Chest wall pain management after chest wall trauma

Abstract

Blunt chest trauma is defined as a high energy injury to the thorax and its structures, and it is usually a strong indicator of severe injury. Its clinical presentation can vary from rib fractures to pneumothorax, hemothorax, lung and soft tissue contusion; these lesions and consequential pain predispose to respiratory failure by compromising respiratory mechanics and by exacerbating pre-existing lung disease.This picture can lead to a number of complications, such as pneumonia or ARDS, that have a significant impact on patients' morbidity and mortality. One of the cornerstones of blunt chest trauma management is providing early and effective analgesia: pain control improves respiratory mechanics, reduces possible complications and allows effective and aggressive physiotherapy. In literature, there are few clinical trials comparing different analgesic techniques for pain relief in blunt thoracic trauma; our review aims to detail the clinical implication, adequacy and possible complications of different analgesic approaches commonly used in thoracic trauma management, such as epidural anesthesia, regional anesthesia, endovenous and intrathecal analgesia. This review is also focused on management and prevention of chronic pain. Pain management, lung toilet, aggressive respiratory therapy and early mobilization are key to a successful patient recovery. In selected patients, operative fixation may lead to better outcomes although further research is needed to clearly identify the category of patients and the ideal timing for surgical intervention. Chronic pain develops in up to 50% of the patients after a thoracic trauma. A multimodal approach tackling both its somatic and neuropathic component is essential to chronic pain prevention. Early and effective pain control demonstrated to have a pivotal role on patient recovery. While endovenous analgesia constitutes the method of choice for intensive care unit (ICU) sedated patients, regional unilateral analgesia should be considered in awake and spontaneously breathing patients. The approach of choice should be tailored on the single patient and, if possible, a multimodal strategy should be established.

Treatment of blunt thoracic trauma in a Level 1 Trauma Center

“…In patients with HTX (80 patients), the mean time of chest tube drainage was 5.90 days (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). In this group, pneumonia occurred in 6 (7.50%) cases.…”

“…The mean time of chest tube drainage for traumatic PTX (60 patients) was 6.37 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) days, the preferred length was 3-4 days. Extended chest tube drainage was applied in patients requiring mechanical ventilation.…”

“…Additionally, the subsequent pain resulting from the damage also plays a crucial role in decreased ventilation. The lack of adequate expectoration results in bronchial secretion retention (3,4,11,14,23). Pneumothorax, hemothorax or the combination of the previous two cases lead to further worsening regarding ventilation.…”

“…The incidence of blunt chest trauma is increasing in direct proportion to the number of traffic accidents, resulting in thoracic injuries having a high rate of morbidity and mortality due to damage to the breathing and circulation system. Pain, damage to the chest wall and/or intrathoracic organs may lead to diminished levels of breathing and circulation, and traumatic pneumothorax (PTX), hemothorax (HTX) or hemopneumothorax (HPTX), all of which can further compromise ventilation (3,4,11,14,18,23).…”

“…The treatment of blunt chest trauma is essentially conservative, relying on pain management (NSAIDs, opioids, intercostal block, continuous epidural or erector spinae block), physiotherapy and early mobilization (3,4,11,23), while in the case of flail chest and/or lung contusion, mechanical ventilation may also be necessary (3,4,6,18,24).…”