الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Multiple rib fractures can be an injury sustained after severe blunt chest trauma and are associated with increased morbidity and mortality. Patients may experience severe and debilitating pain attributed to multiple rib fractures. If pain control is not adequately addressed, Patients may have trouble coughing and shallow respirations which can result in respiratory complications including reduced respiratory capacity, sputum retention, atelectasis, and pneumonia. Persistent untreated pain may adversely affect various body systems including endocrine, cardiovascular, immune, neurologic, and Musculo-skeletal systems and require aggressive treatment of pain as well as the resulting complications. Pain management for patients with rib fractures can be very challenging. Traditionally, IVPCA with opioids, epidural, and paravertebral blocks have been used. These techniques, however, may be contraindicated or have limited application in certain patients. Recently, ultrasound guided myofascial plane blocks such as the ESP block, rhomboid intercostal block, and the SAP block have emerged as alternatives, providing excellent analgesia with minimal side effects. Erector Spinae Plane block is described for acute and chronic pain management. The erector spinae are composed of three separate muscles the spinalis, longissimus thoracis, and iliocostalis that function to keep the back upright. In this block, local anesthetic is injected deeper between the erector spinae muscles and the transverse process. The local anesthetic then spreads approximately five levels cephalad and five levels caudad to the location of the block across the thoracolumbar and nuchal fascia. Ultrasound-Guided • Erector Spinae Plane Block is used for chest wall pain management in patients with multiple rib fractures. ESPB is an interfacial plane block. It has been used successfully to manage severe neuropathic pain arising from ribs. The rationale to use ESPB is its likely site of action which is the dorsal and ventral rami of thoracic spinal nerves. ESPB holds promise as a simple and safe technique for thoracic analgesia in acute post traumatic pain. The rhomboid intercostal block was first described in 2016. The region described is known as the triangle of auscultation that is bounded medially by inferior part of the trapezius, inferiorly by the superior border of latissimus dorsi, and laterally by the medial border of the scapula. In this ultrasound-guided block, the local anesthetic drug is administered between the rhomboid major and the intercostal muscle fascia at the level of T6-T7 and provides analgesia of T3-T8 dermatomes. There is a modification to the rhomboid intercostal block to expand dermatomal coverage. They describe the RISS (Rhomboid Intercostal and Sub-Serratus) block that is a two-injection block of both the rhomboid intercostal and sub-serratus space. After the first injection, the ultrasound probe advances caudally and laterally distal to the inferior angle of the scapula, the second injection applies between the serratus and intercostal muscle fascia. The RISS block is a novel ultrasound guided block that has been shown to provide analgesia from T2–T11 dermatomes. The RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia. The RISS block provides analgesia in patients with multiple rib fractures. As there is little data comparing both types of blocks. Therefore, our study aimed to evaluate the efficacy of ultrasound guided rhomboid intercostal • block combined with subserratus plane block versus ultrasound guided thoracic erector spinae block for analgesia in multiple rib fractures. This prospective randomized double-blind study was carried out on 90 patients presenting to intensive care unit with unilateral multiple fractured ribs. Patients were randomized equally using opaque sealed envelopes into 2 groups: • group I: (N=45) patients received (ESPB) in the form of a bolus dose of 30 mL bupivacaine 0.25% injected midway between the uppermost and the lowest fractured rib. • group II: (N=45) patients received Rhomboid intercostal block combined with subserratus plane block (RISS) using a mixture of 30 ml of bupivacaine 0.25 % (20 ml between the rhomboid major and intercostal muscle fascia than 10 ml between the serratus anterior and intercostal muscle fascia.) Summary of our Results • Patients’ characteristics (age, sex, weight, height, and BMI) showed insignificant difference between both groups. • Injury data (number of fractured ribs, flail segment, hemothorax, pneumothorax, hemopneumothorax, chest tube, pulmonary contusion, subcutaneous emphysema) showed insignificant difference between both groups. • Heart rate in ESPB group and RISS group showed significant reduction at 30 min and 6 hrs., 12 hr. and 24 hr. post block as compared to admission without any significant difference between both groups at admission, 30 min, 6hrs and 24hrs post block, while heart rate showed significant reduction at 12hrs in RISS group as compared to ESPB group. • Mean arterial blood pressure in ESPB group and RISS group showing significant reduction at 30 min and 6 hrs., 12 hr. and 24 hr. post block as compared to admission without any significant difference between both groups at admission, 30 min, 6hrs and 24hrs post block, while mean arterial blood pressure showed significant reduction at 12hrs in RISS group as compared to ESPB group. • Respiratory rate in ESPB group and RISS group showed significant reduction at 30 min and 6 hrs., 12 hr. and 24 hr. post block as compared to admission without any significant difference between both groups at admission, 30 min, 6hrs and 24hrs post block, while it showed significant reduction at 12hrs in RISS group as compared to ESPB group. • Oxygen saturation in ESPB group and RISS group showed significant elevation at 30 min and 6 hrs., 12 hr. and 24 hr. post block as compared to admission without any significant difference between both groups at admission, 30 min, 6hrs and 24hrs post block, while it was significantly better at 12hrs in RISS group as compared to ESPB group. • Ratio of partial pressure of oxygen in arterial blood to inspired oxygen concentration in ESPB group and RISS group showed significant elevation at 30 min and 6 hrs., post block as compared to admission without any significant difference between both groups at admission, 30 min and 6hrs post block. • Peak expiratory flow rate in ESPB group and RISS group showed significant elevation at 30 min and 6 hrs., 12 hr. and 24 hr. post block as compared to admission without any significant difference between both groups at admission, 30 min, 6hrs and • 24 hrs post block, while it showed significant elevation at 12hrs in RISS group as compared to ESPB group. • Numerical pain rating scale showed insignificant difference between both groups at Admission, 30min, 6 and 24 hours and was significantly higher in ESPB group than RISS group at 12 hours. • Total morphine consumption (mg) during the first 24 hours was significantly higher in ESPB group than RISS group. • The time (in hours) to first analgesic requirement was significantly shorter in ESPB group than RISS group. • ICU stay and hospital stay (days) were insignificantly different between both groups. • Subcutaneous emphysema was insignificantly different between both groups. LAST and respiratory depression did not occur in both groups.