The levels of recommendation (I-III) and classes of evidence (1-3) are defined at the end of the "Major Recommendations" field.
Efficacy of Analgesic Modalities
Level 1
- Use of epidural analgesia (EA) for pain control after severe blunt injury and non-traumatic surgical thoracic pain significantly improves subjective pain perception and critical pulmonary function tests compared to intravenous (IV) narcotics. EA is associated with less respiratory depression, somnolence and gastrointestinal symptoms than IV narcotics. EA is safe, with permanent disability being extremely rare and negligible mortality attributable to treatment.
Level II
- Epidural analgesia may improve outcome as measured by ventilator days, intensive care unit (ICU) length of stay, and hospital lengths of stay.
- There is some class I and adequate class II evidence to indicate that paravertebral or extrapleural infusions are effective in improving subjective pain perception and may improve pulmonary function.
Level III
- Though paravertebral or extrapleural analgesia is effective, there is an inadequate quantity of comparative evidence or information regarding safety to establish any recommendation with regard to overall efficacy.
- The information regarding both the effectiveness and safety of intrapleural and intercostal analgesia is contradictory and experience with trauma patients is minimal. Consequently no recommendation can be made regarding overall efficacy of this modality.
Clinical Application of Pain Management Modalities to Treatment of Blunt Thoracic Trauma (BTT)
Level I
- EA is the optimal modality of pain relief for blunt chest wall injury and is the preferred technique after severe blunt thoracic trauma.
Level II
- Patients with 4 or more rib fractures who are >65 years of age should be provided with EA unless this treatment is contraindicated.
- Younger patients with 4 or more rib fractures or patients aged >65 with lesser injuries should also be considered for EA.
Level III
- The approach for pain management in blunt chest trauma requires individualization for each patient. Clinical performance measures (pain scale, pulmonary exam/function, arterial blood gas) should be measured as judged appropriate at regular intervals.
- Presence in elderly patients of cardiopulmonary disease or diabetes should provide additional impetus for EA as these comorbidities may increase mortality once respiratory complications have occurred.
- Intravenous narcotics, by divided doses or demand modalities, may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved.
- High-risk patients who are not candidates for epidural analgesia should be considered for paravertebral (extrapleural) analgesia commensurate with institutional experience.
- A specific recommendation cannot be made for intrapleural or intercostal analgesia based on the available evidence but its apparent safety and efficacy in the setting of thoracic trauma has been reported.
Technical Aspects of Epidural Analgesic Agents
Level I
- There is insufficient Class I and Class II evidence to establish any specific techniques of EA as a standard of care.
Level II
- Combinations of a narcotic (i.e., fentanyl) and a local anesthetic (i.e., bupivacaine) provide the most effective EA and are the preferred drug combinations for use by this route. Use of such combinations allows decreased doses of each agent and may decrease the incidence of side effects attributable to each.
Level III
- While reliable literature describes the safe use of EA on regular surgical floors, most victims of blunt thoracic trauma receiving this modality of treatment will have other primary indications for a higher level of care. Consequently, such patients in general, should be nursed in a monitored setting with cardiac monitoring and continuous pulse oximetry.
- There is insufficient evidence at this time to make a recommendation regarding the use of continuous epidural infusion vs. intermittent injection in trauma patients.
Definitions
Strength of Recommendations
Level 1: The recommendation is convincingly justifiable based on the available scientific information alone. It is usually based on Class I data; however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, weak or contradictory Class I data may not be able to support a level 1 recommendation.
Level 2: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. It is usually supported by Class II data or a preponderance of Class III evidence.
Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. It is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.
Evidence Classification Scheme
Class I: Prospective randomized controlled trials (PRCTs) - the gold standard of clinical trials. Some may be poorly designed, have inadequate numbers, or suffer from other methodological inadequacies, and thus may not be clinically significant.
Class II: Clinical studies in which the data was collected prospectively, and retrospective analyses which were based on clearly reliable data. These types of studies include observational studies, cohort studies, prevalence studies, and case control studies.
Class III: Most studies based on retrospectively collected data. Evidence used in this class includes clinical series, databases or registries, case reviews, case reports, and expert opinion.
