eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Rib: Treatment & Medication
Updated: Apr 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Focus care on airway maintenance and supplemental oxygen.
Emergency Department Care
- Goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.
- Primary focus of treatment for rib fractures is pain relief and adequate clearing of pulmonary secretions.
- Isolated rib fractures, without associated injuries, may be managed on an outpatient basis with oral analgesics.
- Other options include parenterally administered narcotics titrated to prevent respiratory depression.
- Patient-controlled anesthesia allows adequate pain relief with minimal inhibition of respiratory drive.
- Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax.
- For hospitalized patients, consider epidural and intrapleural catheter placement for delivery of anesthetics. Patient-controlled analgesia pumps have also shown to be useful in these patients.
- While rib belts or binders do control pain, they have been linked to hypoventilation, atelectasis, and pneumonia. As a result, their use is no longer recommended.
- For patients with a significant mechanism of trauma, a CT of the chest and abdomen can be useful in scanning for significant related injury.
Consultations
- Because of the close association of rib fractures with injury to underlying structures, the ED physician may need to consult the trauma service.
- Pain management specialists can be helpful for admitted patients.
Medication
Pain control remains the mainstay of treatment, usually with nonsteroidal anti-inflammatory or oral narcotic agents.
A meta-analysis that included 8 studies (232 patients) did not demonstrate significant benefit of epidural analgesia on mortality, ICU, and hospital length of stay compared with other analgesic modalities in adult patients with traumatic rib fractures. Benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics may exist, although hypotension was significantly associated with thoracic epidural analgesia. Further research and evaluation is needed regarding the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.2
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents are used most commonly for the relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually the first-line drug of choice for initial therapy. Other options include fenoprofen, flurbiprofen, ketoprofen, indomethacin, and piroxicam.
Ibuprofen (Ibuprin, Advil, Motrin)
First-line drug of choice for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases prostaglandin synthesis.
Adult
600-800 mg PO q6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderately severe pain and inflammation.
Administer small dosages initially to patients with lower body weights, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and observe closely.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 14 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
Acetaminophen (Tylenol, Panadol, Paracetamol)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Effective in relieving mild to moderate acute pain; however, has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 4 g/d
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Acetaminophen and codeine (Tylenol #2, Tylenol #3, Tylenol #4)
Combines analgesic effects of a centrally acting opium-derived alkaloid (codeine) and a peripherally acting nonopioid analgesic (acetaminophen). Indicated for treatment of mild to moderate pain.
Adult
Tylenol #2: 1-2 tab (15 mg codeine phosphate plus 300 mg acetaminophen) PO q4-6h prn; not to exceed 360 mg codeine or 4 g acetaminophen/24 h
Tylenol #3: 1 tab (30 mg codeine phosphate plus 300 mg acetaminophen) PO q4-6h prn; not to exceed 360 mg codeine or 4 g acetaminophen/24 h
Tylenol #4: 60 mg codeine phosphate plus 300 mg acetaminophen PO q4-6h prn; not to exceed 360 mg codeine or 4 g acetaminophen/24 h
Pediatric
Based on codeine: 0.5-1 mg/kg/dose PO q4-6h
Based on acetaminophen: 10-15 mg/kg/dose PO q4h; not to exceed 75 mg/kg/d or 2.6 g/d
<3 years: Not established
3-6 years: 5 mL (1 tsp) PO qid prn
6-12 years: 10 mL (2 tsp) PO qid prn
>12 years: Administer as in adults
Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hepatotoxicity with acetaminophen possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses and exceed recommended maximum dose
Hydrocodone and acetaminophen (Vicodin)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric
Not established
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose PO oxycodone; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; conversely, toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants; may also potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, and asthma; because of association of aspirin with Reye syndrome, do not use in children who have the flu and are <16 y
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose
Pediatric
<12 years: 10-15 mg/kg/dose PO acetaminophen q4-6h prn; not to exceed 2.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg PO acetaminophen q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly persons
Morphine sulfate
Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation. Reversed by naloxone.
Adult
2.5-5 mg IV q10-15min prn
Pediatric
Neonates: 0.05-0.2 mg/kg/dose IV prn
Children: 0.1-0.2 mg/kg IV q2-4h prn
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
More on Fracture, Rib |
| Overview: Fracture, Rib |
| Differential Diagnoses & Workup: Fracture, Rib |
 Treatment & Medication: Fracture, Rib |
| Follow-up: Fracture, Rib |
| Multimedia: Fracture, Rib |
| References |
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References
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[Best Evidence] Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. Mar 2009;56(3):230-42. [Medline].
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Further Reading
Keywords
rib fractures, broken ribs, blunt thoracic injury, blunt chest trauma, chest trauma, flail chest, rib injury, abdominal trauma, thoracic injuries, blunt trauma
