Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024
Date: April 19, 2024
Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus.
Case: You are doing great things and helping many patients during your shift in the emergency department (ED) when you hear a trauma alert being called overheard. You walk over to the trauma room, and you see a healthy-looking 52-year-old male complaining of chest trauma after being involved in a motor vehicle collision before arrival. His imaging shows mildly displaced rib fractures of ribs four through seven. He is stable but complaining of pain despite initial IV acetaminophen and ketorolac. You offer him some opioids which he says makes him throw up. He’s been texting with his daughter who is an emergency medicine ultrasound fellow, and she mentioned something about using the ultrasound to inject something to decrease his pain.
Background: We have covered rib fractures once before on the Skeptics' Guide to Emergency Medicine. This was on SGEM#324 looking at using spirometry to guide discharging older patients with rib fractures. The evidence was not robust enough back in 2021 to confidently use this potential tool.
We know that rib fractures are associated with an increased risk of morbidity and mortality – specifically related to hypoventilation-related complications [1]. These risks are particularly higher in the elderly [2].
A clinical decision tool called the STUMBL score was derived and validated by Battle et al in 2014 [3]. It risks stratified older patients with blunt trauma. An attempt was made to externally validate this tool in New Zealand by Murkerji et al 2021 [4]. It did not perform as well which is not unusual for a clinical decision instrument [5].
Rib fractures can cause lung splinting and therefore, pain management is a very important part of the management of rib fractures. In addition to coming with a litany of undesired systemic side effects such as a depressed level of consciousness and decreased respiratory drive, opioid pain medications are also short-acting and require frequent redosing.
With the 2014 CDC declaration that prescription drug overdose is one of the five top health threats, there has been a movement away from opioids as the mainstay of pain management for rib fractures [6]. There have been some studies that looked at the efficacy of alternative pain management strategies, but very few have looked at the efficacy or safety of ultrasound-guided erector spinae plane block.
Clinical Question: How effective and safe is an ultrasound-guided erector spinae plane block in patients with rib fractures?
Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024
Population: Adult patients with confirmed rib fractures and a numeric rating score (NRS) greater than 4, despite routine analgesia.
Exclusions: Allergies to specific medications, penetrating thoracic trauma, pregnancy, infection or laceration at the injection site, specific health conditions (e.g., systolic BP < 100 mm Hg, subcutaneous emphysema at the block site), chronic pain, chronic analgesic use, substance abuse, immediate surgical need, or inability to give consent.
Intervention: Ultrasound-guided erector spinae plane block (ESPB) using a high-frequency linear array transducer. The procedure targeted the transverse process corresponding to the fractured rib, where 0.
The Skeptics Guide to Emergency Medicine