Comparison of Epidural and Paracostal Catheter Placement for Pain Control After Rib Fractures

Inclusion Criteria:

- >/= 3 rib fractures on a single side

- Admitted to the Surgical ICU

- Recruited within 24 hours of admission

Exclusion Criteria:

- Patient allergy to local anesthetics

- Patient refusal

- Inability to consent for any reason

- Prisoners

- Age < 18

- Pregnant women (pregnancy screen performed as part of routine trauma admission labs)

- Absolute contraindications for either thoracic epidural or paracostal pain catheter
placement which include:

1. Localized rash or skin infection over the likely site of insertion (We never want
to translocate infectious material from the skin to the epidural space or even
into the soft tissue where paracostal catheters lay, although for these there is
more flexibility in adjusting placement)

2. Spinal/vertebral instability/fracture including any significant vertebral body
injury and 3 or more spinous process fractures near the level of desired epidural
placement (transverse process fractures are not considered a contraindication)

3. History of extensive back surgery at the level of desired epidural placement

4. Severe aortic stenosis, mitral stenosis, or pulmonary hypertension

5. Inability to correct coagulopathy (to International Normalized Ratio>1.5)

6. Persistent hemodynamic instability (hypotension with Systolic Blood Pressure<90
that does not respond to initial fluid boluses and requires ongoing pressors
beyond the 72 hour window for enrollment)

7. Inability to cooperate and participate in placement (if intubated and sedated,
for example) or to lie in the correct position for placement (lateral decubitus
for paracostal pain catheters, either sitting up or lateral decubitus for
epidural placement)

8. Concern for elevated intracranial pressure (we imagine these patients will also
be intubated)