Pathways & Algorithms
Elderly Rib Fracture Pathway
Pathway for elderly patients with rib fractures covering functional pain assessment, multimodal pain management, and mobilization protocol.
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Patients over the age of 60 with rib fractures are a vulnerable group who often should be admitted to a high level of care for:
- Respiratory monitoring
- Pain management
- Pulmonary hygiene
- Supportive care
Three Vital Components of This Pathway
Pain should be assessed not just at rest, but with functional activities (deep breath, cough, movement) • A pain score of ≤ 4/10...Section
Three Vital Components of This Pathway
Pain should be assessed not just at rest, but with functional activities (deep breath, cough, movement) • A pain score of ≤ 4/10...1. Functional Pain Assessment
- Pain should be assessed not just at rest, but with functional activities (deep breath, cough, movement)
- A pain score of ≤ 4/10 with deep inspiration is often the target
- Assess frequently — pain management is dynamic
2. Multimodal Pain Management
Multimodal analgesia minimizes opioid requirements and their associated risks (respiratory depression, delirium) in elderly patients.
- Non-opioid systemic agents: acetaminophen, NSAIDs (if no contraindication), gabapentinoids
- Regional anesthesia: intercostal nerve blocks, serratus anterior plane block, epidural, paravertebral block
- Opioids: used judiciously, titrated to functional pain scores
Specific agents, doses, and block choices are institution-specific and require attending and anesthesia guidance.
3. Mobilization Protocol
- Out-of-bed as early as tolerated
- Incentive spirometry
- Physical therapy consultation
- Incentive spirometry use encouraged
- Pulmonary hygiene: deep breathing exercises, cough assistance (pillow splinting)
Why This Population Is High Risk
Pneumonia (splinting from pain → atelectasis) • Respiratory failure requiring intubation • Mortality (especially > 3 rib fractures...Section
Why This Population Is High Risk
Pneumonia (splinting from pain → atelectasis) • Respiratory failure requiring intubation • Mortality (especially > 3 rib fractures...- Pneumonia (splinting from pain → atelectasis)
- Respiratory failure requiring intubation
- Mortality (especially > 3 rib fractures or bilateral fractures)
Studies have demonstrated that each additional rib fracture increases mortality and pneumonia rates in elderly patients.
Admission Threshold Considerations
Age ≥ 65 with multiple rib fractures (≥ 3) • Bilateral rib fractures • Pulmonary contusionSection
Admission Threshold Considerations
Age ≥ 65 with multiple rib fractures (≥ 3) • Bilateral rib fractures • Pulmonary contusion- Age ≥ 65 with multiple rib fractures (≥ 3)
- Bilateral rib fractures
- Pulmonary contusion
- Hemothorax or pneumothorax
- Respiratory distress or hypoxia
- Inadequate pain control
- Comorbidities (COPD, CHF, anticoagulation)