to forced vital capacity

(FEV1/FVC), forced expiratory flow during the 25 – 75% interval of forced expiration (FEF

25-75), forced expiratory flow (FEF), and peak expiratory flow rate (PEFR). Also the

improvements were better in the intercostals nerve block group than in the intravenous

tramadol group which means superiority of intercostals nerve block with 0.5% bupivacaine

over intravenous tramadol in the relief of chest pain in blunt chest trauma patients with multiple

rib fractures.

3 Therefore the null hypothesis which states that there is no difference between

intercostal nerve block (ICNB) and intravenous tramadol (IVT) in controlling chest pain in

adult patients with blunt chest trauma and multiple rib fractures is hereby rejected while the

alternative hypothesis which states that there is difference between intercostal nerve block

(ICNB) and intravenous tramadol (IVT) in controlling chest pain in adult patients with blunt

chest trauma and multiple rib fractures is accepted. That difference is superiority of intercostal

103

nerve block over intravenous tramadol injection in controlling chest pain in adult patients with

blunt chest injury and multiple rib fractures.

4 The study also shows positive correlation between the degrees of pain relief with

changes in peripheral arterial oxygen saturation in the two limbs of the study. The improvement

in arterial oxygen saturation was more in the intercostals nerve block group which also had

better pain relief figures in comparison with intravenous tramadol injection group.

RECOMMENDATIONS

1. This study recommends the routine use of intercostal nerve block for pain control in

blunt traumatic multiple rib fractures where the expertise and 0.5% bupivacaine

injection are available and there are no contraindications in the patients.

2. Early commencement of analgesic on patients with blunt traumatic multiple rib

fractures to avert onset of pulmonary complications is also recommended.

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APPENDICES

APPENDIX I

PROFORMA FOR DATA COLLECTION: COMPARATIVE STUDY OF REGIONAL AND

SYSTEMIC ANALGESIA FOR PAIN CONTROL IN MULTIPLE RIB FRACTURES IN

ADULT BLUNT CHEST TRAUMA PATIENTS IN UNIVERSITY OF UYO TEACHING

HOSPITAL, UYO, AKWA IBOM STATE, NIGERIA

A) BIODATA

Name --------------------------------------------- Hosp Nos------------------------ Ward-------------

Age ----------------------- Sex ------------------ CXRay Nos ---------------------------------

Occupation --------------------------------------------- Marital Status -----------------------------

111

B) CLINICAL DATA

Date of Presentation:................... Date of Admission:.................. Date of Discharge:................

Presenting Symptoms:..................................................................................................................

......................................................................................................................................................

......................................................................................................................................................

Clinical Diagnosis including mechanism of injury: ....................................................................

......................................................................................................................................................

Radiological Diagnosis: ..............................................................................................................

......................................................................................................................................................

Specification of fractured ribs: ....................................................................................................

Specification of associated injuries if any:...............................................................................

.....................................................................................................................................................

C) ANALGESIC TREATMENT RECEIVED

Type of analgesic: a] Intercostal nerve block [ ]

b] Intravenous tramadol [ ]

Rescue analgesia (intravenous pentazocine): Yes [ ] No [ ]

If yes how many doses: ..................................................

Specify any other treatment received:......................................................................................

112

......................................................................................................................................................

Complication(s) of blunt chest trauma if any:.........................................................................

......................................................................................................................................................

Complication(s) of analgesic technique if any:........................................................................

.....................................................................................................................................................

D) OUTCOME MEASURES

PARAMETE

R

NORMAL

(%

PREDICTED

) VALUES

BEFORE

ANALGESI

A

1 HOUR AFTER

COMMENCEMEN

T OF ANALGESIA

24 HOURS AFTER

COMMENCEMEN

T OF ANALGESIA

Respiratory

rate (/min)

12-20

SaO2 (%) >97

Pain score 0

113

FVC (L) (%

predicted)

≥ 100

FEV1 (L) (%

predicted)

≥ 100

FEV1/FVC

(% predicted)

≥ 100

PEFR (L/s)

(% predicted)

≥ 100

FEF2575(L/s)

(% predicted)

≥ 100

E) OVERALL OUTCOME: ……………………………………………………………………

………………………………………………………………………………………………………..

APPENDIX II

CONSENT FORM FOR COMPARATIVE STUDY OF REGIONAL AND SYSTEMIC

ANALGESIA FOR PAIN CONTROL IN MULTIPLE RIB FRACTURES IN ADULT

BLUNT CHEST TRAUMA PATIENTS IN UNIVERSITY OF UYO TEACHING

HOSPITAL, UYO, AKWA IBOM STATE, NIGERIA

Dear Sir/Madam,

We are conducting a research with two well established methods of pain relief in patients with

multiple rib fracture as a result of blunt chest injury. When completed, the results of this

research shall help us to know the most appropriate method of pain relief for our patients with

multiple rib fractures as a result of blunt chest injury.

114

If you accept to take part in this research, you will receive one of the two methods of pain

relief. Since both methods are well established, there are no harms that you will suffer because

of taking part in this research. If you do not have adequate pain relief with the method of pain

relief you are receiving, you will promptly be given additional treatment for pain. Although the

testing period is only one day, you are also free to discontinue from the research even after you

had accepted to take part in it.

If you have further questions please do not hesitate to ask us or any other doctors.

Please tick in a box below as appropriate:

Consent given [ ] Consent not given [ ]

Name:.................................................................. Signature:.....................................

Hospital number:..................................................

Thank you. Dr. Eyo E. Ekpe

APPENDIX III

RANDOM ALLOCATION OF 64 SUBJECTS (1 – 64) INTO TWO GROUPS: A AND B

USING WIN PEPI COMPUTER SOFTWARE

S/N GRP S/N GRP S/N GRP S/N GRP S/N GRP S/N GRP S/N GRP

1 B 2 A 3 A 4 B 5 B 6 B 7 B

8 B 9 A 10 B 11 A 12 A 13 B 62 A

14 B 15 B 16 B 17 A 18 A 19 A 63 B

20 B 21 A 22 B 23 A 24 B 25 A 64 B

115

26 B 27 B 28 A 29 A 30 A 31 B

32 A 33 A 34 B 35 A 36 B 37 B

38 B 39 A 40 A 41 A 42 B 43 B

44 B 45 A 46 A 47 B 48 B 49 A

50 A 51 A 52 B 53 B 54 A 55 B

56 B 57 A 58 B 59 B 60 A 61 A

APPENDIX IV

The Thorax Trauma Severity Score (TTSS) developed by Pape et al50,51 to predict mortality in

thoracic trauma patients

Grade pao2/fio2 rib fracture contusion pleural involvement age point

0 >400 0 none none <30 0

I 300-400 1-3 1 lobe pt 30-41 1

II 200-300 3-6 2 lobes pt/hpt 42-54 2

116

III 150-200 >3 bilateral <2 lobes pt/hpt 55-70 3

IV <150 flail chest ≥2 lobes tpt >70 5

Abbreviations: PT, pneumothorax; HT, hemothorax; HPT, hemopneumothorax; TPT, tension

pneumothorax; TTSS, Thorax Trauma Severity Score.