Improving Reliability of Pain Management following Rib

Fracture: Introduction of a Rib Fracture Analgesic Ladder

U n i v e r s i t y Te a c h i n g Tr u s t

M. Harrison - Student Nurse, A. Dwyer - Pain Consultant, M. Howarth - Pain Specialist Nurse
Pain Centre, Salford Royal NHS Foundtion Trust, Stott Lane, Salford M6 8HD

Introduction Methods Implementation

l Following the development of a Trauma Service at our
Trust the Acute Pain Team has seen a tenfold increase
Recognise limitation in the traditional approach of the
1 analgesic ladder. At step 3 consider interventional methods
l Education
Pain
and awareness - collaboration with A&E, Trauma and

in referrals for patients with fractures ribs Pain persists

l Identify pathways of care to highlight patient at risk and refer
l Ribfractures account for more than half of the thoracic to pain management
injuries sustained from non-penetrating trauma Severe pain
l Develop policy for early detection and referral to pain services
(Karmakar and Ho, 2003) 3.Strong opioid
+/- NSAID l Utilise electronic systems to alert to admissions with fractured
l Multiplefractures increase the mortality outcome Moderate Pain +/-adjuvants
ribs
as they may compromise normal movement of the 2.Weak opioid
Mild pain +/- NSAID l Organisation of pain and anaesthetic services to access timely
costovertabral and diaphragmatic muscles causing +/-adjuvants
1.Nonopioid Interventional Pain intervention of pain management.
ventilatory insufficiency (Ziegler and Agarwal, 1994)
+/- NSAID Management
which can result in atelectasis, retention of secretions +/-adjuvants PCA, Epidural,
If a patient has been identifed to have fractured ribs and is being admitted
and possible respiratory failure (Middleton et al, 2003) as an inpatient please contact the Pain Team
Nerve block
l Development of major trauma centre at Salford Royal
and increase number of admissions of patients with Pain decreases
multiple fractured ribs BLEEP Automatic alert email ONLINE
Adapted from the WHO Analgesic Ladder (1986) In hours system Out of hours - on
l Identified delays in access to care (via electronic patient call anaesthetist
Incorporate rib fracture score - to identify appropriate pain
l No
clear pathway in Salford Royal or across the North
West.
2 management
records)

Proposed Rib Fracture Analgesic Ladder

breaks x sides + age factor
Breaks Sides Age factor Conclusion
Proposal Number of Unilateral = 1
<50 years
51-60 years
=0
=1 l Targeted pain management is key in providing the best
fractures
l Produce a collaborative care pathway and policy to Bilateral = 2 61-70 years =2 outcome
71-80 years =3
be used in the Trust and highlight as best practice for l Implementation of the protocol supports professional
>80 years =4
other Trusts to adopt development and evidenced based practice
l Disseminate the fractured rib pathway to stakeholders Adapted from Easters Rib fracture score and protocol (2004)
l Rib fracture analgesic ladder sets out clear guidelines
l Introduce the scoring system and analgesic ladder into
clinical practice to direct and influence care. 3 Combine rib fracture scores and analgesic ladder l Red flag system adopted in emergency department
supports multidisciplinary working and seamless care.
Rib fracture score
Pain management based on rib fracture score and clinical presentation

Aims Pain increases/deterioration

11-15
>15
Emergent References
7-10 Aggressive
l Developa protocol for pain management Progressive
3-6 EPIDURAL 1.Karmakar, M.K., & Ho, A.M. (2003) Acute pain management of patients with multiple
incorporating a scoring system which identifies a C onservative PCA +/- EPIDURAL MANAGEMENT fractured ribs. J Trauma. 54(3), 615-25.
MANAGEMENT
pathway of care ORAL / ADJUVANTS
2.Ziegler, D.W., & Agarwal, N.N. The morbidity and mortality of rib fractures. Journal of
Consider current Surgical
IM ANALGESIA Trauma,37(6), 975-9.
Unilateral :Consider management if
l Pain team have early initial contact with each patient Consider current
health conditions
Intrapleural/
health conditions and if indicated / ail 3.Easter, A. (2001) Management of patients with multiple rib fractures. American journal of
If pain persists/ intercostal analgesia
segment
l Multidisciplinary team collaboration 1st fractured rib
monitor increases consider

critical care,10 (5), 320-327.
epidural

l Improvepatient clinical outcome and overall If pain persists/increases Unable to deep Consider coagulation
experience.
consider PCA breathe/cough

Inspirational Spirometry when stable Pain decreases / improvement

G13071801, Design Services, Salford Royal NHS Foundation Trust - all rights reserved 2013

13071801 final.indd 1 29/08/2013 16:10