PEF-Block & Ribs Fractures
Condition: Chest Trauma With Ribs Fractures
MeSH terms: Fractures, Bone; Rib Fractures; Thoracic Injuries
Study type: Interventional

Summary: 
      Rib fractures are frequent injuries found approximately in 10% severe trauma patient. Rib
      fractures were correlated in many studies with a higher morbidity and mortality. This
      impaired outcome is mainly due to pulmonary complications consequences including especially
      pulmonary contusions. Frequently, patients present difficulty deep breathing and coughing.
      These adverse effects can lead to the development of atelectasis, hypoxia, and respiratory
      failure with mechanic ventilation recourse. Effective pain management may prevent these
      complications and reduce the likelihood of developing chronic pain. A multi-modal analgesia
      regimen is widely employed combining regional and systemic analgesia. Epidural analgesia is
      considered by many authors to be the gold standard of pain relief although many side-effects
      are frequently describe including hypotension, urinary retention nausea and vomiting.
      Paravertebral nerve blockade is an adequate alternative that provide similar quality of
      analgesia with lower incidence of complication. However, the failure rate associates with PVB
      is about 13% and it may be associated with hypotension (4.6%), accidental vascular puncture
      (3.8%), accidental pleural puncture (1.1%) and rarely pneumothorax (0.5%). Recently, a
      description of the intercostal paraspinal nerve block. This technic was performed for
      patients undergoing thoracic surgery without complications.More recently, a description of a
      new approach to provide thoracic analgesia named the Posterior Paramedian subchoroidal (PoPS)
      block. The authors consider this technique provide an analgesia of the anterior and the
      posterior branch of adjacent thoracic nerves. The investigators propose to investigate the
      effect of Posterior exothoracic fascial block.
    


Intervention name(s): Intravenous morphine patient-controlled analgesia (PCA); Block of the posterior exo-thoracic fascia with Ropivacaine; Block of paravertebral space with Ropivacaine
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Group 1 control:
Morphine titration at 0.1 mg/kg
Establishment of PCA morphine:
concentration 1mg/ml
1ml bolus
refractory period of 7 minutes
no maximum dose per day. Premedication of the patient with Ketamine 0.15 mg/kg and Propofol 0.5 mg /kg; Group 2 PEF block:
Establishment of PCA morphine:
concentration 1mg / ml
1ml bolus
refractory period of 7 minutes
no maximum dose per day.
Realization of a block of the posterior exo-thoracic fascia (PEF block) at the median level of ribs fractures with ropivacaine 5mg / mL, 3 mg / kg under echography guidance. ALR needle (type neurostimulation) with a length of 100 mm is used. When the injection is performed an analgesia catheter is deposited in the space created by local anesthetics. Realization of ropivacaine bolus 2mg / ml at 0.1ml/kg every 4 hours. Possibility of an additional bolus of 0.1ml / kg every hour if insufficient analgesia.; Group 3 paravertebral block:
Establishment of PCA morphine:
concentration 1mg / ml
1ml bolus
refractory period of 7 minutes
no maximum dose per day.
Realization of a paravertebral block (BPV) at the median level of ribs fractures ropivacaine 5mg / mL, (0.3ml / kg) 1.5 mg / kg under echography guidance. ALR needle (type neurostimulation) with a length of 100 mm is used. When the injection is performed an analgesia catheter is deposited in the space created by local anesthetics. Realization of bolus of ropivacaine 2mg / ml at 0.1ml / kg every 4 hours.
Possibility of an additional bolus of 0.1ml / kg every hour if insufficient analgesia.
In the case of failure of initial management with significant pain despite the iterative boli, epidural analgesia is used in recourse.
Intervention MeSH terms: Morphine; Ropivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment