Intravenous lidocaine for the management of traumatic rib fractures: A double-blind randomized controlled trial (INITIATE program of research)

BACKGROUND: Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in postoperative thoracic and abdominal surgery, and we hypothesized that it would be effective in patients with TRFs. METHODS: We conducted a single-center, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72 hours to 96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the visual analog scale. Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful. RESULTS: Thirty-six patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean visual analog scale pain scores demonstrated significant pain reduction with movement in the lidocaine group compared with placebo (7.05 ± 1.72 vs. 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs. 3.82 ± 1.97; p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, although this did not reach statistical significance (8.3; interquartile range [IQR], 7.0-9.6 vs. 6.3; IQR, 5.2-7.1; p = 0.105). Total morphine equivalents were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167; IQR, 60-340 vs. 290; IQR 148-390; p = 0.194). CONCLUSION: These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.