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Three Part Question

Is [anterior serratus nerve block] an [effective analgesia] in [adults with rib fractures] in ED?

Clinical Scenario

Is anterior serratus nerve block a good analgesic choice for patients with rib fractures in Emergency Departments?

Search Strategy

Medline
Embase
June 2019
Medline
Search term
1 "RIB FRACTURES"/
2 ((rib OR ribs) ADJ3 fracture*).ti,ab
3 (1 OR 2)
4 exp "NERVE BLOCK"/
5 (nerve ADJ1 block*).ti,ab
6 (4 OR 5)
7 (serratus ADJ1 anterior).ti,ab
8 (3 AND 6 AND 7)

Embase
9 exp "RIB FRACTURE"/
10 ((rib OR ribs) ADJ3 fracture*).ti,ab
11 (9 OR 10)
12 exp "NERVE BLOCK"/
13 (nerve ADJ1 block*).ti,ab
14 (12 OR 13)
15 (serratus ADJ1 anterior).ti,ab
16 (11 AND 14 AND 15)

Search Outcome

Evidence of the successful use of this intervention is limited to case reports only (Camacho, 2019;Durant, 2017; Fu 2017; Bossolasco, 2017). There are also several conference abstracts available to suggest benefits of this approach to analgesia (Teniola 2017, Mbuvah 2017, Malik 2015)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Matteo Bossolasco, Emanuele Bernardi and Lucia Fenoglio 01/05/2017	Single case study - 63 year old male with high BMI, COPD and multiple rib fractures.	63 year old male with multiple rib fractures from the second to the ninth ribs on the right side. Pain score 9-10 on numeric rating scale (NRS). Ultrasound guided serratus plane block was placed and a bolus of 15mls of ropivacaine 0.125% and 15mls of 1% lignocaine 4 minutes after administration pain score had reduced to 2-3. A continuous infusion pump was then connected and a continuous infusion of ropivacaine 0.125% was started at 5mls an hour. 12 hours after admission pain score was 0-2 the catheter was removed on the 7th day.	Improved pain score	Improved pain score	Single case report
Fu P.; Weyker P.D.; Webb C.A.J. Mar 2017 Stanford	98 year old 67kg with hypertension, dementia, seizure disorder, and atrial fibrillation	98 year old who had a fall at home 5 days prior to ED presentation and since then has had pain to right side. On day 1 despite IV opioids and a lidocaine patch her pain score remained at 7 and she was showing signs of delirium.	Improved pain score	Improved pain score	Case Report
Durant, Edward; Dixon, Brittany; Luftig, Josh; Mantuani, Daniel; Herring, Andrew Jan 2017 America	2 Adult patients	2 Case studies ultrasound guided serratus anterior plane block used with 30mls of 0.5% ropivacaine. 1st patient 82 year old right rib fractures 4-9th ribs severe pain despite IV morphine. Pain score improved from 8/10 to 0/10 within 30minutes and lasted till the next morning when she was discharged. 2nd patient 65 year old left rib fractures 5-7th ribs in hospital for 3 days prior to block for severe pain. Thirty minutes after block pain had reduced from 9/10 to minimal able to dress self. Pain returned after 10 hours and required an epidural.	Improved pain score	Improved pain score	Case report.
Camacho F.C.D.O.; Segura-Grau E. Jan-Feb 2019 Brazil	Adult Patient	36 year old presenting with thoracic injury rib fractures 1-8 and concomitant ipsilateral pneumothorax and pleural effusion. chest drain inserted and ultrasound guided serratus anterior block with catheter was inserted on day 8 of admission due to severe pain and deteriorating lung function. A bolus of 20mls of 0.25% levobupivacaine was administered and then a continuous infusion of levobupivacaine 0.12% at 5mls an hour was used. % minutes after initial bolus patient felt a significant relief in pain and after a few further minutes breathing felt easier and cessation of pain at rest was achieved. The following day he had a pain score of 0/10. Infusion was maintained for a total of 5 days during which he received paracetamol and NSAID's but required no opiates.	Improved pain score	Improved pain score	Case report

Comment(s)

Evidence is limited to case reports, some of the benefits of anterior serratus nerve block described in the literature include: their simplicity, their ability to be performed in the supine position and in anticoagulated patients, and their ability to facilitate mobility. They can also be used in multisystem trauma and in patients with head injuries where epidural analgesia and paravertebral block is contraindicated. One review highlights the need for further research to determine optimal local anaesthetic dosing and pharmacokinetics, site of catheter placement, site of injection, and efficacy relative to other blocks (Thiruvenkatarajan 2018)

Clinical Bottom Line

Whilst there are several case reports to suggest anterior serratus nerve block may be beneficial the research into the benefits are limited at present evidence is primarily in the form of case reports.

References

1. Matteo Bossolasco, Emanuele Bernardi and Lucia Fenoglio Continuous serratus plane block in a patient with multiple rib fractures. Journal of clinical anesthesia May 2017; vol. 38 ; p. 85-86
2. Fu P.; Weyker P.D.; Webb C.A.J. Case report of serratus plane catheter for pain management in a patient with multiple rib fractures and an inferior scapular fracture A and A Case Reports Mar 2017; vol. 8 (no. 6); p. 132-135
3. Durant, Edward; Dixon, Brittany; Luftig, Josh; Mantuani, Daniel; Herring, Andrew Ultrasound-Guided serratus plane block for rib fracture The American journal of emergency medicine Jan 2017; vol. 35 (no. 1); p. 197
4. Camacho F.C.D.O.; Segura-Grau E. Continuous serratus anterior plane block provides analgesia in multiple rib fractures: a case report Brazilian Journal of Anesthesiology Jan Feb 2019; vol. 69 (no. 1); p. 87-90