Anaesthetics - Nerve Blocks for rib fractures

Pain relief using local anaesthetic for rib fractures

Why is it important to treat rib fractures?

Rib fractures can be very painful. Deep breathing or coughing can make the pain worse, which can cause you to breathe less well.

Shallow breathing increases the risk of getting a chest infection (pneumonia). This may lead to a longer hospital stay or, in very severe cases, be fatal. Pain relief is important to help you breathe more easily and reduce the likelihood of this happening.

What is a nerve block?

A nerve block is an injection of a numbing medication around the nerves that carry the pain signals from your broken ribs. It temporarily stops the nerves from sending these signals to your brain.

The injection goes through the skin to the area where the nerves are. Your doctor will place a small plastic tube called a catheter close to the nerves. This tube will be left in place, which means the medication can be given continuously for several days. The injection either goes into the side of your chest or into your back. Your doctor will decide which one is best after reviewing you.

What does the procedure involve?

You will lie on your back or your side during the procedure. You can adjust your position so that you are comfortable. We will monitor your heart rate, blood pressure and oxygen levels while we perform the block.

Our clinician will numb the injection site, which may sting a little. They will use an ultrasound machine to carefully guide the needle during the injection. They will secure the catheter in place using a dressing. The procedure can take around thirty minutes but sometimes much longer, depending how easy it is to get the catheter in the correct place. You may feel some pressure and pushing where the doctor is working.

The nerve block usually starts to work soon after the procedure. It does not take all the pain away, and most people still need to take other painkillers as well. The catheter is not stitched in, so you need to be careful not to dislodge it, but it is important that you move around as much as you are able as this will also help with your breathing. Nursing staff will help you when you are ready to get out of bed.

What are the benefits of having a nerve block?

The nerve block should:

• Provide pain relief
• Help you to breathe and cough effectively
• Reduce your risk of getting a chest infection
• Reduce the amount of strong painkillers you need

What are the risks of having a nerve block?

• You might not get enough pain relief from the nerve block. It is common to need other forms of pain relief as well
• The block might not work at all. Your doctor may repeat the procedure if this happens (with your permission), or they could offer alternative pain relief
• You could get bleeding and bruising around the injection area
• The injection site might become infected. This is extremely rare and the pain team will see you daily to check for infection (1)
• There is a small risk of temporary nerve damage, which causes numbness around your chest (1 in 1000 people). Permanent nerve damage is very rare (1 in 5000 people) (2)
• The catheter can damage the covering of the lung. This happens to around 1 in 500 people and it can cause chest pain and breathlessness (3). You might need a plastic tube called a chest drain put in place to treat it.

What are the alternatives to nerve blocks?

You can receive other painkillers in tablet form or through a drip. The pain team can discuss these options with you before you decide.

References

1. Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:560879.
2. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth. 2010;105 Suppl 1:i97-107.
3. Tokita H. Incidence of pneumothorax from chest wall blocks for ambulatory breast cancer surgery in a high-volume practice. Regional Anesthesia & Pain Medicine. 2021.
4. (RCOA) RCoA. Risks associated with your anaesthetic. Section 9: Serious allergy (anaphylaxis). 2019.
5. Harper NJN, Cook TM, Garcez T, Farmer L, Floss K, Marinho S, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth. 2018;121(1):159-71