STUDY OBJECTIVES: Managing pain associated with acute rib fractures remains a challenge in the emergency department. The current standard of care involves multimodal pain management and pulmonary hygiene. The Serratus Anterior Plane Block (SAPB) is easily performed at the bedside, offers a favorable risk profile, and provides targeted analgesia for patients with rib fractures. Here, we investigated whether SAPB performed by an emergency medicine (EM) physician in addition to usual care improves the pain, inspiratory capacity, and cough (PIC) score in patients with acute rib fractures compared to usual care alone.
METHODS: We conducted a prospective, open-label, randomized controlled trial at an academic Level 1 Trauma Center. We enrolled adult patients with anterior or lateral rib fractures T2 through T9 and a pain score = 5 out of 10. Participants were randomized to either receive a SAPB plus usual care or usual care alone. The primary outcome was an improvement in the PIC score. The secondary outcome was oral morphine equivalents (OMEs) administered at 24 h. We analyzed changes in PIC scores using a linear mixed-effects model and compared OME consumption using the Wilcoxon rank-sum test.
RESULTS: Thirty-eight patients were included in the final analysis (19 intervention, 19 control). The SAPB group demonstrated a significant improvement in PIC scores at 5 h post-enrollment compared with the control group (estimated average effect 0.90; 95% CI: 0.10 to 1.69; p = 0.03). Patients in the intervention arm received 32.2 mg OMEs versus 54.1 mg OMEs in the control arm at 24 h, which was not statistically significant (p = 0.44). No complications were observed.
CONCLUSIONS: Adding the SAPB to usual care produced a statistically significant improvement in PIC scores among emergency department (ED) patients with rib fractures. SAPB was performed safely by emergency physicians and represents a feasible, scalable adjunct for acute rib fracture analgesia in the ED.
TRIAL REGISTRATION: ClinicalTrials.gov: NCT06299137.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
The clinical significance of the results are hard to evaluate due to the composite nature of the score used.
Physician rater
A formal minimal clinically important difference has not been established for the PIC score in the available literature. The lower bound of 0.10 is close to zero, so the effect could be small and not clinically significant.
Physician rater
Managing pain in patients with multiple rib fractures is a complex clinical challenge. Severe pain can compromise respiratory function and elevate the risk of complications. A multimodal analgesic approach is a viable solution but often proves inadequate. Epidural analgesia may not always be accessible or feasible in EDs. Individual intercostal nerve blocks are time-consuming, require multiple injections, and can be difficult to perform. The SAP block offers a simpler, safe, and effective alternative administered at the bedside. The eligibility criteria and limitations are thoroughly detailed, but the current evidence is limited due to the few trials available and does not sufficiently support the SAP block as a first-line treatment.
Physician rater
These results present interesting preliminary data about the SAPB. However, the study is relatively underpowered to detect major complications, so the intervention still needs further study.
, McMaster University