Improving Outcomes With Invasive Analgesia in Geriatric Trauma Rib Fracture Patients

St Mary’s is a central MTC and receives approximately 340 ‘Major Trauma Calls’ per month.  Rib fractures (RF) are often seen in major trauma, frequently feature in high-acuity mechanisms of injury, and are known to cause extensive pain and distress. St Mary’s RF SOP directs trauma teams to utilise a 24/7 ‘invasive’ analgesic pathway (advance regional nerve blocks/epidurals/PCA’s) as part of a multimodal analgesic approach to acute pain. The RF SOP defines invasive pathways indicated if a patient’s rib fracture severity score ‘STUMBL’ is >16. Our team completed a retrospective cohort data collection and analysis of patients admitted for inpatient care to St Mary’s, who sustained one or more radiologically confirmed traumatic rib fracture between the 01.05.2025 and 31.5.25. The mean age of all analysed patients (n=38) was 65, 37% of these patients received ‘invasive’ analgesia. 78% of the invasive pathway group were cared for on a level one ward bed. All patients admitted to level two or three were admitted for non-rib or lung injury-related pathology (eg intracranial haemorrhage management or aortic injury operative care). 54% of the invasive pathway received thoracic epidurals, generally promptly in ED. In the older person population, contraindications for the epidural were not uncommon;  ESB was equally utilised in 23% of invasive group, often if epidural was contradicted, such as for those on prior anticoagulation or with injury-associated significant acute spinal fractures (34% of all patients analysed had spinal fractures in addition to rib fractures). PCA’s were utilised in the final 23% of invasive patients.  LOS data highlighted patients with high rib fracture severity scores, who gained the most improvement in LOS by the invasive pathway. Invasive patients grouped by STUMBL scores 31-51 benefited from a mean 14-day reduction in LOS when compared to non-invasive (mean invasive group LOS 21 days, non-invasive 35). Those with rib fracture severity scores suggesting less severity (STUMBL score 20-30) also demonstrated a LOS reduction (invasive 14.6, non-invasive 17.2). It is noted that complications (delirium, pneumonia), other than in one hypotensive patient post-epdural, were related to rib fractures and underlying pathologies leading to the trauma call.

MTC: Major Trauma Centre

ICHT: Imperial College Healthcare NHS Trust

SOP: Standard operating procedures

STUMBL: Study of Management of Blunt Chest Wall Trauma Patients Score

ESB: Erector Spinae Block

PCA: Patient Controlled Analgesia

LOS: Length of Stay