A Retrospective Review of Rib Fracture Pain Management at a London Major Trauma Centre Comparing Erector Spinae Plane Blocks, Serratus Anterior Plane Blocks and Epidurals
Conditions: Rib Fractures, Pain, Acute
Sponsor: Imperial College Healthcare NHS Trust

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       1 
 
Rib fracture pain management at a London Major 
Trauma Centre: 
A retrospective comparison of Erector Spinae Plane 
Blocks, Serratus Anterior Plane Blocks and Thoracic 
Epidurals  
 
A retrospective review of rib fracture 
management at a London Major Trauma 
Centre comparing Erector Spinae Plane Blocks, 
Serratus Anterior Plane Blocks and Epidurals 
V3 06/09/2020 
 
 
Main Sponsor:  Imperial College Healthcare NHS Trust  
                                    Ruth Nicholson, Head of Research Governance & Integrity 
                            Imperial College London 
                            Room 215, Level 2, Medical School Building 
                            Norfolk Place, St Mary’s Hospital Campus 
                            London, W2 1PG 
Funders: N/A 
 
Study coordination centre: St Mary’s Hospital, Paddington 
IRAS ID: 276933 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       2 
Study Management Group 
Chief Investigator: Dr Boyne Bellew 
St Mary’s Hospital, Paddington Co-investigators: Dr Alex Wickham, Dr Sabena 
Qureshi, Dr Claire Broe, Dr Liang Lee, Dr. Andrew Smallbones 
Charing Cross Hospital Co-investigators: 
Dr Richard Doyle 
 
 
Statistician: Mr. Roger A’Hern 
 
Study Coordination Centre 
For general queries, supply of study documentation, and collection of data, 
please contact: 
Study Coordinator: Dr Boyne Bellew 
Address: Department of Anaesthesia & Critical Care, 
                 St Mary’s Hospital, Paddington 
                 Anaesthesia / Critical Care / Theatres, Specialist Services - CPG 3 
                 4th Floor, QEQM Building, St Mary’s Hospital, Praed Street,  
                 London W2 1NY 
 
 
Clinical Queries 
Clinical queries should be directed to Dr Boyne Bellew who will direct the query 
to the appropriate person: boyne.bellew@nhs.net 
 
Sponsor 
Imperial College Healthcare NHS Trust is the main research Sponsor for this 
study. For further information regarding the sponsorship conditions, please 
contact the Head of Regulatory Compliance at: ruth.nicholson@nhs.net 
         
Funder 
No funding 
 
 
 
This protocol describes the retrospective review of rib fracture pain management 
at a major trauma centre. Every care was taken in its drafting, but corrections or 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       3 
amendments may be necessary. These will be circulated to investigators in the 
study.  
This study will adhere to the principles outlined in the Data Protection Act 2018 
and General Data Protection Regulations (Europe) and other regulatory 
requirements as appropriate.  
 
Glossary of Abbreviations 
TARN 
Trauma Audit & Research Network 
ESPB 
Erector Spinae Plane Block 
SAPB 
Serratus Anterior Plane Block 
MTC 
Major Trauma Centre 
ICU 
Intensive Care Unit 
TEA 
Thoracic Epidural Analgesia 
NIV 
Non-Invasive Ventilation 
 
 
 
Keywords : Trauma, rib, fracture, analgesia 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       4 
Study Summary 
Title 
Rib fracture pain management at a London Major Trauma 
Centre, a retrospective comparison of Erector Spinae Plane 
Blocks, Serratus Anterior Plane Blocks and Thoracic Epidurals 
Design 
Single centre retrospective cohort study 
Aims 
To determine whether novel fascial plane blocks, i.e. SAPB 
and ESPB, are safe and effective in patients with rib fractures. 
Outcome Measures 
What are the effects of novel regional anaesthesia blocks on: 
- Proportion of patients with a reduction in pain 
- Pain scores 
- Opioid use 
- Nausea & vomiting 
-Lung complications due to pain 
-ICU admission for respiratory complications,  
- Use of NIV/invasive ventilation 
--Block related complications 
Population 
Males and Females 
Eligibility 
Patients aged over 18 with rib fractures 
Duration 
Retrospective review of 5 year period of outcome data 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       5 
Contents 
1. Introduction 
1.1 Background……………………………………………………………………………………………………………………….6 
1.2 Study Rationale…………………………………………………………………………………………………………………6 
       
2. 
Study Objectives .................................................................................................................................. 7 
2.1 
Primary Objective .............................................................................................................................. 7 
2.2 
Secondary Objectives ......................................................................................................................... 7 
3. Study Design ............................................................................................................................................ 7 
4. 
Study Outcome Measures .................................................................................................................... 7 
5. 
Regulatory Issues ........................................................................................................................... 10 
5.1 
Ethics approval ......................................................................................................................... 12 
5.2 
Consent .................................................................................................................................... 12 
5.3 
Confidentiality .......................................................................................................................... 12 
         5.4  Indeminity……………………………………………………………………………………………………………………………..11 
         5.5  Sponsor………………………………………………………………………………………………………………………………….12 
5.6 
Funding ........................................................................................ Error! Bookmark not defined. 
5.7 
Audits ....................................................................................................................................... 13 
6. Study Management ........................................................................................................................... 13 
7. Publication Policy .............................................................................................................................. 13 
8. REFERENCES ...................................................................................................................................... 14 
Appendix A. Imperial NHS Acute Rib Fracture Pathway……………………………………………………………… 15-32 
 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       6 
1. Introduction 
1.1 Background 
 
Rib fractures are commonly seen in Trauma Centres around the world, making up two thirds of 
all chest trauma admissions1. In the United Kingdom, 15,000 patients attend hospital with rib 
fractures annually according to Trauma Audit and Research Network figures. More than a third 
of these cases develop either short term and or long-term complications, including pneumonia, 
respiratory failure and chronic pain2. Complications typically arise due to poor pain relief in the 
acute setting. 
Pain from rib fractures restricts chest wall movement leading to hypoventilation and impaired 
coughing ability, which leads to sputum retention and mucus plugging. The injured lung tissue 
under the fractures also has impaired gas exchange and may contain blood. This causes 
shunting of blood, ventilation perfusion mismatch, and reduced compliance3. These combine 
to cause atelectasis and increase patients’ predisposition to pneumonia. Pneumonia affects up 
to 30% of patients, with or without sepsis, causing further respiratory compromise. The 
combination of hypoventilation, atelectasis and/or lobar collapse and impaired gas exchange 
results in hypoxaemia, respiratory failure and, in some cases, a need for mechanical 
ventilation. These complications typically develop over 48 – 72 hours following injury4-7. The 
provision of adequate analgesia is widely viewed as a key priority in managing rib injury 
patients to facilitate improved respiratory effort and enable chest physiotherapy for 
rehabilitation after rib fractures. 
1.2 Study Rationale 
 
Thoracic epidural analgesia (TEA) is widely considered to be the current gold standard 
treatment for rib fracture pain and is used in the Imperial invasive treatment pathway for rib 
fractures. 1,7 However, TEA are often contraindicated due to other injuries or the use of 
anticoagulant medications, which also contraindicates other invasive nerve block techniques 
e.g. paravertebral catheters. A number of case reports have reported the safe use of 
alternative techniques such as SAPBs and ESPBs8 and the anaesthesia community has taken 
them up widely based on this relatively limited evidence. In view of this, Womack et al recently 
published a large retrospective review examining the safety and efficacy of ultrasound guided 
paravertebral catheter analgesia techniques in rib fracture management along with small 
numbers of ESPBs9. However, this data did not report the analgesic efficacy, patient reported 
pain relief or respiratory complications. We wish to advance this body of evidence by reviewing 
our larger data set concerning the use of TEA and alternative regional techniques such as ESPB 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       7 
and SAPB. This comprehensive review will benefit patients by documenting the efficacy and 
safety of these techniques for clinicians managing rib fracture patients. 
2. Study Objectives 
2.1 Primary Objective 
Our primary objective is to examine whether novel fascial plane blocks, e.g. SAPB and ESPB, are 
effective pain relief modalities in patients with rib fractures  - the proportion of patients with a 
reduction in pain. 
2.2 Secondary Objectives 
 
We will review the safety profile and complications of TEA and alternative analgesic techniques 
such as ESPB and SAPB used for rib fracture management in our trauma centre. In particular, 
we will examine the effects of regional anaesthesia techniques on: 
1) Opioid use 
2) Nausea & vomiting 
3) Respiratory complications 
4) Intubation & non-invasive ventilation (NIV) 
5) ICU admission for respiratory complications 
We will assess the duration of use and complication profile of regional anaesthetic techniques, 
including infection, analgesic failure and damage to other structures during insertion e.g. the lung. 
3. Study Design 
 
3.1 Design & Purpose 
A single centre retrospective anonymised data study of a 5 year cohort of rib injury patients 
managed in a major trauma centre within the Imperial College Healthcare Trust. 
3.2 Data Collection & Methods 
Records will be identified by searching the Trauma Audit and Research Network (TARN) 
database, a routinely collected database of all patients admitted with traumatic injury within 
the Imperial College Healthcare Trust. This will be collected by the ICHT TARN co-ordinator. The 
TARN database provides basic demographic and injury data including hospital number. We will 
use this information to identify the cohort of patients who were triaged to the Imperial College 
Healthcare Trust invasive rib fracture care pathway. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       8 
Individual patient data will then be obtained from the electronic health record (Cerner) using 
the patient’s hospital number. The data will be pseudo-anonymised and will be collected by 
members of the study team, all of whom are NIHR Good Clinical Practice trained members of 
the direct care team. Data will be reviewed and stored on password protected NHS desktop 
computers in a folder only accessible to members of the study team. Any hard copies of 
patient data will be stored in a locked filing cabinet within a secure NHS office in St. Mary’s 
Hospital. The study will be conducted from 30/09/2020 until the 31/01/2021. We plan to 
review rib injured patient’s electronic notes that have received these interventions from 
January 2016 until December 2019 and categorise the information for analysis as set out in 
study outcomes. Our sample size is estimated at 1200 participants, as per the TARN co-
ordinator.  This information will allow us to assess the safety and efficacy of these alternative 
techniques as compared to TEA. 
3.3 Inclusion Criteria 
• Patients aged > 18 years of age presenting with traumatic rib fractures in a major 
trauma centre over the past 5 years 
• Meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture 
management pathway' (see Appendix A) 
3.4 Exclusion Criteria 
• Under 18 years old 
• Prisoners 
• Pregnant 
• Private patients 
• Meet the criteria for the Imperial College Healthcare NHS Trust 'Non-invasive rib 
fracture management pathway' (see Appendix A) 
3.5 Data Analysis 
ESP Block (N=~40) : The primary hypothesis is that the proportion of patients showing lower 
pain scores 48-72 hours relative to pain scores at baseline is 70% (approximately 2 out of 3) or 
more. A rate of 50% or less (1 in 2) would be considered unsatisfactory. With 40 patients it is 
possible to achieve 80% power at the 5% significance level to distinguish between these two 
scenarios. The probability that 26 or more of the 40 patients have lower 48-72 hour scores if 
the true rate is 70% is 81%, if the true rate is 50% there is a 4% chance this will occur. The 
lower one-sided 95% confidence limit will be presented for the proportion of patients showing 
lower pain scores at 48-72 hours relative to pain scores at baseline, this estimate will provide a 
lower limit for the success rate. 
   
SAP Block (N=~35): Similar considerations to those ESPB apply, but in this case the true 
proportion showing lower pain scores at 48-72 hours would need to be 75% or more to 
confidently show that the true rate is greater than 50%. For example, the probability that 23 or 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       9 
more of the 35 patients have lower 48-72 hour scores (if the true rate is 75%) is 92%, if the true 
rate is 50% there is a 4.5% chance this will occur. 
 
TEA (N=~250) 
 
The large number of subjects in this group means that the aim of distinguishing 70% versus 
50% success rates can be confidently achieved, with a power of more than 99% at the 5% 
significance level. 
 
 
Generally, for binary endpoints, 95% confidence intervals for the proportions of at most +/- 
17% can be estimated for SAP Block subjects, +/- 16% for ESPB subjects and +/- 7% for TEA 
subjects. 
 
4. Study Outcome Measures 
 
4.1 Primary Outcome Measure 
We aim to review pain scores as recorded by clinical staff over 72 hours to assess 
pain relief efficacy, A verbal rating scale classifying pain as mild, moderate or severe is 
used at Imperial  Data from the acute pain round records will also provide details 
regarding breathing comfort levels of the patient, coughing ability and deep inspiratory 
effort. These are recorded as yes/no answers and we will assess the proportion of 
patients showing a reduction in pain scores. 
 
4.2 Secondary Outcome Measures 
4.2.1 Indication for the nerve block 
All patients with rib fractures who met the criteria for the invasive rib fracture care pathway as 
set out in Appendix A. The diagram below describes the main criteria for allocation to the 
invasive or non-invasive pathway for rib fracture pain management. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       10 
 
 
4.2.2 A marker of injury severity e.g. Battle score 
 
  
4.2.3 Morphine based products/other analgesic medications used 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       11 
Data regarding type of opiate use, mode of delivery, dosage requirement in 24 hours and 
complications associated with opiates such as constipation, delirium and respiratory 
depression. 
4.2.4 Nausea & vomiting 
The incidence of nausea and vomiting pre-chest wall block and in the 72 hours post block will 
be recorded with the number of episodes and number of anti-emetic medications required to 
treat. 
4.2.5 Lung complications as a result of pain 
     1) Lower Respiratory Tract Infection (LRTI): for this study is defined as  patients showing 
clinical features of  chest infection including pyrexia (temperature >37.5°C), an increase in 
oxygen requirements from baseline, radiological evidence of chest infection or antimicrobial 
treatment of an LRTI started by the treating team. 
    2) Empyema/Parapneumonic effusions: defined as radiological evidence of fluid collections 
within the pleural space and therapeutic interventions required for treatment e.g.  aspiration 
and drainage. 
4.2.6 Intensive care admission  
- ICU admission for respiratory complications  
-Number of patients requiring intubation and ventilation 
- Number of days of mechanical ventilation 
-Length of ICU stay 
4.2.7 Other nerve block complications 
1) Block failure: defined as persistent moderate to severe pain following insertion of TEA, ESPB 
or SAPB catheters in spite of adequate dosing of analgesia at any time after initial placement. 
2) Number of catheter resiting events 
3) Number of catheter top-ups required within a 24 hour period 
4) Regional anaesthetic catheter associated infection 
5) Pneumothorax secondary to regional anaesthesia technique 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       12 
5. Regulatory Issues 
5.1 
Ethics approval 
The Chief Investigator has obtained approval from the Health Research Authority. The study 
must also receive confirmation of capacity and capability from each participating NHS Trust 
before starting the study. The study will be conducted in accordance with the 
recommendations for physicians involved in research on human subjects adopted by the 18th 
World Medical Assembly, Helsinki 1964 and later revisions 
5.2 
Consent  
 
This is a retrospective case notes review study. This data is collected as routine care and for the TARN 
database. As the study only involves retrospective data collection at a single time point that will not 
impact clinical care, obtaining informed consent is not necessary. The only personal identifiable 
information we intend to collect is the hospital number, which is pseudonomyised. Each patient has a 
unique number according to their order within the data excel spreadsheet and the link to these will be 
recorded and stored on a password protected disc stored on password protected NHS Trust computers 
accessible only by members of the study team. 
5.3 
Confidentiality 
This is a retrospective pseudo-anonymized data collection study of available clinical data so no 
consent is needed. Data will be extracted and reviewed by members of direct care team who 
are also members of the research team. Only anonymized data will be analysed and published. 
All identifiable information will be securely held in NHS Trust computers and there will be held 
in strict compliance to NHS Data Protection and Confidentiality regulation. The Chief 
Investigator will preserve the confidentiality of participants taking part in the study and is 
registered under the Data Protection Act. Data and all appropriate documentation will be 
stored for 5 years after the completion of the study, including the follow-up period. If data is 
missing this will be stated and not included in the final data analysis.  i 
We will employ the use of passwords to restrict access to electronic documents and store hard 
copies of study documents in a locked cabinet in secured location within the anaesthetic 
department at St Mary’s Hospital. The data will only be accessible by the research team 
involved in the project. Only pooled population data will be used in outputs. 
5.4 Indemnity 
 
Imperial College Healthcare NHS Trust holds standard NHS Hospital Indemnity and insurance 
cover with NHS Resolution for NHS Trusts in England, which apply to this study 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       13 
5.5 Sponsor 
Imperial College Healthcare NHS Trust will act as the main Sponsor for this study. Delegated 
responsibilities will be assigned to the NHS trusts taking part in this study. 
5.6 Funding 
No funding is required for this study. 
5.7 
Audits  
The Joint Research Compliance Office, Imperial College London Imperial College Healthcare 
NHS Trust may audit the study. 
 
6. Study Management 
The day-to-day management of the study will be co-ordinated through Dr Boyne Bellew.   
7. Publication Policy 
The study results will be presented at specialty conferences and published in a peer reviewed 
anaesthetic journal. No patient identifiable information will be included. 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       14 
8. REFERENCES 
 
1. Simon, B. J. et al. (2005) ‘Pain Management Guidelines for Blunt Thoracic Trauma’, The Journal 
of Trauma: Injury, Infection, and Critical Care, pp. 1256–1267. doi: 
10.1097/01.ta.0000178063.77946.f5. 
 
2. The Trauma Audit and Research Network. Performance comparison: northern. 2018. 
www.tarn.ac.uk/Content.aspx? ca=15&c = 3468 (accessed 01/06/2018). 
 
3. Ahn, Y. et al. (2013) ‘Pain-associated Respiratory Failure in Chest Trauma’, Anesthesiology. The 
American Society of Anesthesiologists, 118(3), pp. 701–708. doi: 
10.1097/ALN.0b013e318283996b. 
 
4. Barnea, Y. et al. (2002) ‘Isolated rib fractures in elderly patients: mortality and morbidity.’, 
Canadian journal of surgery. Journal canadien de chirurgie. Canadian Medical Association, 
45(1), pp. 43–6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11837920 (Accessed: 4 
June 2019). 
 
5. Jones, K. M., Reed, R. L. and Luchette, F. A. (2011) ‘The ribs or not the ribs: which influences 
mortality?’, The American Journal of Surgery. Elsevier, 202(5), pp. 598–604. doi: 
10.1016/J.AMJSURG.2010.09.029. 
 
6. May, L., Hillermann, C. and Patil, S. (2016) ‘Rib fracture management’, BJA Education. Narnia, 
16(1), pp. 26–32. doi: 10.1093/bjaceaccp/mkv011. 
 
 
7. Witt CE, Bulger EM (2017) ‘Comprehensive approach to the management of the patient with 
multiple rib fractures: a review and introduction of a bundled rib fracture management 
protocol’ Trauma Surgery & Acute Care Open 2017;2:e000064. doi: 10.1136/tsaco-2016-000064  
 
8. Adhikary, S. D. et al. (2019) ‘The effect of erector spinae plane block on respiratory and 
analgesic outcomes in multiple rib fractures: a retrospective cohort study’, Anaesthesia. John 
Wiley & Sons, Ltd (10.1111), 74(5), pp. 585–593. doi: 10.1111/anae.14579. 
 
9. Womack, J  at al. (2019) “Safety, complications and clinical outcome after ultrasound-guided 
paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective 
observational study; Anaesthesia 2019, 74, 594–601, doi:10.1111/anae.14580 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       15 
Appendix A. Imperial NHS Acute Rib Fracture Pathway 
 
1) 
SUMMARY 
This revised guideline provides a framework for the assessment and 
management of adult patients with rib fractures at Imperial College Healthcare 
NHS Trust. The guideline has been updated to take account of new evidence 
in 
patient 
risk 
assessment, 
analgesic 
management 
strategies 
and 
physiotherapy techniques. Additionally, criteria for accepting referrals for 
tertiary level care of rib fractures are provided. 
 
2) 
INTRODUCTION 
2.1 
Incidence 
Blunt chest-wall trauma accounts for 10-15% of all trauma admissions to 
Emergency Departments (EDs) globally1,2. Rib fractures may complicate up to 
two thirds of these injuries2. North West London Trauma Network treats 
approximately 450 patients with rib fractures per year, of whom approximately 
two thirds receive tertiary care at St Mary’s. 
 
2.2 
Importance 
Rib fractures are markers of severe injury and are associated with significant 
morbidity and mortality. Patients with these injuries are at greater risk of 
complications and poor outcomes2-4. Associated injuries occur in 94% of 
patients, typically concomitant thoracic trauma, but also injuries to the head, 
abdomen and limbs3. Mortality associated with rib fractures is hard to calculate, 
as death often happens indirectly, however it has been estimated as between 
10–13%3,4, with one article reporting up to 30%5. Common immediate thoracic 
sequelae 
of 
rib 
fractures 
include 
pneumothorax, 
haemothorax, 
haemopneumothorax, pneumatocoele, pulmonary contusions. Solid organs, 
such as the liver, kidneys and spleen, may also sustain lacerations from broken 
ribs1. 
 
Pain is the most common symptom from rib fractures and a key component in 
pulmonary complications. Pain restricts tidal volume, leading to hypoventilation, 
and impairs coughing ability, leading to sputum retention; these combine to 
cause atelectasis and predispose to pneumonia. Additionally, injured lung 
tissue underlying the fractures has impaired ability to exchange gasses (leading 
to shunt and VQ mismatch) and reduced compliance. Compensatory increases 
in respiratory rate may increase oxygen consumption. Pneumonia occurs in up 
to 30% of cases, with or without sepsis, causing further respiratory compromise. 
The combination of hypoventilation, atelectasis and/or lobar collapse and 
impaired gas exchange results in hypoxaemia, respiratory failure and, in some 
cases, a need for mechanical ventilation. Respiratory complications typically 
develop at 48 – 72 hours post injury. Other respiratory complications include 
pulmonary embolus, pulmonary effusions, empyema and acute respiratory 
distress syndrome (ARDS)1-6. 
 
Patients with rib fractures often require hospital admission, and in more 
significant injuries, to level 2 or 3 care. The associated incremental costs have 
not been fully evaluated, but can be considered in terms of length of inpatient 
stay, ‘ICU bed days’ and ‘ventilator days’ and are likely to be significant. Studies 
evaluating longer term outcomes have demonstrated high rates of chronic 
disability and chronic pain3,6,7,10. The severity of acute pain predicts chronic pain 
whilst disability is predicted by acute pain intensity and the presence of bilateral 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       16 
fractures10. Elderly patients (aged 65 years or older), have been consistently 
shown to have worse outcomes, higher complication rates and greater mortality 
after rib fractures than younger patients3,7. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       17 
 
3) 
DEFINITIONS 
• 
Rib fracture: a break in a bone making up the rib cage. 
• 
Flail chest: at least 2 fractures per rib in at least 2 adjacent ribs are needed to produce a flail segment. 
Flail segments cause paradoxical inspiratory movements, compromise breathing and may be life 
threatening. 
• 
Verbal Rating Scale: a method for assessing pain on an alphanumeric scale. ICHNHST recommends mild, 
moderate and severe, whilst in the ED the numerical scale 0-10 is used. 
• 
Thoracic Epidural (TE): a fine bore catheter placed into the thoracic epidural space which is used to give 
analgesic drugs. 
• 
Paravertebral block (PVB): regional anaesthetic technique providing analgesia to a segment of one 
hemithorax. 
• 
Patient Controlled Analgesia (PCA): a method of allowing a patient to administer their own analgesia 
intravenously, usually opioid based. 
• 
Non-invasive ventilation (NIV): facial Continuous Positive Airways Pressure (CPAP) or Bi-level Positive 
Airways Pressure (BIPAP) ventilation 
• 
Morphine Immediate Release (IR): a morphine immediate release preparation (available as a liquid - 
commonly known as Oramorph - and tablets) 
• 
Oxycodone Immediate Release (IR): a oxycodone immediate release preparation (available as a liquid and 
capsules) 
 
4) 
SCOPE 
These guidelines are for all staff involved in the care of adult trauma patients with rib fractures but are 
of particular relevance to those working in the Emergency Department, Theatres, Anaesthesia, Major 
Trauma Ward and other wards receiving trauma patients. They may also be adopted more widely 
within the North West London Trauma Network. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       18 
 
FULL GUIDELINE 
The use of multidisciplinary bundled care pathways is associated with improved outcomes in patients 
with rib fractures/ blunt chest injury3,24. 
 
4.1 
Identifying the high-risk patient 
Multiple risk factors have been identified for poor outcomes in rib fractures, but the variables can be 
simply classified into anatomical, physiological and other categories, see table 1. 
 
Many scoring systems are available to predict the risk of complications after blunt chest trauma, all of 
which combine different variables from table 1. These include the AISchest, Pulmonary Contusion score 
(PCS), Wagner-score, the Thoracic Trauma Severity score (TTS), the Chest Trauma Score (CTS), 
RibScore and Easter’s Rib Fracture Score. Battle et al recently used robust methodology to develop 
an up to date risk prediction tool that is based on a UK population2. The risk of developing 
complications increases with an increasing score, see table 2 for details. 
 
Table 1: risk factors for morbidity after rib fractures1-8 
 
• Number of ribs fractured 
• Presence of flail segment 
• Bilateral rib fractures 
• First rib fractured 
• Degree of fracture displacement 
• Fractures in the anterior, lateral and 
posterior regions 
• Presence of pulmonary contusions 
• Presence of ≥2 distant injuries 
• Reduced physiological reserve: 
o Increasing age 
o Premorbid respiratory disease 
o Smoking 
o Overweight or obese (BMI >25) 
o Obstructive sleep apnoea 
o Premorbid cardiovascular disease 
o Premorbid diabetes 
• Reduced SpO2 at presentation 
• Reduced vital capacity (VC) 
• Post injury pneumonia 
• Premorbid use of anticoagulants 
• Treated in low volume centres 
• Treated outwith a pathway 
 
 
 
 
Table 2. Rib fracture risk score and risk of complications from Battle et al2 
 
Battle’s tool has been incorporated into the pathway to guide enrolment into the non-invasive (simple 
analgesia) or invasive (incorporating advanced analgesic techniques) pathway with a cut off point of 
15. An example case of a 58 year old man with COPD who has sustained 5 rib fractures and has 
oxygen saturations of 94% is provided in table 3. 
 
Table 3. Rib fracture risk score adapted from Battle et al2 
Age 
+1 per additional 10-year increase starting at 10 years of age 
4 
Anatomical 
Physiological 
Other 
Variable 
Score 
Example 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       19 
 
Number of rib fractures 
+3 per rib fractured 
15 
Chronic lung disease 
+5 if present 
5 
Pre-injury anti-coagulant use 
+4 
0 
Peripheral oxygen saturation levels (SpO2) 
+2 per 5% decrease SpO2 starting at 94% at time of 
2 
assessment 
Total 
26 
Objective measures of respiratory function, such as peak expiratory flow rate (PEFR), inspiratory 
volume (ISV) and vital capacity (VC) have been evaluated8,9. VC less than 30% of a patients 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       20 
 
predicted value predicts pulmonary complications and each 10% increase in VC is associated with a 
reduced chance of pulmonary complications (odds ratio 0.64)9. The risk of complications can be 
reduced by adhering to the key principles of management: optimal analgesia, respiratory support, 
early mobilisation and appropriate surgical intervention. 
 
4.2 
Analgesic options 
As pain is a significant contributor to the morbidity arising from rib fractures, optimisation of analgesia 
is key to preventing complications. There are many options for managing pain from rib fractures 
including multimodal oral therapy, intravenous analgesia, topical treatments and a variety of regional 
anaesthetic blocks. 
 
Acute pain should be assessed according to the Imperial College Healthcare NHS Trust Acute Pain 
Guideline. In particular for rib fracture patients, assess pain at rest and on coughing/ deep inspiration 
and ask about features of neuropathic pain for example tingling, burning and electric shock like 
sensations. Multimodal oral analgesia should be started on admission and include regular 
paracetamol, ibuprofen and opioids. Morphine should be prescribed both regularly and for 
breakthrough (PRN). 
 
In patients aged 65 years or older, ibuprofen should be omitted and the regular opioid changed to 
oxycodone, which has a better pharmacokinetic profile for elderly patients. In patients with renal 
impairment, defined as eGFR <30mls/min, ibuprofen should be omitted and the oxycodone dose 
reduced. All patients should receive adjunctive treatments for opioid analgesia including laxatives and 
anti-emetics. See figure 1 for details. 
 
Opioids may be administered via a patient controlled analgesia (PCA) device if the pain requires more 
frequent opioid dosing than the standard prescription allows. Patients with features of neuropathic 
pain such as burning, tingling, electric shock like sensations or numbness should be prescribed a 
gabapentinoid. 
 
Ketamine may be trialled intravenously (up to 10mg) and continued orally or as an infusion, following 
the Imperial College Healthcare NHS Trust guidelines, in patients with difficult to manage pain. In any 
patient with pain that is difficult to control using conventional measures, conversion to the invasive 
pathway should be considered. (Note the use of ketamine in pain management is unlicensed). 
 
All regional anaesthetic techniques for rib fracture analgesia impair impulse transmission at various 
points along the intercostal nerve. Thoracic Epidural analgesia remains the gold standard analgesic 
modality. They are the most widely studied mode of analgesia, and their use in rib fractures is 
endorsed by several systematic reviews and international bodies1,3,7. Expertise at St Mary’s allows for 
timely epidural insertion by senior anaesthetists and appropriate management once sited. Despite 
this, epidurals have a low but significant complication rate11 and in some patients may be contra-
indicated (see table 4); there is also an inevitable failure rate and their benefit has been questioned12. 
Thoracic epidurals and blocks should only be inserted, doses titrated and drugs bolused by 
appropriately trained members of healthcare staff. The first line epidural infusion should be mixed 
levobupivacaine 0.125% with fentanyl 2micrograms/mL. In patients with rib fractures and other injuries 
arising from the same incident, a plain 0.125% levobupivacaine epidural infusion can be started in 
conjunction with an opioid PCA. Commencing and caring for a patient with an epidural infusion should 
follow the clinical guideline Epidural Analgesia: Continuous Infusions Clinical Guidelines for Adult 
Patients. 
 
 
 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       21 
 
 
 
  Table 4: Contra-indications to epidural analgesia. Starred items apply to regional blocks 
 
Contraindications to epidural analgesia 
  
Absolute 
  
Relative 
 
1. Patient refusal* 
2. Spinal cord injury or haematoma 
3. Epidural haematoma 
4. Thoracic vertebral body fracture at 
level of insertion 
5. Local or generalised sepsis* 
 
1. 
Unable to position patient* 
2. 
Traumatic Brain Injury with 
uncontrolled Intracranial Pressure 
3. 
Incomplete spinal evaluation 
4. 
Previous thoracic spinal surgery 
5. 
Coagulopathy: INR >1.4 or platelets 
<80 x 109/L* 
6. 
Active Anticoagulant therapy. 
AAGBI RAPAC guide.* 
7. 
Extubation not anticipated within 5 
days (ICU patients)* 
   6.   Open wound at site of insertion* 
 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       22 
 
Alternatives to epidurals include intercostal, interpleural and paravertebral blocks, but all have 
significant drawbacks and lack evidence of benefit over epidurals13. Newer techniques, including 
serratus anterior plane and erector spinae plane blocks, have not yet been robustly evaluated14,15,23 
in the rib fracture population but are used in some trauma units and are the subject of much research 
interest. They may be of use in patients with unilateral injuries, when thoracic epidurals are contra-
indicated or are not possible to insert. 
 
In addition to trauma specific cautions and contra-indications (see table 4), standard cautions should 
be applied prior to inserting an epidural or regional anaesthetic block. Invasive monitoring and critical 
care should be considered in patients with pre-existing comorbid disease that may be affected by an 
epidural or regional block e.g. stenotic valvular heart lesions. 
 
4.3 
Ventilation Management 
Rib fractures are commonly associated with underlying pulmonary contusions and pleural injuries 
such as pneumothorax and haemothorax. These, combined with pain, can lead to  respiratory failure. 
 
To prevent complications and ensure a timely recovery, all patients admitted with rib fractures should 
receive respiratory support titrated to their individual needs. Patients should be managed on wards 
with nursing staff familiar with the injury. Supplemental oxygen should be prescribed and administered 
at the lowest concentration required to achieve peripheral oxygen saturations (SpO2) of 94-98%, or 
88-92% in patients at risk of carbon dioxide retention. If more than 2-4L/min via nasal cannulae is 
required, administered oxygen should be humidified to loosen secretions. Sodium chloride (NaCL) 
0.9% nebulisers may be prescribed as required or regularly to assist expectoration. Salbutamol 
nebulisers can be prescribed for bronchospasm. Patients should be mobilised where possible and 
when in bed, be nursed sitting as upright as possible with attention to pressure area care. All rib 
fracture patients should receive physiotherapy input at least once a day (see below)  until respiratory 
function normalises and mobility restored to baseline. 
 
Advanced respiratory support including Continuous Positive Airways Pressure (CPAP), Non- Invasive 
Ventilation (NIV) and Nasal high flow oxygen (Optiflow/ Airvo etc) can be considered, in liaison with 
critical care staff, for patients with anticipated or deteriorating respiratory failure. Decisions regarding 
which of these treatment modalities is appropriate will be specific to individual patients and determined 
by the clinical judgement of the attending trauma, anaesthetic and critical care teams. Patients with 
significant flail segments in particular should be referred early for critical care review regarding 
advanced respiratory support, even without evidence of respiratory failure, with the goal of maintaining 
lung volume and effective cough. A proactive approach to Chest X-Rays should be adopted for 
patients with flail segments; changes such as atelectasis warrant prompt referral to critical care. 
Preventative ventilatory support is a key strategy that must be adopted. 
 
4.4 
Physiotherapy 
Physiotherapy should be started within 24 hours of admission in all patients to support ventilation and 
prevent complications. The ability of patients to participate in physiotherapy is dependent on adequate 
analgesia using non-sedative doses. 
 
All patients should be taught to perform a simple active cycle breathing technique (ACBT), huffing and 
encouraged to cough. This can be initiated by nursing staff if necessary, for example at weekends 
and in the evenings. ACBT consists of taking 3-5 deep breaths with an inspiratory hold of 2-3 seconds 
followed by 3 relaxed breaths. Patients should be asked to complete ACBT hourly when awake. 
Instructions for patients (adapted from the Association of Chartered Physiotherapists in Respiratory 
Care leaflet GL-05): 
1. 
Please take a long, slow, deep breath in, ideally through your nose. 
2. 
Hold your breath for 2-3 seconds. 
3. 
Breathe out gently, like a sigh. 
4. 
Repeat this technique for 3-5 breaths approximately every hour. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       23 
 
Huffing is a rapid exhalation of air through an open mouth and throat, as if trying to mist up a mirror. 
It helps to move sputum up the airways from where it can be coughed out. Huffing should be followed 
by the deep breathing cycle described above. 
 
In patients who are able to mobilise, early and regular mobilisation should be encouraged. Exercise 
bikes/floor pedal exercisers can be provided to assist patients who are only able to move into a chair. 
Shoulder exercises should be taught in appropriate patients to prevent movement restrictions post 
injury which can limit return to work. 
 
4.5 
Surgery 
Surgical fixation and stabilisation of flail chest injuries is associated with reductions in duration of 
mechanical ventilation, ICU stay, total hospital stay, hospital acquired pneumonia and mortality 
rates16-20. In the long term patients return to work sooner and have a reduced incidence of chronic 
pain and analgesic dependence18-22. Studies have also shown similar beneficial outcomes in patients 
with multiple rib fractures but without a flail segment21. A multidisciplinary approach to patient selection 
for surgery is essential. The National Institute of Clinical Health and Excellence has approved and 
issued guidance on surgical fixation of flail chest injuries22. 
 
4.6 
Referral criteria for tertiary care in North West London Trauma Network 
Many patients with rib fractures will present to trauma units within the North West London Network. 
Some may require tertiary level services, however, the majority can receive care and pain relief at 
their local trauma unit following local rib fracture pain management guidelines. 
 
Indications for referral to St Mary’s Major Trauma Centre are detailed below. Acute referrals should 
be made to the Trauma Team Leader (TTL) on duty via the TTL mobile or bleep 1328 via switchboard. 
Internal referrals for consideration of rib fixation should be made to the rib fracture team, via e-mail 
(imperial.ribfracture@nhs.net). 
 
1. Rib fractures associated with: 
a. 
Significant pneumothorax 
b. 
Haemothorax 
c. 
Flail segment 
d. 
Moderate/ significant pulmonary contusions 
 
2. 
Rib fractures in a polytrauma patient. 
 
3. 
Consideration for rib fracture fixation. Indications (adapted from NICE IPG 361)22 include: 
a. 
Clinical evidence of flail chest (visible paradoxical chest movements) associated with respiratory 
failure 
b. 
≥3 displaced rib fractures not responding to adequate analgesia 
c. 
Significant chest wall deformity or ≥25% lung volume loss on CXR 
d. 
Bilateral rib fractures 
e. 
Non-invasive ventilation/ invasive ventilation dependent 
f. 
Presence of clavicle or scapular fracture 
 
4.7 
Placement of patients at St Mary’s Hospital 
Most patients will be admitted onto the major trauma, orthopaedic or general surgical wards, but some 
patients can be admitted elsewhere. Patients with thoracic epidurals should be admitted to major 
trauma ward or the critical care complex. 
 
Clinical Decision Unit 
Patients with rib fractures can be considered for admission to CDU only if they meet certain criteria: 
• 
Patients 65 years or older: less than or equal to 2 rib fractures. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       24 
 
• 
Patients aged under 65 years: less than or equal to 3 rib fractures. 
• 
Exclusion criteria for all age groups: 
▪ 
Injury includes: flail segment, significant pneumothorax or haemothorax. 
▪ 
Pain relief: requires PCA, epidural or block. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       25 
 
Patients with isolated rib fractures, meeting CDU criteria, who are well pre-injury and who have 
adequate social support can be considered for immediate or early discharge. Such patients should 
be counselled to seek medical advice if symptoms change or deteriorate. 
 
Intensive Care Unit 
Patients in ICU receiving level 2 care should follow the standard non-invasive or invasive pathway as 
appropriate. Patients who would benefit from non-invasive ventilation should also be considered for 
arterial line insertion and regular blood gases to assess respiratory function. 
 
In patients who are receiving level 3 care (i.e. sedated, intubated and ventilated), the following 
principles should be considered: 
• Ventilation: 
o 
Use lung protective ventilation strategies. 
o 
Nurse with the head of the bed elevated to ≥30 degrees if not contraindicated by other injuries. 
o 
Regular subglottic suctioning. 
• Analgesia: 
o 
Assess pain regularly and treat with multimodal analgesic therapy. 
o 
Contact 1201 to arrange for a thoracic epidural: 
▪ 
In patients showing signs of impaired respiratory effort e.g. tachypnoea, poor tidal volumes, 
signs of pain or the patient indicates they are in pain. 
▪ 
In the 24 hours prior to planned extubation in patients meeting the invasive pathway criteria. 
• Consider referral for rib fixation (and concurrent epidural) if: 
o 
Flail chest or paradoxical chest movement during weaning from a ventilator 
o 
> 6 ribs fractured 
o 
Bilateral rib fractures 
o 
Hypoxia and/or hypercarbia under 40% inspired oxygen inhalation 
o 
Repeated atelectasis 
o 
Significant chest wall deformity 
o 
Not responding to thoracic epidural and do not require intubation and ventilation otherwise 
4.8 
Discharge 
Prior to discharge, patients should be given information, for example the NHS choices rib injury sheet, 
to ensure their progress after discharge is optimal. Pain should be adequately controlled such that 
patients are discharged with weak opioids (as well as other multimodal agents) in the TTO pack. If 
stronger opioids, e.g. morphine, are still in use, a clear weaning plan should be in place for the GP. 
Patients should be advised to see their GP if the pain isn’t responding to prescribed analgesics or if 
they develop features of chest infection. Other simple interventions that can be recommended for 
completion at home include continued use of the active cycle breathing  technique, use of ice packs, 
use of splints when coughing (e.g. a rolled-up towel), encouragement of mobilisation but avoidance 
of heavy strenuous exercise or work. Patients who have received surgical rib fracture fixation should 
be followed up in fracture clinic at 6 weeks after discharge. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       26 
 
Figure 1: Overview of Imperial rib fracture pathway 
  
R i b F r a c t u r e P a t h w  a y O v e r v i e w 
 
 
 
 
 
*IR = Immediate Release 
 
 
Age 
+1 per additional 10-year increase starting at 10 years of age 
Number of rib fractures 
+3 per rib fractured 
Chronic lung disease 
+5 if present 
Pre-injury anti-coagulant use 
+4 
Peripheral oxygen saturation levels (SpO2) 
+2 per 5% decrease SpO2 starting at 94% at time of assessment 
  Total 
 
Please document Battle score on Cerner 
Consider other risk factors for morbidity and the need for fib fixation: 
Risk factors for morbidity 
Early review for surgical rib fixation 
Pulmonary contusion 
Current smoker 
Flail chest 
Chest wall deformity 
Cardiovascular disease 
Frailty 
≥3 displaced rib fractures 
CXR: ≥25% lung volume loss 
Presence of ≥2 distant injuries 
Obesity & OSA 
≥65 years old 
NIV/ ventilator dependent 
 
 
 
 
2 
Start multimodal analgesia and adjuncts 
1 
Rib fractures confirmed on CXR / CT 
3 
Assess Risk (Battle’s score) 
Variable 
Score 
4 
Start on appropriate arm of pathway 
Adult patients 
Paracetamol 1g PO/ IV 6 hourly 
(if weight <50kg dose at 15mg/kg IV) 
Morphine IR* 10 - 20mg PO 4 hourly 
+ 
Morphine IR* 5 – 10mg PO 4 hourly PRN 
Ibuprofen 400mg PO QDS 
Laxatives: macrogol 1 sachet BD and 
senna 15mg ON 
Anti-emetics 
Patients aged 65yrs or older 
Paracetamol 1g PO/ IV 6 hourly 
(if weight <50kg dose at 15mg/kg IV) 
Oxycodone IR* 2.5 – 5mg PO 4 hourly 
+ 
Oxycodone IR* 2.5 – 5mg PO 4 hourly PRN 
Avoid NSAIDs 
Laxatives: macrogol 1 sachet BD and 
senna 15mg ON 
Anti-emetics 
Patients with renal impairment (eGFR <30) 
Paracetamol 1g PO/ IV 6 hourly 
(if weight <50kg dose at 15mg/kg IV) 
Oxycodone IR* 1.25 – 2.5mg PO 4 hourly 
+ 
Oxycodone IR* 1.25 – 2.5mg PO 4 hourly PRN 
Avoid NSAIDs 
Laxatives: macrogol 1 sachet BD and senna 
15mg ON 
Anti-emetics 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       27 
 
 
 
 
 
 
 
Non Invasive 
If score 0 – 10: consider CDU if meets criteria or 
discharge if appropriate 
If score 11 – 15 or other risk factors for morbidity 
present: consider more advanced analgesia &
Invasive 
If score ≥30: consider early liaison with critical care 
team 
Battle score 0 – 15 
Battle Score ≥16 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       28 
 
Figure 2: Non-Invasive pathway for rib fracture management 
  
N o n – I n v a s i  v e P a t h w a  y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nursing care provided by staff familiar with major trauma patients 
Monitor oxygen saturation (SpO2) and Vital Capacity 
Encourage to sit upright and mobilise early where possible 
Provide supplemental oxygen at the lowest concentration to achieve appropriate SpO2 
Oxygen should be humidified 
Prescribe NaCL 0 9% 10ml nebulisers 4 hourly regularly or as required to assist expectoration
Active Cycle Breathing Technique including “huffing” hourly when awake 
Encourage early and regular mobilisation for those able 
Pedal exercisers for patients unable to mobilise beyond a chair 
5 
Regular reassessment and titration of therapy 
3 
Confirm analgesia is prescribed and titrate as required 
Adult patients 
Paracetamol 1g PO/ IV 6 hourly 
(if weight <50kg dose at 15mg/kg IV) 
Morphine IR* 10 – 20 PO 4 hourly 
+ 
Morphine IR* 5 – 10mg PO 4 hourly PRN 
Ibuprofen 400mg PO QDS 
Patients with renal impairment (eGFR <30) 
Paracetamol 1g PO/ IV 6 hourly 
(if weight <50kg dose at 15mg/kg IV) 
Oxycodone IR* 1.25 – 2.5mg PO 4 hourly 
+ 
Oxycodone IR* 1.25 – 2.5mg PO 4 hourly PRN 
Avoid NSAIDs
Consider IV opioid PCA: Morphine 1st choice, Fentanyl 2nd choice (unless renal impairment). 
Give pregabalin if features of neuropathic pain. Consider PO ketamine after successful IV trial. 
Contact pain team (bleep 1043) or anaesthetic team (bleep 1213) for advice 
Anti-emetics 
Laxatives: macrogol 1 sachet BD and 
senna 15mg ON 
Avoid NSAIDs 
Oxycodone IR* 2.5 – 5mg PO 4 hourly 
+ 
Paracetamol 1g PO/ IV 6 hourly 
Patients aged 65yrs or older 
1 
Admit to appropriate ward and start regular monitoring 
2 
Start respiratory support 
4 
Start regular physiotherapy within 24 hours of admission 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       29 
 
 
 
SpO2/ PaO2/ Vital Capacity reducing 
O2 needs increasing 
SpO2/ PaO2/ Vital Capacity improving/ stable 
O2 needs reducing/ stable 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       30 
 
Figure 3: invasive pathway for rib fracture management 
 
  
I n v a s i  v e P a t h w a  y 
 
 
 
 
 
 
 
 
 
 
No contraindications 
 
 
 
            TE 
contraindicated 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nursing care provided by staff familiar with major trauma patients 
Monitor oxygen saturation (SpO2) and Vital Capacity 
As per items 2-4 on the Non-Invasive Pathway 
TE is the 1st choice block for rib fractures. If there are contraindications, consider a block. 
Both should be booked under “Emergency NCEPOD” on Cerner and completed within 6 hours of admission. 
4 
Regular reassessment and titration of therapy 
Pain score worse 
Pain controlled 
Continue regular 
reassessment and titration 
1 
Admit to Major Trauma Ward and start regular monitoring 
2 
Start regular analgesia, ventilation support and physiotherapy 
3 
Anaesthetic Review for Thoracic Epidural (TE) – bleep 1201/1213 
Thoracic Epidural 
Initial bolus of 10 – 15mls levobupivacaine 0.125% 
Prescribe mixed bag levobupivacaine 0.125% + 
2mcg/ml fentanyl at 15mls/hr + rescue bolus 10mls 
Serratus Anterior or Erector Spinae Plane Block 
Initial bolus of 40mls levobupivacaine 0.125% + 
1:400000 adrenaline 
Prescribe plain levobupivacaine 0.125% at 
15mls/hr + rescue bolus 20mls 4 hourly PRN
SpO2/ PaO2 reducing 
Vital Capacity deteriorating 
SpO2/ PaO2/ Vital Capacity improving/ stable 
O2 needs reducing/ stable 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       31 
 
 
Call 1213 for epidural/ 
block trouble shooting 
Re-site if necessary
Contact ICU/ outreach 
Consider Chest X-Ray 
Consider NIV/ nasal high flow
Consider step down to non 
invasive pathway if 
sustained improvements

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       32 
 
       Figure 4: Rib fixation pathway 
 
Decision making for potential candidates 
Review by member of rib fracture fixation team. 
• MDT may include: rib fracture fixation team, MTW consultant, anaesthetist, 
Discussion & Decisions 
intensive care consultant, physiotherapist, occupational therapy & nursing staff. 
• Decision for surgery made by 2 consultants. 
Liaise with thoracic/ trauma surgeons if suspicion of large air leak or visceral injury. 
If ipsilateral clavicle fractured, have low threshold for ORIF clavicle. 
Pre-operative 
Book 
Half day theatre session. 
Drugs 
Give prophylactic LMWH ≥12 hours before planned surgery. 
Equipment 
MatrixRib fixation kit is sterile and available. 
Imaging 
3D CT reconstruction thorax complete. 
Blood results 
FBC, renal profile (U&E & creatinine), clotting screen/ TEG. 
Blood products 
2 units of packed red blood cells cross matched. 
 
 
 
Anaesthetic team 
Intra-operative 
1. Insert thoracic epidural prior to anaesthetic induction if not already in situ OR 
ensure the dressings are distant to the operative site. 
2. Use standard single lumen endotracheal tube. 
3. Insert arterial line if anticipating NIV or inability to extubate. 
All theatre team 
Position patient supine or laterally after discussion with surgeons 
1. Plan surgical incision(s) by identifying fractures clinically or with ultrasound. 
Surgical team 
 
 
 
Chest drains 
2. If thoracic epidural not possible or contraindicated, insert paravertebral block/ 
catheter under direct vision at the end of the procedure. 
3. Clean and debride original thoracostomy site to prevent infective complications. 
1. Replace any pre-existing chest drains prior to operative fixation through a new 
thoracostomy 
2. Insert a minimum of 1 chest drain per operated hemi-thorax at the end of the 
procedure and connect it to an underwater seal. 
Mobile Chest X Ray at end of procedure in recovery or HDU to confirm drain position. 
 
 
 
Post theatre destination 
 
 
 
Analgesia 
Postoperative 
1. Aim to extubate at end of procedure. Arrange Major Trauma Ward/ Level 2 bed. 
2. If intubated pre-op or significant respiratory compromise, to remain intubated and 
transfer back to ICU. 
1. Give epidural levobupivacaine 0.125%/ fentanyl 2 mcg/ml mixture at 15 mls/hr. 
2. Remove epidural 3-5 days after insertion (7 days maximum, if tunnelled, at 
discretion of anaesthetist & pain team). 
3. Follow the invasive pathway 
Su r g i c a l Ri b F i x a ti o n P a th w a y 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       33 
 
Rehabilitate 
1. Regular ACBT and physiotherapy 
2. Sit up and ambulate ASAP. 
1. Continue ACBT at home 4 hourly. 
Discharge planning 
2. Wound review at 2 weeks. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       34 
 
Figure 5: Rib fracture tertiary referral form 
 
 
 
 
 
 
Referral details 
 
Responsible Consultant: 
 
Referring 
clinician 
Contact telephone 
(mobile): 
Contact e-mail address: 
Hospital 
 
Ward 
 
Name: 
 
Date of birth: 
Patient 
NHS number: 
 
Home address: 
 
General Practitioner: 
 
Injury 
Mechanism: 
Rib fractures: 
Pneumothorax? Yes 
Associated injuries: 
No 
Haemothorax? Yes 
No 
Pulmonary contusion? Yes 
No 
 
Interventions 
Intercostal drain? Yes 
No 
Date of insertion:  …… / …… / …… 
Persistent air leak? Yes 
No 
Imaging and findings 
Chest XR + CT chest (including 3D reconstruction rendered images) transferred by IEP: Yes 
No 
Thoracic epidural in situ: Yes 
No 
Ventilation: 
Self-ventilating 
Non-invasive ventilation 
Intubated 
FiO2 
ABG results 
Details of any other treatment/surgery received: 
 
Pre-morbid state 
 
Co-morbidities: 
Previous thoracic/ 
cardiac/ thoracic spinal 
surgery: 
NORTH WEST LONDON TRAUMA NETWORK 
RIB FRACTURE TERTIARY REFERRAL FORM 
It is the policy of the North West London Major Trauma Centre to repatriate patients 
within 72 hours of rib fracture surgery if deemed medically fit 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       35 
 
Anticoagulant history 
including VTE 
prophylaxis: 
 
Please e-mail referral to imperial.ribfracture@nhs.net 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       36 
 
5) 
IMPLEMENTATION 
Training required for staff 
☑ Yes 
☐ No 
If yes, who will provide training: 
Anaesthetic department: Epidurals and RA techniques 
Major Trauma Department: overall management 
When will training be provided? 
At induction of junior doctors, new consultants and regularly at 
nursing updates. 
Date for implementation of 
guideline: 
1/3/2019 
 
6) 
MONITORING / AUDIT 
When will this guideline be 
audited? 
Ongoing currently (clinical governance reference number 1850) 
Who will be responsible for 
auditing this guideline? 
Dr Alex Wickham, Consultant Anaesthetist 
Mr Ian Sinha, Consultant Orthopaedic Surgeon 
Are there any other specific 
recommendations for audit? 
None 
 
7) 
REVIEW 
Frequency of review 
Please indicate frequency of review: 
3 years 
Person and post responsible for the review: 
Mr Ian Sinha, Consultant Orthopaedic Surgeon 
Dr Alex Wickham, Consultant Anaesthetist 
 
8) 
REFERENCES 
1. EAST Practice Management Guidelines Work Group. Pain management in Blunt Thoracic Trauma. J Trauma 2005; 
59(5):1256-1267. 
2. Battle C et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new 
prognostic model. Crit Care 2014, 18:R98. 
3. Witt C & Bulger E. Comprehensive approach to the management of the patient with multiple rib fractures: a review 
and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017; 2:1–7. 
4. Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, et al. Pain management for blunt thoracic trauma: 
a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma 
Anesthesiology Society. J Trauma Acute Care Surg 2016; 81:936–51. 
5. Jones KM, Reed RL, 2nd, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg. 2011; 
202(5):598Y604. 
6. May L, Hillermann C & Patil S. Rib Fracture Management. BJA Education 2016; 16(1):26-32 
7. Unsworth A, Curtis K & Asha SE. Treatments for blunt chest trauma and their impact on patient outcomes and 
health service delivery. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2015; 23:17 
8. Butts C et al. Do simple beside lung function tests predict morbidity after rib fractures? Am J Surg 2017; 
213(3):473-477. 
9. Carver T, Milia D, Somberg C, Brasel K & Paul J. Vital capacity helps predict pulmonary complications after rib 
fractures. J Trauma Acute Care Surg 2015; 79(3):413-6. 
10. Gordy S et al. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014; 207(5): 659-62. 
11. Royal College Of Anaesthetists. National Audit Project 3: Major Complications of Central Neuraxial Block in the 
United Kingdom. Report and Findings. January 2009. RCOA; London. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       37 
 
12. Carrier F, Turgeon A, Nicole P et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic 
review and meta-analysis of randomized controlled trials. Can J Anesth 2009; 56:230–242. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       38 
 
13. Jarvis AM, Cook CH, Lindsey DE, Reilley TE, Steinberg SM, Beery RM, Whitmill ML, Papadimos TJ, Stawicki SP. 
Comparison of epidural versus parenteral analgesia for traumatic rib fractures: A meta- analysis. OPUS 12 Scientist 
2009; 3(3): 50-57. 
14. Kunhabdulla NP, Agarwal A. Serratus Anterior Plane Block for Multiple Rib Fractures. Pain Physician 
2014; 17: E651-662 
15. Fu P, Weyker PD, Webb CAJ. Case Report of Serratus Plane Catheter for Pain Management in a Patient with 
Multiple Rib Fractures and an Inferior Scapular Fracture. Anesth Analg 2017; 8(6):132-135. 
16. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, Fitzgerald M. Prospective 
randomised controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013; 216(5):924-32. 
17. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and 
ventilation. J Thorac Cardiovasc Surg. 1995; 110:1676-80. 
18. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization or internal pneumatic stabilization? A prospective 
randomized study of management of severe flail chest patients. J Trauma. 2002; 52:727– 732. 
19. Lafferty PM, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: indications, technique, and 
outcomes. J Bone Joint Surg Am 2011; 93:97–110. 
20. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M & Fitzgerald M. Prospective 
Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. J Am Coll Surg 2013;216:924-932. 
21. Bottlang M, Walleser S, Noll M, et al. Biomechanical rationale and evaluation of an implant system for rib fracture 
fixation. European Journal of Trauma and Emergency Surgery 2010; 36(5): 417–426. 
22. National Institute for Health and Care Excellence (NICE). Interventional procedure guidance 361: Insertion of metal 
rib 
reinforcements 
to 
stabilise 
a 
flail 
chest 
wall. 
2010. 
NICE: 
London. 
Available 
from: 
https://www.nice.org.uk/guidance/ipg361 
23. Adhikary S, Liu W, Fuller E, Cruz-Eng H and Chin K. The effect of erector spinae plane block on respiratory and 
analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia 2019; published online 
https://doi.org/10.1111/anae.14579 
24. Todd S et al. A multidisciplinary clinical pathway decreases rib fracture–associated infectious morbidity and 
mortality in high-risk trauma patients. Am. J Surg 2006; 192: 806–811. 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       39 
 
9) 
GUIDELINE DETAIL 
Start Date: 
27th August 2019 
Approval Dates 
Anaesthetics and Major Trauma January 2015 
Surgery, Cardiovascular and Cancer 
Major Trauma Board January 2015 
Drugs and therapeutics Committee 26th March 2019 
(chair’s action 2nd April 2019 and 27th August 2019) 
Has all relevant legislation, 
national guidance, 
recommendations, alerts and 
Trust action plans been 
considered, and included as 
appropriate in the development 
of this guideline? 
Please list ALL guidance considered: 
National Institute for Health and Care Excellence (NICE). 
Interventional procedure guidance 361: Insertion of metal rib 
reinforcements to stabilise a flail chest wall. 2010. NICE: London. 
Have all relevant stakeholders 
been included in the 
development of this guideline? 
Please list all (name and role): 
Mr C Aylwin, Consultant trauma and vascular surgeon 
Mr S Hettiaratchy, Consultant plastic surgeon 
Surg Commander M Khan, Consultant trauma surgeon 
Mr I Sinha, Consultant orthopaedic surgeon 
Dr S Qureshi, Consultant Anaesthetist 
Miss N Batrick, Consultant Emergency Physician & NWL Network 
lead 
Dr V Garnelo Rey, Consultant Intensivist & Trauma Lead 
Dr B Graham, Consultant Anaesthetist & Service Director 
Dr G Peck, Consultant Geriatrician 
St Mary’s pain service: Dr J Illingworth, Dr A Knaggs, CNS A 
Fiamavle 
Dr B Bellew, Consultant Anaesthetist 
Mr K Bharkhada, Lead Pharmacist for Major Trauma and 
Pharmacy 
Miss N Marroney, Major Trauma Physiotherapist 
Mrs J Lockwood, Major Trauma Matron 
S H Jama, Senior Lead Pharmacist – Emergency, Acute and 
Elderly Medicine 
M Balic, Senior Lead Formulary Pharmacist and New Drugs Panel 
secretary 
Who will you be notifying of the 
existence of this guidance? 
All clinical staff groups who are involved with the care of 
adult inpatients with rib fractures. 
Related documents 
Epidural Analgesia: Continuous Infusions Clinical Guidelines 
for Adult Patients 
Ketamine use for analgesia Guideline 
Pain management guidelines for adult patients with acute or 
chronic pain 
Analgesia Guideline for the Management of Acute and 
Chronic Pain for Adults with Renal Impairment 

 
V3 ESPB/SAPB/TEA protocol 06/09/2020       (IRAS ID 276933)                                       40 
 
Author/further information 
Name: Dr A Wickham, Mr I Sinha, Dr S Qureshi 
Title: Consultant Anaesthetist, Consultant Surgeon, Consultant 
Anaesthetist 
Division: Surgery, Cancer & Cardiovascular 
Site: St Mary’s Hospital 
Telephone/Bleep: 26162 
Trust email address: Alex.Wickham@nhs.net, 
Ian.Sinha1@nhs.net, Sabeena.Qureshi@nhs.net 

V2 17/01/2020 (IRAS ID: 270191) 
 
41 
 
Document review history 
Next review due: 2nd April 2022 
Version 1: Major Trauma Board review July 2015 
Version 2: DTC review and recommendations 26/3/19 
Version 2.1: Update to CDU criteria 
THIS GUIDELINE REPLACES: 
Rib Fractures in Major Trauma: a guideline for management 
version 1, July 2015 
 
10) INTRANET HOUSEKEEPING 
Key words 
Major Trauma, Rib Fracture, Epidural, Rib fixation 
Which Division/Directorate 
category does this belong to? 
Surgery, Cancer & Cardiovascular 
Which specialty should this 
belong to when appearing on the 
Source? 
Major Trauma 
 
11) EQUALITY IMPACT OF GUIDELINE 
Is this guideline anticipated to have any significant equality-related impact on 
patients, carers or staff? No 
☑