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Emerg Med J. 2007 December; 24(12): 848–849.
PMCID: PMC2658360

Best Evidence Topic Reports

Epidural analgesia/anaesthesia versus systemic intravenous opioid analgesia in the management of blunt thoracic trauma

Report by Richard Parris, Consultant in Emergency Medicine

Checked by Barbara Scobie, ST3 in Emergency Medicine

Royal Bolton Hospital, UK

Abstract

A short cut review was carried out to establish whether an epidural infusion provided any advantage over intravenous analgesia in the management of blunt thoracic trauma. Only four papers presented evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are presented in table 22.. The clinical bottom line is that epidural analgesia may provide better pain relief, but may not alter clinical outcomes.

Table thumbnail
Table 2

Three part question

In a [patient with blunt thoracic injury] is an [epidural infusion rather than intravenous administration of opioids] [superior in relieving pain or reducing complications] from his chest wall trauma?

Clinical scenario

A 65‐year‐old pedestrian involved in a road traffic accident has sustained four fractured ribs and has a small area of contused lung noted on the chest x ray. You wonder whether placement of an epidural catheter and infusion of opioid or local anaesthetic agents offers any benefit over intravenous opioid analgesics (by intermittent bolus or patient controlled analgesia) in relieving the patient's pain or reducing complications from his injury.

Search strategy

Medline: [rib fracture.exp OR thoracic injuries.exp] AND [injections,epidural exp OR analgesic epidural exp]

Embase: [Thorax blunt trauma OR thorax injury OR rib fracture] AND [epidural anaesthesia OR thorax epidural]

Cochrane: Thoracic trauma

Search outcome

Medline produced 56 papers, EMBASE 103, of which four were relevant and of sufficient quality (table 22).).

Comments

The limited quantity and quality of evidence illustrates the difficulties in studying this patient group and determining the most relevant outcomes. A significant number of patients will be excluded due to the presence of contraindications to epidural analgesia or to physician concerns that epidural analgesia may prevent continued assessment of the multiply injured patient. All four studies looked at slightly different patient groups, different treatment regimens and outcomes with consistently poor reporting of timing of placement of epidural catheters and administration of intravenous analgesics. Despite these limitations, the evidence hints that epidural analgesia/anaesthesia is superior to intravenous analgesia. However, it is very difficult to be confident that epidural analgesia/anaesthesia offers superior pain relief and that this effect is translated into improved clinical outcomes with no significant side effects.

Clinical bottom line

On limited evidence from moderate quality studies, epidural analgesia/anaesthesia offers some benefits over intravenous analgesia but further studies are needed to strengthen this conclusion.

References

  • Bulger E M, Edwards T, Klotz P. et al. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004;136:426-30. [PubMed]
  • Moon M R, Luchette F A, Gibson S W. et al. Prospective randomised comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999;229:684-91. [PubMed]
  • Mackersie R C, Karagianes T G, Hoyt D B. et al. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma 1991;31:443-9. [PubMed]
  • Ullman D A, Fortune J B, Greenhouse B B. et al. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth 1989;14:43-7. [PubMed]

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