Washington University Emergency Medicine Journal Club – August 11, 2026
Dr. Brian Cohn
Hey all,
This month’s journal club will be on regional anesthesia, led by colleagues from our wonderful ultrasound division. The PGY-1, PGY-2, and PGY-4 articles will be appraised using the Therapy form, and the PGY-3 article will be appraised using the Single Arm Interventional Study form.
Vignette
You’re two hours into a busy evening shift when EMS rolls in a 74-year-old man who was found at the bottom of a flight of stairs at his grandson’s birthday party. He is awake, in obvious distress, and splinting the left side of his chest with every breath.
He arrives alert and oriented, but visibly uncomfortable. His blood pressure is 158/92, heart rate is 104, respiratory rate is 26, and oxygen saturation is 91% on room air, coming up to 95% on 2L nasal cannula. He is taking shallow, guarded breaths and refuses to cough. Chest CT shows acute fractures of the left 5th through 9th lateral ribs with a small pulmonary contusion and no pneumothorax or hemothorax. His incentive spirometry volume at bedside is a dismal 500mL, and he grades his pain at 9 out of 10 despite Tylenol, Robaxin, lido patches and escalating doses of Dilaudid. He has a history of COPD and takes apixaban for atrial fibrillation.
The nurse asks whether you’d like to keep titrating up the opioids. Your attending notes that multimodal analgesia and aggressive pulmonary toilet are the cornerstone of rib fracture care, and that admission for pain control and monitoring is the usual course. You remember hearing about a growing body of evidence suggesting that fascial plane blocks placed early in the emergency department improve pain and respiratory mechanics in rib fracture patients and you wonder whether you could place an erector spinae or serratus anterior plane block yourself, right now, before he’s even admitted. You order the opioids the nurse is already drawing up, but decide that after your shift you’re going to do a deeper dive into the evidence.
PICO Question
Population: Adult patients with traumatic rib fractures presenting to the ED or
admitted to a trauma service
Intervention: Regional anesthesia (erector spinae plane block or serratus anterior
plane block), including earlier administration
Comparison: Standard/routine analgesia alone, sham procedure, or delayed
regional anesthesia
Outcome: Pain scores (at rest and with inspiration), opioid/rescue analgesia
requirements, pulmonary function (incentive spirometry), hospital/ICU length of
stay, and complications (pneumonia, mortality)
Article 1: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of
ultrasound-guided erector spinae plane block compared to sham procedure in adult
patients with rib fractures presenting to the emergency department: A randomized
controlled trial. Acad Emerg Med. 2024 Apr;31(4):316-325. [Answer Key].
Article 2: Maghsoudi T, Bower K, Locklear T, et al. How Timing of Regional
Anesthesia Impacts Outcomes in Traumatic Rib Fracture Patients: A Trauma Quality
National Improvement Program-Based Study. J Surg Res. 2026 Jun;322:104-112.
[Answer Key].
Article 3: Palachick BJ, Carver RA, Byars DV, Martyak MT, Collins JN. Erector Spinae
Plane Blocks for Traumatic Rib Fractures: A Prospective, Interventional Study. Am
Surg. 2022 Sep;88(9):2124-2126. [Answer Key].
Article 4: Partyka C, Asha S, Berry M, et al. Serratus Anterior Plane Blocks for Early
Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg.
2024 Jul 1;159(7):810-817. [Answer Key].
Bottom Line
We examined the medical literature for evidence on regional anesthesia techniques for managing pain in patients with traumatic rib fractures, spanning erector spinae plane block (ESPB), serratus anterior plane block (SAPB), and the timing of regional anesthesia (RA) administration more broadly.
A single-center randomized controlled trial from India involving 46 patients found that ultrasound-guided ESPB produced significantly lower NRS pain scores than blunt-tip pressure sham at rest and during deep inspiration at 30, 60, and 120 minutes post-intervention (p < 0.001), though this difference lost significance by 360 minutes. Rescue analgesia use was about 50% lower in the ESPB group compared to sham (median 10 mg vs. 20 mg morphine equivalents, p ≤ 0.01). There was no significant difference in chest expansion or adverse events between groups, and no serious adverse events occurred. Lack of true blinding (patients could likely tell whether they received the block) and external validity concerns — the trial used IV tramadol, an opioid not typically used at U.S. institutions — limit generalizability of these results.
A retrospective, observational study using 2021 Trauma Quality Improvement Program (TQIP) data evaluated the use regional anesthesia (RA), which included epidural, muscular, subcutaneous, and peripheral nerve/plexus anesthetic administration. Using nearest neighbor matching for comparison, the authors found that earlier RA administration was associated with shorter hospital length of stay at every threshold examined: 5 vs. 7 days for RA given within 4 hours (p = 0.0102), 6 vs. 7 days within 12 hours (p = 0.0008), and 6 vs. 7 days when given within 24 hours (p = 0.0001). Delaying RA beyond 24 hours was linked to 2.5-fold increase in unplanned ICU admissions (30 vs. 12, p = 0.0046) and more ventilator days. As a retrospective, observational study, this is limited by selection bias, confounding, and recall bias, and the authors did not assess pain scores, analgesia use, or patient satisfaction.
A small, single-arm prospective study of ESPB in trauma-service patients with multiple rib fractures found that mean pain scores decreased from 7.93 (SD 1.95) pre-block to 4.47 (SD 2.40) 16 hours post-block (p < .001), and mean incentive spirometry volumes increased from 1,160 cc to 1,495 cc (p = 0.035). No procedure-related complications occurred. Because this study lacked a comparison group, these changes cannot be attributed to ESPB itself — improvement over the 16-hour interval could reflect the natural course of pain and pulmonary mechanics rather than a treatment effect.
The SABRE trial, a multicenter, open-label RCT from Australia that enrolled a convenience sample of 210 patients found that the primary composite pain outcome (≥2-point reduction and absolute score <4/10 at 4 hours) was met by 41% of the SAPB group vs. 19.6% of controls (RR 0.73, 95% CI 0.60–0.89, p = 0.001; NNT = 5). Cumulative opioid consumption was significantly lower with SAPB at all time points (24-hour median 45 mg vs. 91 mg morphine equivalents, p = 0.006). There were no significant differences in pneumonia, hospital or ICU length of stay, or 30-day mortality, though delirium was numerically higher in the SAPB group (20% vs. 9%, p = 0.09). Lack of blinding for the subjective pain outcome introduces risk of performance bias.
Across all four sources, regional anesthesia techniques (ESPB and SAPB) consistently demonstrated reduced pain scores and opioid requirements in rib fracture patients, with the two randomized trials providing the strongest evidence for a genuine treatment effect. Earlier RA administration, regardless of technique, was also associated with shorter length of stay and fewer unplanned ICU admissions. Safety profiles were reassuring across all four studies. External validity is limited by differing practice settings (India, U.S. trauma registries, Australia) and by two of the four studies lacking blinding or a comparison group. While this evidence is far from compelling, these nerve blocks are safe and seem to at least have some benefit in pain reduction and should be considered for patients with pain due to rib fractures.