American Society of Regional Anesthesia and Pain Medicine August 2017 - 17

Problem-Based Learning Discussion (PBLD): Management of a
Trauma Patient with Rib Fractures
Problem-based learning discussion (PBLD) is a relatively new feature to ASRA News. We received a lot of positive feedback about the
first PBLD that was published in the November 2016 issue.
In addition to the responses we solicited from our contributors, we polled our social media crowd and Twitter followers about
management of this case. The Twitter poll results are included in the body of this article. Dr. Donnelly provided the case and compiled
the responses.
If you like to be part of this feature:
1. Send de-identified cases you would like to see discussed within this format to the ASRA News at mailto:ASRAEditor@asra.com.
We will collectively choose the most suitable cases for discussion.
2. Please let us know if we can count on you as a contact to reply to cases and provide your opinion on how you would manage said
case. Please send your name, practice setting, and contact information to mailto:ASRAEditor@asra.com.
Thanks and enjoy!
CASE
You are called by the trauma
service to see a 76-year-old male
who was recently admitted with
bilateral rib fractures, T3 on the
right and T4-T9 on the left (no
other injuries) after falling off a
ladder. He is currently on Bilevel
Positive Airway Pressure (BiPAP)
treatment. The trauma service
requests a block for pain control.
The only medical history that can
Melanie Donnelly, MD
be obtained from him is that he has
Assistant Professor
diabetes and hypertension and had
University of Colorado
a nondebilitating stroke many years
Aurora, CO
ago that left him with a slightly
clumsy left foot and hand. The
patient states he can't remember all the medications he is currently
taking but that they include insulin and metoprolol. His family is not
currently available but should be at some point later today. He has
not received care at your facility in the past. The trauma service
would like a block to provide pain control in this patient because
it is felt that pain is impairing adequate ventilation. The trauma
service is hopeful that an epidural may help him avoid intubation.

Dr. Gilloon: Without a complete medical history, including
complete medication list, and labs (ie, international normalized
ratio [INR], platelet count), I would not proceed with an epidural
or paravertebral. The patient has a history of stroke and could
conceivably be on blood thinners. If he cannot verify a complete
medication list, then his family, primary care provider, or pharmacy
needs to be contacted. I appreciate the trauma team's sense of
urgency in wanting to prevent intubation; however, I would not risk
performing an invasive procedure that could result in harming the
patient. While trying to collect more information, I would initiate a
ketamine infusion.

1. How would you proceed at this point (epidural, paravertebral
block/catheters, ketamine infusion, multimodal analgesia)?
Dr. Guha: Assuming that he (or someone else) is able
to appropriately provide consent and the patient has no
coagulopathies or other contraindications, I would offer an epidural.
This would cover both the right- and left-sided rib fractures.
Multimodal analgesia may be provided in addition to the epidural
but is unlikely to offer the same degree of pain relief on its own
that an epidural would.

American Society of Regional Anesthesia and Pain Medicine
2017

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2017