The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust Clinical Guideline for the Pain Management of Rib Fractures in Adults.

Transcription

1 Clinical Guideline for the Pain Management of Rib Fractures in Adults A Clinical Guideline for use in: By: For: Division responsible for document: Key words: Name of document author: Job title of document author: Name of author s Line Manager: Job title of author s Line Manager: Supported by: Assessed and approved by the: Organisation-wide Doctors, Nurses and Physiotherapists Adult patients with rib fractures Elective - Acute Pain Service Rib fracture, flail, pneumothorax, haemothorax, pulmonary contusion, paravertebral, epidural, serratus, Dr James Stimpson Clinical Lead for Acute Pain Dr Sue Abdy Clinical Director Sr Chris Hedges / Acute Pain Management Nurse Sr Elizabeth Heighton Advanced Nurse Practitioner Pain Management Acute Pain Clinicians / Anaesthetics department Major Trauma Committee Clinical Guidelines Committee Date of approval: 17/12/2015 Ratified by or reported as approved to: To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Reference: Major Trauma Committee Anaesthetics Clinical Governance Committee March 2018 Acute Pain Service RA9 Version No: 1.0 Description of changes: Compliance links: If Yes - does the guidance deviate from the recommendations of NICE? If so why? (for revised versions) (e.g. NICE, CQC) This guideline has been approved by the Trust's Clinical Guidelines Group as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Clinical l Guideline Author/s: Dr Stimpson Author/s title: Clincal Lead for Acute Pain Approved by: CGC Date approved: March 2016 Review date: Page 1 of 16

2 Contents page 1 DEFINITIONS OF TERMS USED / GLOSSARY QUICK REFERENCE PAIN MANAGEMENT OF RIB FRACTURES OBJECTIVE / RATIONALE ASCERTAINING SEVERITY OF INJURY (SCORING) Chest Trauma Score: (Pressley) Rib fracture scoring (Easter): OPTIONS FOR PAIN RELIEF Simple analgesia Systemic opioids Non-opioid analgesia Ketamine REGIONAL BLOCK ANALGESIA Thoracic epidural Thoracic paravertebral Intercostal nerve blocks Intrapleural block Serratus Plane block Lidocaine patches PHYSIOTHERAPY Out of Hours Physiotherapy SURGERY GUIDELINE TRAINING / AUDIT SUMMARY OF DEVELOPMENT AND CONSULTATION PROCESS UNDERTAKEN BEFORE REGISTRATION AND DISSEMINATION REFERENCES APPENDICES APPENDIX 1 MONITORING COMPLIANCE APPENDIX 2 EQUALITY IMPACT ASSESSMENT APPENDIX 3 PLAN FOR DISSEMINATION OF PROCEDURAL DOCUMENTS

3 1 DEFINITIONS OF TERMS USED / GLOSSARY Fractured rib(s) A break through the cortex of a rib Flail segment Two or more fractures along the same rib on the same side Pulmonary contusion Damage to the structural tissue of the lung Haemothorax Presence of blood in the pleural cavity outside of the visceral pleura Pneumothorax Presence of air in the pleural cavity outside of the visceral pleura Epidural Administration of local anaesthetic into the epidural space within the spinal canal, but outside of the dura mater Paravertebral block Administration of local anaesthetic into the paravertebral space, a space lying lateral to the spinal canal through which the intercostal nerves run Intrapleural block Administration of local anaesthetic between the parietal and visceral pleura Serratus block Administration into the fascial planes either above or below the serratus anterior muscle on the upper lateral chest wall Intercostal nerve block Administration of local anaesthetic to the neurovascular bundle situated under the lower aspect of each rib 3

4 2 QUICK REFERENCE PAIN MANAGEMENT OF RIB FRACTURES 4

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6 3 OBJECTIVE / RATIONALE Rib fractures are a common consequence of trauma to the thoracic cage. Primary causes are road traffic accidents, and simple falls in the older person. They are associated with significant morbidity and mortality, especially with more serious injuries. Complications may be increased if adequate pain relief is not provided. This document is intended to provide a rationale and guideline for the pain management of patients with multiple rib fractures. It is written as a reference for all involved in the direct patient care of these patients, including individual consultant anaesthetists, anaesthetic trainees, surgical doctors, emergency department staff, nurses and allied healthcare practitioners. It is available on the intranet to allow all to access it. It includes a flowchart algorithm for ease of use. 4 ASCERTAINING SEVERITY OF INJURY (SCORING) Several scoring systems have been suggested and are used for assessing likelihood of complications related to rib fractures. 4.1 Chest Trauma Score: (Pressley) Points AGE < >65 3 PULM CONTUSION None 0 Unilat Minor 1 Bilat Minor 2 Unilat Major 3 Bilat Major 4 RIB SCORE < >5 3 BILATERAL No 0 Yes 2 Mortality by Chest Score (total n=1361, with 73 mortality or 5.4%) CTS Mortality 2.3% 0.8% 3.2% 5.9% 9.0% 10.4% 15.4% 20.8% 6.3% 12.5% 0% # patients Useful in predicting severity and mortality. 6

7 4.2 Rib fracture scoring (Easter): Rib Fracture score = (breaks) x (sides) + age factor Where the age factor is: Age Score < >80 4 Used to predict severity, and as part of tool to guide pace and requirement for management: RFS score Timing Actions Analgesia Respiratory Activity 3-6 Conservative Simple Incentive Up and mobile spirometry Regular turning 7-10 Progressive PCA Regular turning Aggressive Epidural Initial control As dictated by with As dictated by needs >15 Emergent appropriate needs block, then: Epidural 5 OPTIONS FOR PAIN RELIEF 5.1 Simple analgesia Should be instituted for all rib fractures, and include regular paracetamol and weak opioid. Dihydrocodeine would be preferred as the oral weak opioid due to slightly greater efficacy and better side effect profile. Tramadol may be beneficial if tolerated due to an antineuropathic action and a descending inhibitory tract activation effect. Non-steroidal antiinflammatory drugs (NSAIDs) should be used if not contraindicated. 5.2 Systemic opioids Required for the immediate control of severe pain related to rib fractures, especially of a higher severity. For suitable treatment of severe pain, consider using intramuscular or intravenous morphine. Oral morphine is not suitable for the initial management of severe pain caused by rib fractures; however oral strong opioids may be suitable for the on-going management of severe pain which has been controlled, depending on the severity. 5.3 Non-opioid analgesia NSAIDs should be given if there are no contraindications. 7

8 Consider using gabapentin 300mg tds if pain management likely to be complex or there is pre-existing chronic pain. 5.4 Ketamine Ketamine should be considered for pain which is non-responsive to opioids, especially if a regional block is contra-indicated. This should be commenced with a ketamine trial, detailed in the specific Trust guideline. 6 REGIONAL BLOCK ANALGESIA For all these techniques, please inform the acute pain team to achieve on-going follow-up. If you are unfamiliar with, or untrained in a technique which will be of benefit to the particular patient, then identify someone who can perform the technique at the earliest opportunity. Use this as a training experience. Inability to act is no justification for failure to act. MORTALITY IN THIS GROUP OF PATIENTS IS HIGHER THAN YOU EXPECT! 6.1 Thoracic epidural An exceptionally powerful analgesic mode in the management of rib fractures with a worse severity, or those at higher risk of complications. (See scoring charts and algorithm). Suitable for bilateral rib fractures. Used to allow participation with chest physiotherapy. Involves an experienced anaesthetist inserting a special catheter into the epidural space within the spinal canal. The epidural should be sited at the level of the mid-point of the extent of the fractured rib segments (ie for fractures of T3 to T7, choose T5). The drug of choice for loading AND infusion is levobupivacaine 1mg/ml (with 2mcg/ml Fentanyl) 1.25mg/ml (with 4mcg/ml Fentanyl). Consider using a solution WITHOUT fentanyl (1.25mg/ml plain bupivacaine) in the elderly, confused or with a recent head injury. Should be run for as long as required this will be monitored by the acute pain team. For infusions >48hrs the filters will be changed every 48hrs. Consideration should be given to tunnelling the catheter at time of insertion. Caution in the presence of thoracic vertebral injury (actual or suspected). Contraindications are many see Trust policy for epidurals for further information. 8

9 6.2 Thoracic paravertebral Another powerful analgesic tool for the management of rib fractures with a worse severity, or those at higher risk of complications. (See scoring charts and algorithm). Only suitable for unilateral rib fractures. Used to allow participation with chest physiotherapy. The paravertebral catheter should be sited at the level of the mid-point of the extent of the fractured rib segments (ie for fractures of T3 to T7, choose T5). The drug of choice for loading AND infusion is levobupivacaine 1mg/ml (with 2mcg/ml Fentanyl) 1.25mg/ml (with 4mcg/ml Fentanyl). Use a solution WITHOUT fentanyl (1.25mg/ml plain bupivacaine) in the elderly, confused or with a recent head injury. Should be run for as long as required this will be monitored by the acute pain team. For infusions >48hrs the filters will be changed every 48hrs. Consideration should be given to tunnelling the catheter at time of insertion. 6.3 Intercostal nerve blocks Injections are given at multiple levels to achieve a rapid onset, short acting pain relief. Generally used to provide immediate analgesia in the context of severe pain and respiratory difficulty. Every level must be individually blocked, including 1 level above and below the extent of the injury (ie rib fractures T3-7 need blocks T2 T8). Expect blocks to last 4-6hrs if using levobupivacaine. Caution with local anaesthetic dosing as these blocks have a rapid systemic absorption and may achieve toxic peak levels within 15 minutes if high doses used. Requires monitoring. SUBSEQUENT ACTION NEEDS TO HAPPEN CONSIDER EPIDURAL OR PARAVERTEBRAL CATHETER. 6.4 Intrapleural block An injection of local anaesthetic to within the pleural cavity. Done with a loss of resistance technique by a specialist experienced anaesthetist. Intrapleural blocks are not hugely reliable, and their primary role in the context of fractured ribs is to provide short term pain relief where control is necessary and other routes are not available. 6.5 Serratus Plane block A recently described technique to block the lateral branches of the intercostal nerves as they pass adjacent to the serratus anterior muscle on the upper lateral thoracic wall. A catheter can be placed and infused for the required duration. 9

10 Only reliable for lateral rib fractures. This is an ultrasound guided procedure and must be done by an experienced anaesthetist. 6.6 Lidocaine patches Topical application of lidocaine patches to the thoracic wall has been demonstrated to provide analgesia for rib fractures. However, multiple patches need to be applied, increasing the expense and the risk of adverse effects from systemic plasma lidocaine concentrations. Currently lidocaine patches are not formulary in this Trust for this indication. 7 PHYSIOTHERAPY The aim of rib fracture management is to allow for optimal respiratory function and compliance with chest physiotherapy, in order to reduce atelectasis, small airway collapse, pneumonia and/or respiratory failure requiring ventilation. Following effective pain management, early referral for physiotherapy is advised to assist with Active Cycle of Breathing Techniques, early mobilisation, supportive cough, positioning, Incentive Spirometry, Humidified oxygen or Intermittent Positive Pressure Breathing (Bird) ventilation as appropriate. 7.1 Out of Hours Physiotherapy Patients whose respiratory status would deteriorate without physiotherapy before the start of the next working day should be seen by the On Call Physiotherapist. Clinical indications would include: respiratory depression respiratory Rate > 23/min increased work of breathing retained secretions inability to clear independently deteriorating ABGs decreased SpO2 8 SURGERY Surgical fixation of fractured ribs is not currently offered at this hospital. Our nearest centres for consideration of fixation are thoracics at the Norfolk and Norwich University Hospital, or cardiothoracics at Papworth Hospital. Our major trauma centre at Addenbrooke s Hospital may provide further advice. Indications for surgery include: Flail segment Severely displaced fractures without flail 10

11 Difficulty weaning from mechanical ventilation There is evidence that fixation of severe thoracic wall injuries is associated with reduced length of stay, reduced duration of ventilation, reduced duration on critical care, better control of pain and reduced mortality. Further advice or additional help can be obtained through the Trauma Network Coordination Service. 9 GUIDELINE A flowchart guideline is provided to allow ease of planning of patient care. This includes severity scoring, appropriate referral route, and when to consider alternatives for analgesia. This is available in section 3 above as the quick reference guide. 10 TRAINING / AUDIT No formal training is required following dissemination of this guideline through the surgical and medical wards, and to the admission areas. A review of the outcomes of patients who have a diagnosis coding of rib fracture will be undertaken following the next complete year after implementation. 11 SUMMARY OF DEVELOPMENT AND CONSULTATION PROCESS UNDERTAKEN BEFORE REGISTRATION AND DISSEMINATION The authors listed above drafted this document on behalf of the Acute Pain Service who has agreed the final content. During its development it has been circulated for comment to: Acute Pain Service Anaesthetic Department Trauma Committee Clinical Guidelines Committee Comments were received suggesting minor changes to include appropriate levels of physiotherapy, and amendments to the drug regimes suggested. These were included in this initial version of the document. This version has been endorsed by the Acute Pain Service, Trauma Committee and the Clinical Guidelines Committee. 11

12 12 REFERENCES Easter A. Management of patients with multiple rib fractures. American Journal of Critical Care 2001; 10(5) Sept: Maxwell CA, Mion LC, Dietrich MS. Hospitalized Injured Older Adults Clinical Utility of a Rib Fracture Scoring System Journal of Trauma Nursing 2012; 19(3): Pressley CM, et al. Predicting outcome of patients with chest wall injury. American Journal Surgery 2012; 204(6): APPENDICES 1 Monitoring Compliance 2 Equality Impact Assessment 3 Plan for Dissemination 12

13 14 APPENDIX 1 MONITORING COMPLIANCE Key elements Process for Monitoring By Whom (Individual / group /committee) Responsible Governance Committee /dept Frequency of monitoring Patients managed according to plan c/w total coded patients Audit APS Anaesthetics Clinical Governance Annual 13

14 15 APPENDIX 2 EQUALITY IMPACT ASSESSMENT Equality Impact Assessment Tool STAGE 1 SCREENING Name & Job Title of Assessor: James Stimpson, Acute Pain Lead Date of Initial Screening: 8/12/2015 Policy or Function to be assessed: PAIN MANAGEMENT FOR RIB FRACTURES 1. Does the policy, function, service or project affect one group more or less favourably than another on the basis of: Yes/No Comments Race & Ethnic background Gender including transgender Disability:- This will include consideration in terms of impact to persons with learning disabilities, autism or on individuals who may have a cognitive impairment or lack capacity to make decisions about their care Religion or belief Sexual orientation Age No No No No No No 2. Does the public have a perception/concern regarding the potential for discrimination? If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact Assessment. Signature of Assessor: James Stimpson Date: 8/12/2015 No Signature of Line Manager: Date: 14

15 STAGE 2 EQUALITY IMPACT ASSESSMENT If you have indicated that there is a negative impact on any group, is that impact: 1. Legal/Lawful under current equality legislation? Yes/No Comments 2. Can the negative impact be avoided? 3. Are there alternatives to achieving the policy/guidance without the impact? 4. Have you consulted with relevant stakeholders of potentially affected groups? 5. Is action required to address the issues? It is essential that this Assessment is discussed by your management team and remains readily available for inspection. A copy including completed action plan, if appropriate, should also be forwarded to the Equality & Diversity Lead, c/o Human Resources Department 15

16 16 APPENDIX 3 PLAN FOR DISSEMINATION OF PROCEDURAL DOCUMENTS To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust Title of document: RA9 Pain Management of Rib Fractures Date finalised: 3/2016 Dissemination lead: Print name and contact Previous document No details already being used? James Stimpson (1069) If yes, in what format and where? Proposed action to retrieve out of date copies of the document: To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Anaesthetic dept awareness Intranet Anaesthetic trainees awareness Intranet Intranet Intranet Intranet Consultant body Intranet Dissemination Record - to be used once document is approved Date put on register / library of procedural documents: March 2016 Date due to be reviewed: March 2018 Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date Disseminated: No. of Copies Sent: Contact Details / Comments: