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#RibFractureAnalgesia #RegionalAnaesthesia #PainMedicine #AcutePain #TraumaPain #ChestWallBlocks #ESPB #SAPB #IntercostalNerves #PainGenerator #DynamicPain #OpioidSparingAnalgesia #GrayZoneInRA #GrayAreasInRA
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β
Rib fractures are not rare injuries.
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They account for nearly 10% of trauma admissions & may be seen in up to 39% of blunt thoracic trauma.
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Real challenge is not only the fracture.
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It is the pain-driven respiratory compromise that follows.
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Before choosing a block, we must understand the anatomy.
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β«οΈ Ribs are mainly supplied by intercostal nerves, which are anterior rami of thoracic spinal nerves.
β«οΈ Pain also comes from periosteum, collateral branches, lateral cutaneous branches, intercostal muscles, endothoracic fascia, and exothoracic fascia.
β«οΈ So rib fracture pain is not one nerve, one rib, or one simple pathway.
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β«οΈ Posterior / posterolateral fractures may have stronger posterior chest wall and paraspinal contribution.
β«οΈ Lateral / anterolateral fractures commonly involve lateral cutaneous and intercostal territories.
β«οΈ Anteromedial fractures may require anterior intercostal or parasternal coverage.
β«οΈ Multilevel or bilateral fractures may need broader neuraxial or paravertebral strategies.
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β«οΈ ESPB may be a selective option for posterior or posterolateral rib fractures.
β«οΈ SAPB may be more anatomically congruent for lateral and anterolateral rib fractures.
β«οΈ Parasternal / anterior intercostal approaches may be useful for anteromedial pain.
β«οΈ Thoracic paravertebral or epidural analgesia may provide broader coverage when clinically appropriate.
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β«οΈ ESPB is a posterior fascial plane technique.
β«οΈ Dorsal ramus involvement is more consistent.
β«οΈ Ventral ramus, paravertebral, or epidural spread may be variable.
β«οΈ Central convergence of pain does not mean all peripheral blocks behave equally.
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β«οΈ Deep inspiration
β«οΈ Effective cough
β«οΈ Dynamic pain during movement
β«οΈ Physiotherapy participation
β«οΈ Incentive spirometry performance
β«οΈ Pneumonia prevention
β«οΈ Delirium and functional recovery
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β«οΈ It is controlled systemic local anesthetic exposure.
β«οΈ It may modulate neuronal excitability and central sensitization.
β«οΈ Elderly trauma patients may have a narrower therapeutic margin.
β«οΈ LAST monitoring should be systematic, not casual.
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β«οΈ Map the fracture.
β«οΈ Identify the neural territory.
β«οΈ Understand the block mechanism.
β«οΈ Choose the technique accordingly.
π« One-size-fits-all analgesia may miss the dominant pain generator.
𦴠Rib fracture analgesia is not just about blocking pain - it is about restoring breathing, coughing, mobilization, and recovery.
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