A 35 year-old male is the unrestrained driver during a high-speed MVC with rollover. Injuries include cranial epidural hematoma, non-displaced C3 fracture without evidence of spinal cord injury, grade 4 splenic laceration, non-displaced T6 vertebral body fracture, bilateral hemopneumothoraces with right-sided rib fracture 3-8 and left-sided 3-5 (posterior, displaced fractures), right tibial plateau fracture, and left scapula fracture.
Vent settings are as follow: Rate of 12, CPAP 10, Vt 700mL, FiO2 0.6, P/F ratio=170
This is ICD day number 2, and you are consulted for epidural placement for rib fractures.
1. Is there any other information you would like to obtain during this consult?
2. How would you elect to proceed?
3. What is the state of the evidence for thoracic epidurals in patients with rib fractures? For thoracic paravertebrals?
4. Are there surgical guidelines for the placement of thoracic epidurals in patients with rib fractures?
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There are 2 most important questions: neurological status( ICP, what patient does on exam…) pulmonary status(regardless of the pain). Both questions will predict a success rate for weaning and extubation. No matter how good pain control is if patient is obtunded or has full blown ARDS there is no future in extubation … Most people will probably remove epidural or paravertebral catheter after a week, so it is important to time the placement of those continuous blocks when patient will benifit from it the most : when pt is ready for extubation and need perfect pain control so pain does not cause “splinting” and affect weaning…We have seen quite a few cases when patient had outstanding pain control but remained on the vent for days because of other issues and eventually we had to discontinue RA due to risk of infection….
Regarding the choice between epidural and paravertebrals: 1)trauma patient who can not tolerate hypotension from sympathectomy and fluid boluses due to lung contusion may not do as well with epidural as with paraveretebrals that usually have very little effect on hemodynamic. 2) both techniques have potential for dural puncture but dural puncture is more common with epidural( risk of herniation if ICP is high),3)paravertebral is probably much safer then epidural in regarding of epidural hematoma( most our trauma patients are on lovenox).Having said this we realise that 1)paravertebral has a chance of pneumo so if patient does not have CT yet …2) due to unpredictable spread of local with paravertebral most of the time we place more then one catheter to have a better coverage.So if we deal with multiple bilateral fractures 1 epidural catheter sounds more logical then 4 paravertebral catheter (provided that all other risks are relativelly equal).
At the same time I do not know if our usual logic has any hard data behind it. In general I have seen people doing quite well without any blocks despite multiple rib fractures and seen quite opposite …and it is difficult to predict who will do what.
I wish we organize a prospective studdy to answer this important questions.
Epidurals- hypotension from sympathetectomy, dural puncture a major concern in patients with raised ICP, spinal hematoma
Paravertebrals- pleural puncture and pnuemothorax, epidural spread may occur with large volumes and placing a bilateral paravertebral catheter causes a bilateral sympathectomy similar to an epidural, less risk of spinal hematoma.
When presented with a patient with bilateral fractures, I would prefer an epidural as opposed to a bilateral paravertebral catheter. As Boris mentioned, there are no randomized controlled studies looking at the 2 methods. As surgical protocols, I am not aware of any society driven guidelines.
Here is an article published in journal of trauma looking at the various modalities in managing rib fracture pain
http://journals.lww.com/jtrauma/Abstract/2003/03000/Acute_Pain_Management_of_Patients_with_Multiple.31.aspx