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Rib Fracture Management Protocol (RIG Scoring)

Definition

The Rib Injury Guideline (RIG) provides a structured framework for evaluating, admitting, and managing patients with rib fractures. The RIG score stratifies patients by risk for respiratory compromise and pain-related morbidity, guiding triage, analgesia, and the need for Advanced Pain Service (APS) involvement.

Principles

  • The RIG score determines admission level and pain management intensity.
  • Early multimodal analgesia and respiratory optimization reduce pulmonary complications.
  • Consider APS consult for RIG ≥ 6, uncontrolled pain, or epidural indication.
  • ICU admission is warranted for high-risk patients (RIG >10) or those requiring advanced airway or analgesic interventions.

Stepwise Evaluation

1. RIG Scoring Criteria

Criteria Points
Age > 60 years 4
Incentive spirometer < 750 mL (assessed 1 hr after PO pain meds) 4
Imaging shows severe pulmonary contusions (unilateral or bilateral) 2
>4 rib fractures 2
History of COPD, smoking, or asthma 2
Presence of hemothorax, pneumothorax, or chest tube in situ 2
Pain score >6/10 (1 hr after PO analgesia) 1
Weak or absent cough 1

Total Score Interpretation: - >10 points: ICU admission
- 3–9 points: Floor admission
- <2 points: Eligible for discharge

2. Initial Evaluation and Supportive Care

  1. Assess pain, oxygenation, and work of breathing.
  2. Calculate RIG score.
  3. Determine admission level and notify appropriate service (Trauma, ACS, ICU).
  4. Encourage incentive spirometry and pulmonary toilet on all admitted patients.
  5. Begin multimodal analgesia immediately on admission or at time of extubation.

Management

Multimodal Analgesia Regimen

Scheduled (unless contraindicated): - Acetaminophen 650 mg PO q6h - Gabapentin 200 mg PO q8h - Lidocaine transdermal patch (Lidoderm) - Methocarbamol 750 mg PO TID (Robaxin) - Ketorolac (limit 48 hours; avoid if GFR <30 mL/min, orthopedic injury, or cerebrovascular bleeding)

PRN Options: - Oxycodone PO for breakthrough pain
- IV Dilaudid or IV Morphine for uncontrolled pain

Reassess pain after 8–12 hours. - If pain remains >6/10, consider PCA or Epidural analgesia per attending discretion.

Epidural Analgesia

Indications: - Flail chest
- Escalating narcotic requirements with persistent pain >6/10
- Underlying cardiopulmonary disease (COPD, CHF, etc.)

Contraindications: - Patient refusal or inability to consent
- Platelets <50,000
- INR >1.5
- Infection at insertion site
- Epidural/spinal hematoma
- Prophylactic LMWH within 10 hrs or therapeutic LMWH within 24 hrs
- Major TBI (GCS <9)
- Hemodynamic instability
- Deep sedation (RASS < –3)
- Transverse process fractures near intended insertion level

Consult APS for placement and management.

Pain Escalation Pathway

  1. Start multimodal analgesia.
  2. If pain >6 despite optimized oral/IV therapy, initiate PCA or epidural.
  3. Reassess frequently and titrate therapy based on RIG score and functional pain response.

References

  • Arizona Trauma Association, 2023. Thoracic: Rib Injury Guidelines (RIG) – Rib Fracture Protocol.
  • American Society of Regional Anesthesia (ASRA), 2018. Guidelines for Antithrombotic Therapy and Regional Anesthesia.
  • Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
  • Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
  • *Institutional Trauma and ACS Policies, 2025.