Managing Pain in Elderly Rib Fracture Patients (>65 years)

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Managing Pain in Elderly Rib Fracture Patients (>65 years) - #9

Take Quiz

Review an algorithm for pain management of rib fractures.

Assessment

See “Pain Plan” protocol below.  Tap image to view enlarge Pain Plan.
 

Context

Hospitalized elderly patients with rib fractures.

Action

Implement an effective pain management protocol for elderly patients hospitalized with rib fractures.

Incidence / Prevalence

Rib fractures are a common injury for patients presenting to emergency departments with blunt thoracic trauma, with approximately 10% of these patients requiring admission to a trauma center. The Medicare Short-term Stay Survey from 2007 identified nearly 353,000 patients admitted with a rib fracture diagnosis code, with the true incidence of rib fractures likely higher as bony fractures within the thorax are often under-detected using traditional radiography (Simon et. al., 2005). Rib fractures are most often sustained during falls, traffic-related events involving motor vehicles and pedestrians, or crush events involving high energy loads. When rib fractures result from major trauma or high energy loads, concurrent injuries to the heart, lungs, liver and spleen are not uncommon. Mortality rates may range from 3-13% (Carrier et al., 2009), and as high as 18% in patients 65 years and older (Winters, 2009). Age and the number of rib fractures are the strongest predictors of mortality.

Underlying Sciences

Elderly patients are at a greater risk for rib fractures due to decreased bone density with age and osteoporosis, and, to a lesser extent, a greater likelihood of metastatic neoplastic lesions to the bone. Rib fractures elicit intense pain due to the insertion of inspiratory muscles on the rib bone. Inspiration causes force and subsequent movement of the bone, aggravating the fracture and eliciting pain. The patient subsequently limits respiratory tidal volume with a then increased risk of atelectasis, pneumonia, and other pulmonary complications (Bulger et al., 2000). Adequate pain control is the key in prevention of these complications.

Science Principles

Connective Tissue Changes
Impaired homeostasis
Post-mitotic tissue and age related degeneration

Objectives

  1. Explain the underlying etiology of acute rib fracture pain in elderly patients.
  2. List pulmonary complications which may result from poor pain management.
  3. Apply the “Pain Plan” for elderly rib fracture patients correctly in patient care.

Keywords/Tags

References

  1. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. Jun 2000; 48(6):1040-6. http://www.ncbi.nlm.nih.gov/pubmed/10866248
  2. Carrier FM, Turgeon AF, Nicole PC, Trepanier CA, Fergusson DA, Thauvette D, Lessard MR.  Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials.  Canadian Journal of Anesthesiology 2009; 56(3):230-42. http://www.ncbi.nlm.nih.gov/pubmed/19247744
  3. Simon BJ, Chu Q, Emhoff TA, Fiallo VM, Lee KF.  Delayed hemothorax after blunt thoracic trauma: An uncommon entity with significant morbidity.  J Trauma 1998; 45:673-6. http://www.ncbi.nlm.nih.gov/pubmed/9783603
  4. Winters BA.  Older adults with traumatic rib fractures: an evidence-based approach to their care.  J Trauma Nurs. Apr 2009; 16(2):93-7. http://www.ncbi.nlm.nih.gov/pubmed/?term=older+adults+with+traumatic+rib+tractures+an+evidence+based+approach
  5. Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-Related ulcer complications. Am J gastroenterology 2009; 104(3):728-38. http://www.ncbi.nlm.nih.gov/pubmed/19240698
This GFF ___ my competence in geriatrics.

Authors

Jeremy Juern MD, John Petronovich, Travis Webb, MD, Kathryn Denson MD, Bambi Wessel

Author Affiliation

Medical College of Wisconsin, Milwaukee, Wisconsin.

Copyright

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