lail Chest The management of patients with flail chest has evolved significantly over the

previous decade; however, there is little controversy about the importance of adequate pain control
and chest physiotherapy in these patients. Because delayed and inadequate pain control can result
in atelectasis, pneumonia, and the need for ventilatory support, early aggressive pain control should
be managed by a dedicated pain service. The pain service should utilize regional analgesia that has
been found to provide more effective pain relief with fewer side effects and improved outcomes
relative to intravenous (IV) narcotic administration.12 These effects are likely due to decreased
central nervous system depression with improved pulmonary toilet.20 Regional anesthetics include
epidural catheters, intercostal and intrapleural blocks, and paravertebral blocks. Each method allows
the delivery of local anesthetic, most commonly bupivacaine, through either bolus or continuous
injection, to allow significant pain control without sedation and respiratory depression. Limited
literature exists comparing regional techniques; however, specific patient considerations can guide
choice of technique. The most extensive body of literature supports the use of epidural analgesia for
significant improvement in subjective pain score and pulmonary function tests when compared to IV
opioid analgesia alone. Epidural analgesia has been shown to decrease hospital length of stay, total
ventilator days, and ICU stays.21-23 Direct head-to-head comparisons with narcotic regimens reveal
superior outcomes in patients with epidural anesthesia when compared to IV narcotic use. These
trials also found that epidural analgesia is associated with decreased mortality and fewer pulmonary
complicatind gross neu