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with traumatic rib fractures. Although local regional tech- where there has been a prolonged tourniquet time or another
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niques have been used in the austere environment, techniques cause of rhabdomyolysis or renal failure, NSAIDs should be
such as intercostal nerve blocks and erector spinae blocks are avoided. In cases where opioid medication is required for
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time-consuming and require multiple injections and repeated analgesia, we suggest an adjunct pain control strategy be ini-
treatments by a skilled provider, 13,25 which are not always tiated to reduce opioid use and its deleterious side effects. We
available in a deployed environment. suggest that lidocaine infusions are an easy adjunct to admin-
ister with a low infection risk and a short user learning curve
A recent double-blind, randomized, placebo-controlled trial and, therefore, have applicability to the diversity of medical
regarding the use of intravenous (IV) lidocaine infusions for personnel experience and training that exists in the deployed
adult civilian patients with two or more traumatic rib frac- environment. If the care team has the skills and equipment to
tures may have important combat applications. Lidocaine run an infusion, IV lidocaine can be used. This is particularly
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has general approval from the U.S. Food and Drug Admin- important in non-intubated patients to decrease respiratory
istration for local and regional anesthesia as well as cardiac complications, need for intubation, and likely even mortality.
arrhythmias; systemic use for analgesia is an off-label ap- Another advantage in the austere environment is the stability
plication. This study demonstrated a decrease in pain with of the drug, which requires no special handling or transporta-
movement, increased patient satisfaction, and a trend toward tion, and the ability to administer it with basic medical skills
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reduced opioid use. These prospective findings are consistent and equipment.
with recently published retrospective data, which demonstrate
decreased pain scores, shortened length of stay, and decreased Lidocaine infusions are only efficacious while they are run-
opioid use for trauma patients with rib fractures treated with ning; the analgesic effect wears off quickly once infusion has
IV lidocaine. There is robust safety literature on postopera- stopped. Therefore, this must be just one part of an overall
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tive IV lidocaine use, as summarized in two thorough system- pain management strategy. Although lidocaine toxicity is rare,
atic reviews. 12–14 It has been shown to improve pain scores and providers must be educated about its signs and symptoms, in-
decrease opioid consumption by up to 85%, and a Cochrane cluding tinnitus, so that the infusion can be stopped if they

review did not identify any major adverse events from systemic appear.
lidocaine use. 17,18,28 No incidences of lidocaine toxicity were
observed in the recent randomized trial. The safety profile, Another medication that can be considered for pain manage-
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ease of use, and efficacy of this intervention make it particu- ment in this scenario is ketamine. This is a dissociative anes-
larly well suited for the combat environment. It requires very thetic that is considered safe and effective for battlefield pain
little time to administer and is easier to learn than invasive and does not worsen head injury. The dissociative nature of
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blocks and epidurals. Adequate analgesia to allow for cough- ketamine can make it difficult to evaluate the patient’s neuro-
ing and mobility is paramount for the combat casualty, both to logical status or have them participate in their care; however,
prevent atelectasis and secretion retention as well as for patient lower analgesic doses of ketamine may mitigate this issue.
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comfort as they move through the chain of evacuation. 13,15,18,28 Furthermore, ketamine increases a patient’s heart rate, which
can mask early signs of blood loss. The treating physician may
Recommendations attribute elevated heart rate to ketamine administration and
We recommend an initial lidocaine bolus of 2mg/kg IV lido- not blood loss. Ketamine has been used effectively for combat
caine, followed by a continuous infusion starting at 2mg/kg/h. pain control.
The infusion may be titrated up to the maximum dose of
4mg/kg/h, as needed. 26
Conclusion
For a 70-kg combat casualty with rib fractures, 140–280mg of Combat casualties can have complicated injuries that require
lidocaine would be used per hour. If 2g of lidocaine is placed complex medical care. Rib fractures may not be the most dra-
in 500mL of a 5% dextrose solution, that would provide 7–14 matic injuries faced by the deployed medical team, but they
hours of therapy. can carry significant morbidity and mortality. As body armor
improves, survival from ever-larger blasts becomes possible,
We propose an evidence-based algorithm for the management resulting in more rib fractures. Some soldiers with isolated
of combat casualties with traumatic rib fractures (Figure 1). rib fractures may be able to return to duty with the help of
All patients with rib fractures should receive both acetamin- appropriate analgesia, but many will have concomitant inju-
ophen and NSAIDs if there are no contraindications. In cases ries requiring repatriation for higher-level care. The use of a
thoughtful approach to the care of rib fractures is appropriate.
FIGURE 1 Algorithm for management of rib fractures.
Author Contributions
The initial concept was devised by IB. The manuscript was
drafted by SS and RH. All authors participated in the cre-
ation of the algorithm and review and refinement of the final
manuscript.

Disclosures
The ideas expressed in this paper are the authors alone and do
not reflect the position of the Canadian Armed Forces.

Funding
IV = intravenous; NSAID = nonsteroidal anti-inflammatory drug. No funding was received for this work.

86 | JSOM Volume 23, Edition 1 / Spring 2024