AuthorsInstitutions

Background

Rib fractures are the most common thoracic injury

Rib fractures are associated with an increase in hospital morbidity and mortality

Pulmonary function can be compromised

Pain control is critical in decreasing the pulmonary complications

Lidocaine 5% patch Mechanism

Penetrates the skin Binds sodium

channels Block influx

sodium Reduce abnormal

ectopic discharges produced by damaged nerves

www.endo.com

Lidocaine Patch Use

FDA Approval: Post herpetic neuralgia

Other Studies: Back pain Headache Postoperative pain after lap ventral

hernia repair Trauma patients with rib fractures

Hypothesis

The lidocaine patch would reduce the amount of narcotic pain medication used by hospitalized traumatically injured patients with rib fractures.

Study Design

Randomized, double blinded placebo controlled Level I evidence

Setting Spectrum Health – Butterworth Hospital Jan 2007 – Aug 2008

Intervention

Randomized trauma patients with rib fractures to receive either Lidocaine or placebo patch

Data collected for 72 hoursAge

Sex

Injury Severity Score

History of asthma/COPD

Mechanism of injury

Number of rib fractures

Chest tube placement

History of tobacco use and current use

Patch Specifics

10 x 14 cm 5% lidocaine applied to non-woven

polyester felt backing 700 mg lidocaine, 3 + 2% absorbed Mean blood concentration 0.13

µg/mL (1/10 of the therapeutic concentration for arrhythmias)

Outcome Variable Assessment 10 point pain scale administered by

nursing Pain assessments were conducted per

hospital protocol (each shift and prior to administering pain medication)

IV and PO narcotic pain medications were analyzed independently

Incidence of pulmonary complications Length of stay

Patients

Inclusion Criteria Trauma patients with rib fracture on

CT/Xray Age > 18 years of age

Exclusion Criteria Inability to communicate a pain score Inability to use an incentive spirometer History lidocaine allergy Open wounds at the site of patch

application

Primary Outcome

Decrease narcotic use when use lidocaine patch after trauma injury with rib fracture

p = 0.88

Pain Assessment and Narcotic Utilization

Outcome comparison of Lidocaine and Placebo groups

Lidocaine group Placebo group

Total IV narcotics used (in mg morphine)*

23 (7, 102) 26 (8, 59) P = 0.88

Total po narcotics used (in tabs Vicodin)*

4 (2, 10) 7 (2.5, 14) P = 0.22

Pain score# 5.6 + 0.4 6.0 + 0.3 P = 0.39

* Median (interquartile range)# Mean + SEM

Outcome comparison of Lidocaine and Placebo groups

Lidocaine group Placebo group

Pulmonary complications#

72.7% (24/33) 72% (18/25) P = 0.95

Length of Stay# 7.8 + 1.1 6.2 + 0.7 P = 0.28

# Mean + SEM

* Median (interquartile range)

Pre-Injury Characteristics of Lidocaine and Placebo groups

Characteristic Lidocaine groupn = 33

Placebo groupn = 25

Age* 54.8 + 3.1 49.7 + 4.0 P = 0.31

Gender (% male) 72.7% (24/33) 76% (19/25) P = 0.78

History lung disease 9.1% (3/33) 20% (5/25) P = 0.27

History of smoking 39.4% (13/33) 24% (6/25) P = 0.22

Current smoker 24.2% (8/33) 20% (5/25) P = 0.70

* Mean + SEM

Mechanism of Injury

Injury Characteristics

Characteristic Lidocaine groupn = 33

Placebo groupn = 25

Injury Severity Score*

17.3 + 1.3 17.9 + 1.3 P = 0.74

AIS (chest)# 3 (3-4) 3 (3-4) P = 0.17

Number of ribs fractured*

5.3 + 0.4 4.9 + 0.4 P = 0.50

Chest tube placed 36.4% (12/33) 24% (6/25) P = 0.31

* Mean + SEM# Median (interquartile range)

Lidocaine Patch in Trauma Patients

Zink et al. Oregon Health & Science University. Presented at EAST. January 2009 Retrospective 29 patients each group Lidocaine 5% patch patients had

decreased pain scores, but no difference in narcotic use

Conclusion: Further prospective studies needed

Conclusions

Lidocaine patches do not decrease narcotic pain medication use in hospitalized trauma patients with rib fractures

No difference in pain scores pulmonary complications length of stay

Should not be routinely used in multi-system trauma patients with rib fractures