1. RIB FRACTURES AND THE SERRATUS PLANE BLOCK
Matthew Carr MD
PGY-3
Brookdale Emergency Medicine

2. RIB FRACTURES

3. RIB FRACTURES
The most common injuries resulting from blunt chest trauma (25%)
Usually seen on x-ray
But we can also use ultrasound!

4. ULTRASOUND FOR RIB FRACTURES
Sensitivity
Ultrasound 80-78%
Plain radiography 23-12%
Clinical acumen 26%
Why does it matter?
Gauge severity of traumatic mechanism
Disposition
Analgesic requirements
Further studies (CT)
ACEP guidelines:

5. 20 patients with minor blunt chest trauma
X-rays reviewed by 2 radiologists
Ultrasound performed by 1 radiologist
Patients all had negative radiographs
Fractures of the rib, costochondral junction, and costal cartilage were denoted by a clear disruption of the anterior echogenic margin
26 fractures were found in 18 of the 20 patients
Bottom line: US reveals more fractures

6. 61 patients with suspected rib fractures US vs. 2 view X-ray
US found 58 rib fractures in 33 patients
X-ray found 32 rib fractures in 20 patients
Also showed that US takes less time than radiology studies
The average duration of USG was (12 ± 3) min (range 7-17 min), whereas the duration of radiography was (27 ± 6) min (range min)
US = better and faster than X-ray

7. METHOD Linear transducer
Use a lot of gel to minimize pain to the patient
Look in the area of maximum tenderness
Slide along length of rib, can look in both axes
Disruption of anterior cortex
Hematoma
Bending with compression

11. Rib
With compression

12. PEARLS AND PITFALLS
Remember the angle of the ribs necessitates angling of the probe. 
Keep the probe perpendicular to the rib surface. 
Use a copious gel to enable minimal pressure on a painful area.
Look for multiple fractures when one is found.
Some fractures will show a hematoma around the fracture area
ACEP guidelines:

13. SERRATUS PLANE BLOCK

14. Compared injection superficial vs. deep to serratus anterior muscle
Gadolinium and MRI to view spread
Wide spread for superficial or deep injection, more to posterior area when injected superficially
Mean duration of paresthesia:
752 min for intercostal nerves, 778 for motor nerves after superficial injection
386 min for intercostal nerves, 502 for motor nerves after deep injection

15. PROCEDURE Place patient on monitor and pulse ox Position
Be aware of local anesthetic toxicity symptoms
Position
Lateral decubitus
Supine if lateral decub not possible
Linear probe at 5th intercostal
Transverse plane
Marker facing nipple
Mid-axillary line

16. PROCEDURE Clean, prep Insert needle, in plane approach
Inject 1-2 ml, confirm by seeing fascial plane separate
Inject 2-3 ml at a time, up to 30 ml total
0.25% bupivicaine
toxic dose 3 mg/kg

19. BENEFITS OF THE BLOCK Adequate analgesia Decrease the use of opioids
Altered sensorium, decrease in respiratory drive
Maintain pulmonary function, compliance with IS
Prevent pneumonia

20. RISK FACTORS FOR MORTALITY IN BLUNT CHEST TRAUMA
Systematic review and meta-analysis evaluated risk factors that contributed to mortality in blunt chest trauma patients
Advanced age doubles your risk of death. 
Age > 64 had an OR for death of 1.98 ( , 95% CI)
Three or more rib fractures doubles your risk of death
OR of 2.02 ( , 95% CI)
Pre-existing cardiopulmonary disease (CHF) doubles risk of death
OR of 2.43 ( , 95% CI)
Development of pneumonia has a huge impact on mortality
OR 5.24 ( , 95% CI)
Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012 Jan;43(1):8-17. doi: /j.injury Epub 2011 Jan 22.

21. REFERENCES
Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol. 2010 Nov;17(6): doi: /s Epub 2010 Jul 23.
Elham Pishbin a, Koorosh Ahmadi b, Molood Foogardi c, Maryam Salehi d, Farrokh Seilanian Toosi e, Vafa Rahimi-Movaghar. Comparison of ultrasonography and radiography in diagnosis of rib fractures. Chinese Journal of Traumatology 20 (2017)
ACEP guidelines:
R. Blanco, T. Parras, J. G. McDonnell, A. Prats-Galino. Serratus plane block: a novel ultrasound- guided thoracic wall nerve block. Anaesthesia 2013, 68, 1107–1113.
Nagdev A, Mantuani D, Durant E, Herring A. The ultrasound-guided serratus anterior plane block. ACEP Now. 2017;36(3):12-13.
Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):
Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012 Jan;43(1):8-17. doi: /j.injury Epub Jan 22.