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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 850-854
Comparing epidural block and intercostal block in patients with 3–4 broken ribs following chest cage blunt trauma


1 Department of Anesthesiology, Arak University of Medical Science, Arak, Iran
2 Department of Surgery, Arak University of Medical Science, Arak, Iran

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Date of Web Publication5-Oct-2017
 

   Abstract 


Introduction: Pain in trauma patients with injuries due to rib fractures and chest trauma is one of the primary goals of management. Through various methods including oral medications, intravenous and intramuscular and different techniques of regional analgesia such as block intercostal, par vertebral block, and epidural block are performed. This study aimed to compare the efficacy of epidural block and block intercostal among patients with rib fractures. Methods: This study was a randomized, double-blind clinical trial involving 82 patients with fractures of the ribs 4-3 visit to Valiasr Hospital, and no pneumothorax as well as hemothorax was carried out. They were randomly divided into two groups of 41 people intercostal block and epidural blocks. In the first group in the thoracic epidural block, using the Marcaine 0.25% 0.3 cc/kg was given. In the second group, posterior dose 0.2 cc/kg Marcaine 0.25% block was given through intercostal. Results: The mean pain score (vascular-space-occupancy, the pain before surgery) was not significantly different between the two groups with respect to P ≥ 0.05. However, compared to the pain in 15 min, 1 h, 2 h, 12 h, and 24 h after block was significantly different between the two groups, according to P ≤ 0.01 and the pain was lower in the epidural block. In terms of age, sex, and chest X-ray changes, there was no significant difference between the two groups (P ≥ 0.05). Conclusion: The results of our study showed the effectiveness of thoracic epidural block in patients with 3–4 intercostals rib fracture which results in blunt trauma.

Keywords: Broken ribs, cage blunt trauma, epidural block, intercostal block

How to cite this article:
Kamali A, Broujerdi GN, Bagheri H. Comparing epidural block and intercostal block in patients with 3–4 broken ribs following chest cage blunt trauma. Ann Trop Med Public Health 2017;10:850-4

How to cite this URL:
Kamali A, Broujerdi GN, Bagheri H. Comparing epidural block and intercostal block in patients with 3–4 broken ribs following chest cage blunt trauma. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 17];10:850-4. Available from: http://www.atmph.org/text.asp?2017/10/4/850/215852



   Introduction Top


Rib fracture is one of the most common damages caused by chest cage blunt trauma.[1] It constitutes up to 10% of all traumatic cases which indicates how vulnerable the chest cage is. As the number of fractured bones increases, the complications and the death toll also goes up.[2],[3] Various research undertaken point to a frequency of 4%–10% for rib fracture among hospitalized traumatic patients. These bone fractures account for 3%–13% of death tolls and 16%–60% of pulmonary complications. Damages caused to the chest cage, particularly several fractures of ribs cause severe pains and restrict patients' ability to cough and breathe deeply. Subsequently and as a result of restriction of respiratory ventilation, pulmonary discharges, atelectasis, pulmonary infections, and pulmonary failures will be inevitable. Pain control in traumatic patients with chest cage damages resulting in rib fracture is one of the primary goals of managing traumatic patient accomplished through various methods such as oral medications such as anti-inflammatory drugs and injected narcotics including opioids and various local analgesia techniques including intercostal block, paravertebral block, and epidural block.[1],[4],[5] Although there is a preference for epidural method in recent guidelines, no specific comparison has been made with other blocks.[4],[5],[6] This method also has complications such as hematoma or abscess in epidural space. Although these complications are not very common, their occurrence is a sign of great danger. Urinary retention, headache, respiratory depression, and nervous damages are some other complications reported.[6] Considering the above-said points and keeping in mind different ideas on the suitable analgesic method following chest cage blunt trauma, we decided to study the reduction of pain score and cardiac complications and the length of hospitalization with two methods of intercostal block and epidural block.


   Materials and Methods Top


All patients with 3–4 fractured ribs reporting to Valiasr Hospital of Arak who had no signs of pneumothorax and hemothorax were randomly divided into two groups. Each group consisted of 41 people where one was treated with intercostal block and the other with epidural block. Those patients qualified for inclusion underwent intercostal block and epidural block treatment according to the table of randomized numbers. Before commencing the research on pain blockade, the informed consent of all patients was obtained. Those patients with pneumothorax and hemothorax or unstable hemodynamics or those who were in a state of shock were excluded from the research. Having taken IV and given 3 cc/kg normal saline, the researchers asked the patients to assume a sitting position. Following prep and drape using 20 G epidural needle (epidural set made by Bibron Co., Germany) in thoracic cavity based on the site of fracture, the patients underwent epidural blockade. Using Marcaine 0.25%, a dose of 0.3 cc/kg was defined for each patient. As for those patients in intercostal group, they were prepared for the procedure after the researchers took IV and gave them 3 cc/kg of normal saline, and the prep and drape processes were completed for them. Using a 22 G needle and considering the site of fracture, nerve blockade in distal area was conducted through the intercostal space. A 0.2 cc/kg dose of Marcaine 0.25% was defined for this process. Having accomplished this block, pulse rate per minute, average arterial blood pressure, and level of oxygen saturation were checked every 15 min. Using the visual analog scale (VAS) ruler, the analgesic score was checked and recorded 15 min, 1 h, 2 h, 4 h, 12 h, and 24 h after the procedure. Finally, the questionnaire including data on patients' demography, their pain score, and the pulmonary or coronary complications following the procedure and length of their hospitalization were analyzed using SPSS version 18 SPSS version 16.0 software (SPSS Inc, Chicago, IL, USA).


   Results Top


Of all the patients studied in intercostal group, 19.5% were female and the remaining 8.5% were male. Similar percentages were also observed in epidural group and as P ≥ 0.05, no significant difference was observed between the two groups in terms of gender [Table 1].
Table 1: Comparing patients in terms of their gender

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No significant difference was observed between the two groups in terms of the age of participants (P ≥ 0.05). The age of the participants in intercostal block group ranged from 17 to 62 years with an average age of 35, whereas the age of those in epidural block groups ranged from 21 to 68 with an average age of 40 years [Table 2].
Table 2: Comparing patients in terms of their age

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No statistically significant difference was observed between the two groups in terms of electrocardiogram (EKG) changes as the analysis indicated in [Table 3].
Table 3: Comparing the patients in both groups in terms of electrocardiogram changes

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Of all the patients studied in both groups, only two (1 in each group) people (2.4%) were suffering from arrhythmia. This is not statistically significant [Table 4].
Table 4: Comparing the patients of both groups in terms of arrhythmia

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The results of chest X-ray (CXR) changes indicate 22% pneumonia and 7.4% atelectasis in intercostal group, whereas a 17.1% pneumonia and 4.9% atelectasis were observed in epidural block group. As P ≥ 0.05, no statistically significant difference was observed between the two groups [Table 5].
Table 5: Comparing both groups in terms of chest X-ray changes

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Based on the analysis conducted in comparison with vascular-space-occupancy (preoperation pain levels), no significant difference was observed between the two groups (P ≥ 0.05). A comparison of pain levels 15 min, 1 h, 2 h, 12 h, and 24 h after operation found lower pain levels in epidural block group as P ≤ 0.01 [Table 6].
Table 6: Comparing both groups in terms of visual analogue scale

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In terms of length of hospitalization, no statistically significant difference was observed between the two groups as P ≥ 0.05 [Table 7].
Table 7: Days of hospitalization for intercostal and epidural groups

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No significant difference was observed between patients suffering from rib fracture following cage chest blunt trauma in both groups in terms of age and gender. EKG changes, arrhythmia, CXR changes, and the length of hospitalization in both groups exhibited no significant difference. However, within 15 min, 1 h, 2 h, 12 h, and 24 h following the block, patients' pain scale according to VAS was less in epidural group (P ≤ 0.01).


   Discussion Top


Identifying a method to reduce the severe pain caused by rib fracture is of great significance. As observed in this research, the pain scale of patients (based on VAS) following intercostal block and epidural block decreased significantly and a 12%–15% reduction was observed in pulmonary complications. No significant difference was observed in any of the two groups in terms of ECG changes and CXR. The pain scale in epidural block group within 15 min, 1 h, 2 h, 12 h, and 24 h following the operation was clearly less. The results of this research are more or less in line with the results of the studies conducted by other researchers. In a research by Carrier et al. titled “the effect of epidural analgesia on patients with rib fracture following trauma,” several randomized clinical trials that compared epidural analgesia with other methods which compared the death rate, length of hospitalization, and length of mechanical ventilation. Epidural analgesia was found to have no major influence on the death rate. The length of hospitalization in this method was comparable to other methods. A shorter period of mechanical ventilation was required in epidural method. Anyway, further research is required to study the weakness and strength of epidural analgesia in this group of patients before considering this method as a standard analgesic method.[4] This research had pointed to a frequency of 16%–60% for pulmonary complications and this number decreased significantly following blockade.[4] Although our research failed to find a statistically significant difference between these two groups in terms of pulmonary complications, we managed to show that epidural block is more effective than intercostal block in terms of reducing the pain scale of those patients with fractured ribs following chest cage blunt trauma. This was statistically significant at P ≤ 0.01. A research by Sanjay et al. confirmed the effectiveness of epidural analgesia as a standard method for durable control of pain.[5] This research sought to compare intercostal block and thoracic epidural analgesia in controlling thoracotomy. Forty patients took part in that research and were randomly divided into two groups. No difference was found between these two groups in terms of their short-term pain control effects, but the analgesic effect of epidural method in controlling pain was more durable.[5] Our research could also prove the effectiveness of this method. Although intercostal block was also reported to be useful and effective in reducing the postfracture pain scale, epidural block was reported to be more effective and useful. In another research by Truitt et al. titled “Continuous intercostal block in rib fracture,” 102 patients took part in a prospective research. Catheter was placed outside the paravertebral thoracic and 0.2% ropivacaine was injected. Number of breaths, pain scale, maximum volume of lung while resting, cough, and length of hospitalization were studied. It finally turned out that this method was capable of improving pulmonary performance and reduce pain and length of hospitalization.[7] In another research by Shuklaa et al. (2008) titled “continuous paravertebral block to reduce pain in unilateral rib fracture,” 11 patients with several unilateral rib fractures took part in a retrospective and nonrandomized research and paravertebral thoracic block was carried out in the site of rib fracture by epidural catheter. The patients were then compared against one another in terms of pain scale while resting and coughing, number of breathes, oxygen saturation, and the scale of changes in spirometry. This research finally introduced continuous paravertebral block as a safe and effective analgesic method for patients with several unilateral rib fractures.[1] Another research was conducted by Hakim et al. to compare lumbar and thoracic injections of epidural morphine for severely isolated chest cage blunt trauma. As many as 55 patients took part in this research and were randomly injected with lumbar or thoracic epidural morphine. Pain scale, the amount of morphine, length of hospitalization, and medical complications were all compared against one another.[2] In a research conducted by Kieninger et al. titled “Comparison between epidural analgesia and injected pain control among the elderly with rib fracture,” people older than 55 with rib fracture were studied in terms of trauma, length of hospitalization, coronary and pulmonary diseases, complications, and type of analgesia. One hundred and eighty-seven patients took part in the research. It was finally concluded that epidural analgesia resulted in a longer period of hospitalization and greater complications among the elderly. Epidural analgesia among the elderly with rib fracture require further prospective examination.[6] In another research carried out by Haenel et al. titled “extra-plural bupivacaine in improving several rib fractures”, as many as 15 patients with at least three fractured ribs following blunt trauma entered the research in a prospective and nonrandomized manner, and epidural catheter was planted in the front area of fractured rib and bupivacaine 0.25% was injected by Epinephrine. The patients were compared against one another in terms of pain scale and spirometry prior and after injection. Continuous nerve block achieved through this method is effective and simple and improved the pain caused by rib fracture. Although no complications were observed in this research, further studies are required.[8] In a research conducted by Osinowo et al. titled “the effect of intercostal block with 0.5% Bupivacaine in maximum exhale and arterial oxygen saturation in patients with rib fracture,” 21 patients were studied in a prospective manner. A major rise in the level of oxygen saturation and the maximum exhale volume was observed following intercostal block which improved respiratory mechanics.[9] In a research conducted by Ho et al., the pain control among patients with rib fracture was studied. They finally reported epidural thoracic, paravertebral thoracic, and intercostal block as favorable methods to treat patients with several rib fractures. They had nearly similar effects in controlling pain. Each method had its weakness and strength, but this research found paravertebral thoracic as the more favorable method.[10] The results obtained in this research were in line with most previous researches. Considering the number of patients studied in this research, future researches are recommended to be carried out with more patients so that more generalizable results may be achieved.


   Conclusion Top


Epidural block is a more effective and safer method to reduce postblunt trauma of chest cage in patients with fib fracture.

Acknowledgment

In the end, the author wishes to thank all the dear staff of the emergency service unit and operation room of Valiasr Hospital of Arak.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Shuklaa AN, Ghaffarb ZB, Auangb AC, Rajahb U, Tanb L. Continuous paravertebral block for pain relief in unilateral multiple rib fracture: A case series. Acute Pain 2008;10:39-44.  Back to cited text no. 1
    
2.
Hakim SM, Latif FS, Anis SG. Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: A randomized open-label trial. J Anesth 2012;26:836-44.  Back to cited text no. 2
    
3.
Truitt MS, Mooty RC, Amos J, Lorenzo M, Mangram A, Dunn E. Out with the old, in with the new: A novel approach to treating pain associated with rib fractures. World J Surg 2010;34:2359-62.  Back to cited text no. 3
    
4.
Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: A systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2009;56:230-42.  Back to cited text no. 4
    
5.
Sanjay OP, Prashanth P, Tauro DI. Intercostal nerve blockade versus thoracic epidural analgesia for post thoracotomy pain relief. Indian J Thorac Cardiovasc Surg 2003;19:141-4.  Back to cited text no. 5
    
6.
Kieninger AN, Bair HA, Bendick PJ, Howells GA. Epidural versus intravenous pain control in elderly patients with rib fractures. Am J Surg 2005;189:327-30.  Back to cited text no. 6
    
7.
Truitt MS, Murry J, Amos J, Lorenzo M, Mangram A, Dunn E, et al. Continuous intercostal nerve blockade for rib fractures: Ready for primetime? J Trauma 2011;71:1548-52.  Back to cited text no. 7
    
8.
Haenel JB, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM. Extrapleural bupivacaine for amelioration of multiple rib fracture pain. J Trauma 1995;38:22-7.  Back to cited text no. 8
    
9.
Osinowo OA, Zahrani M, Softah A. Effect of intercostal nerve block with 0.5% bupivacaine on peak expiratory flow rate and arterial oxygen saturation in rib fractures. J Trauma 2004;56:345-7.  Back to cited text no. 9
    
10.
Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple fractured ribs: A focus on regional techniques. Curr Opin Crit Care 2011;17:323-7.  Back to cited text no. 10
    

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Correspondence Address:
Gholamreza Nouri Broujerdi
Department of Surgery, Arak University of Medical Science, Arak
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_197_17

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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