Hi
I need help
**medicalwhump but not really..i just don't know
So my 24 yr old male whumpee,he had leukemia-and now a relapse but he doesn't know yet-is running a fever and it's making him so nauseous..
He slipped and hit his chest against the bathtub edge and got a fracture rib.
The fever and the pain were severe and he couldn't breathe.
Afraid that he might get pneumonia if he kept his breathing that shallow,he was given a an intercostal nerve block.
My questions are😅
Is this a reasonable scenario?
Are analgesic patches a better choice?are they efficient in his case?
*His whole body aches but he won't be given morphin for fear of respiratory centre depression.
How long does it take for the nerve block to wear off?
Could this scenario lead to intubation?what might urge them to intubate him?
I mean i initially wanted him to have pneumothorax but then i was like..maybe not
I appreciate your answer
Thanks so much in advance
Previous rib injury asks: Basic - Surgery - Tension Pneumothorax - Other Rib Injuries - CPR
If it's a single broken rib, the ribs above and below it form a natural splint, so very little is generally needed to actually treat the injury besides a padded splint and a "swath" or piece of fabric/foam that goes around the person's body to hold the arm in place and protect the injury.
Pain-wise, rib fractures definitely hurt, and deep breaths and coughing can be especially painful. You're right that failing to take deep breaths can increase the risk of pneumonia, especially in someone who is already immunocompromised.
To help with this, the person is taught to hold a pillow or folded blanket firmly over the injury when coughing or taking deep breaths (which decreases the movement around the injury). They are also encouraged to take deep breaths often (usually 10 times per hour while awake, and given a chart to help them keep track of this). This is because early on they may not automatically do so or avoid doing so because of the pain.
I really had never heard of an intercostal block being used for rib fractures before your ask (they're usually used for surgery, chronic rib pain, and shingles). They are occasionally used for pain control in rib injuries in the US, though this is more common when surgery is required or multiple ribs are fractured.
A single rib break requires a block on the ribs above and below too, which causes a risk of pneumothorax (from the block itself, not the rib injury) of over 5.6% (about 1 in 20). Since they wear off after 6-12 hours, these would happen multiple times per day to provide pain relief, which is a pretty big risk for something as relatively small as a simple rib fracture. These are also not something a nurse or the patient could do themself, and since otherwise the patient would probably get discharged straight from the emergency department, it would be logistically difficult and expensive.
For a simple rib fracture it would be more likely they'd go with a combination of acetaminophen, ibuprofen, and maybe a few days of an oral opioid like tramadol, hydrocodone or oxycodone. A 24 year old man with normal liver and kidney function on a low dose of an oral opioid is unlikely to have respiratory depression unless they intentionally take more than prescribed. They might also use a lidocaine patch as you referenced. These combined with techniques like wearing a sling when moving, bracing with a pillow while coughing, and icing the area intermittently are generally sufficient for pain control.
There'd be no reason to intubate someone with a simple rib fracture unless they were having some other trouble breathing. Since the rib is naturally splinted, there's no structural problem making it hard to breathe, and if the patient isn't getting enough oxygen because they're breathing shallowly due to pain, it would be a lot easier to give a little oxygen until they could get their pain under control.
Also, a single rib fracture would be unlikely to cause a pneumo- or hemothorax, so if you want to go with that, you're probably gonna need much, much more injury. Even that probably doesn't need intubated, but it might require a hospital stay.
