الفهرس 
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Abstract
Pain management of the acutely injured patient with rib fractures can be difficult for even the most experienced emergency physician. Severe pain from multiple rib fractures (or even one) can impair ventilatory function, decreasing the ability to clear respiratory secretions and increasing rates of nosocomial pneumonias.
The ultrasound-guided serratus anterior plane block (SAPB) is a promising single injection method to anesthetize the chest wall in patients with multiple rib fractures, providing optimal emergency department care.
The anterior, lateral chest wall is innervated from the lateral cutaneous branches of the thoracic intercostal nerves (T2–T12). The thoracic intercostal nerves run with the intercostal artery and vein, just under the rib, traveling in an anterolateral direction. As the thoracic intercostal nerve reaches the mid-axillary line, the lateral cutaneous branch of the intercostal nerve pierces the internal intercostal muscle, external intercostal muscle, and serratus anterior muscle to innervate the musculature of the thorax, The serratus anterior muscle is a sonographic landmark, located posterior to the lateral edge of the pectoralis muscle and anterior to the lateral edge of the latissimus dorsi muscle. The distal branches of the thoracic intercostal nerves (lateral cutaneous intercostal nerves) provide innervation to the lateral thoracic cage and lie in the fascial plane just superficial to the serratus anterior muscle.
This study aimed to evaluate the safety and efficacy of serratus anterior muscle block as a regional analgesia technique performed in patient with fracture ribs. This interventional, randomized and controlled study was carried out in Sohag University Hospital, Department of Anesthesia and Intensive Care Unit. Forty patients with lateral multiple rib fractures (3 to 6 in numbers) included in this study. All patients were suffering with excruciating pain and were not responding to conventional analgesics. The patients were randomly assigned into two groups, 20 patients each:
1- (group A) for whom serratus anterior plane block was done under sonographic guide
2- (group B) for iv morphine infusion 0.1mg/kg as aloading dose 10-20mic / kg infusion.
The use of the Visual Analogue Scale (VAS) were explained to all patients (in which 0 represents no pain and 10 the worst imaginable pain).
Demographic data were compared: sex, age, weight, height, body mass index, ASA physical status classification and evaluation of analgesia management of failed block. The use of ultrasound was introduced to improve the success rate and accuracy of the serratus anterior block and to prevent potential complications.
In this study, there were no significant difference between the two groups as regards the demographic data including age, gender and weight of the patients. In group A, the mean pain score before block was 9.1 ± 0.7, while the mean pain score after block was 0.6 ± 0.7. In group B, the mean pain score before iv morphine infusion was 9.3 ± 0.8, while the mean pain score after iv morphine infusion was 1.15 ± 0.8. Pain scores gradually decreased. There were no significant difference between the two groups when the other trauma surveys were compared.
This study found that there were statistically high significant differences between the two groups regarding onset of analgesia and pulse. But, there were no significant differences between the two groups regarding duration of analgesia and analgesia demand.
Conclusion
Ultrasound guided Serratus Anterior Plane block is an effective technique for providing analgesia in patients with anterior and lateral rib fractures with fewer risks of complications.
Recommendations
Ultrasound guided SAPB should be generalized as much as possible for all patients with fracture ribs and to be done by experienced specialist when there were no contraindictions to the block.
Further study on SAPB espicially for intoduce of catheter to prolong period by continuous infusion of local anathetic, pharmackinetics of the drug used, comparing the efficacy of this block with other regional anaesthetic techniques and evaluate the efficacy of Serratus Plane Block for thoracic wall blockade if fractures are occurring in posterior 1/3 part.