American Journal of Emergency Medicine xxx (xxxx) xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

An alternative plane block for multiple rib fractures: Rhomboid

Intercostal and Sub-Serratus block (RISS)
Ahmet Murat Yayik a, Muhammed Enes Aydin b, Erdal Tekin c, Ali Bilal Ulas d, Ali Ahiskalioglu b,⁎
a
Department of Anesthesiology and Reanimation, Regional Training Research Hospital, Erzurum, Turkey
b
Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
c
Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
d
Department of Thorax Surgery, Ataturk University School of Medicine, Erzurum, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Rib fractures are a common injury, which occur after severe blunt chest trauma. Sufficient and early pain control
Received 17 June 2019 is essential to avoid respiratory complications. In recent years, the serratus plane and the erector spinae plane
Received in revised form 4 September 2019 blocks have been used in ED for pain related to rib fractures. The Rhomboid Intercostal and Sub-Serratus
Accepted 5 September 2019
(RISS) block can be utilized for pain control in patients with multiple rib fractures. We report two cases of patients
Available online xxxx
with multiple rib fractures in which pain reduction was achieved with application of the RISS block.
Keywords:
© 2019 Elsevier Inc. All rights reserved.
Rib fracture
Plane block
Rhomboid Intercostal and Sub-Serratus

1. Introduction block is a novel ultrasound-guided block that has been shown to pro-
vide analgesia from T2–T11 dermatomes [3].
Multiple rib fractures can be an injury sustained after severe blunt We report two cases in which adequate analgesia was achieved in
chest trauma and are associated with increased morbidity and mortality patients with multiple rib fractures using the RISS block.
in patients. Patients may experience severe and debilitating pain attrib- Informed written consent was obtained from the patients whose
uted to multiple rib fractures. If pain control is not adequately ad- data are used in this report.
dressed, patients may experience difficulty coughing and shallow
respirations, which can result in respiratory complications including re-
duced respiratory capacity, sputum retention, atelectasis, and pneumo- 2. Case reports
nia [1].
The rhomboid intercostal block was first described in 2016 [2]. The 2.1. Case-1
region described is known as the triangle of auscultation that is
bounded medially by inferior part of the trapezius, inferiorly by the su- A 45-year-old male presented to our emergency department after a
perior border of latissimus dorsi, and laterally by the medial border of motor vehicle accident with blunt chest trauma. The patient was diag-
the scapula. In this ultrasound-guided block, the local anesthetic drug nosed with multiple (2nd–7th) left sided posterior rib fractures. Despite
is administered between the rhomboid major and the intercostal mus- 50 mg dexketoprofen trometamol and 2 mg morphine given intrave-
cle fascia at the level of T6–T7 and provides analgesia of T3–T8 derma- nously, adequate analgesia was not achieved. A RISS block was per-
tomes [2]. Elsharkawy et al. described a modification to the rhomboid formed and adequate pain control was obtained 30 min after the
intercostal block to expand dermatomal coverage. They describe the block. Sensory block was tested with cold alcohol-soaked compress,
RISS (Rhomboid Intercostal and Sub-Serratus) block that is a two- the loss of cold sensation was achieved at the T2–T11 dermatome site.
injection block of both the rhomboid intercostal and sub-serratus Pain control was assessed using the Visual Analogue Scale (VAS 0: no
space. After the first injection, the ultrasound probe advances caudally pain; VAS 100: the worst possible). Prior to the procedure, the patient
and laterally distal to the inferior angle of the scapula, the second injec- reported a VAS score of 90/100. Thirty minutes after the procedure,
tion apply between the serratus and intercostal muscle fascia. The RISS the patient reported a VAS score of 20/100. Notably, twenty-four
hours after the procedures, the patient reported a VAS score of 0–20/
⁎ Corresponding author at: Ataturk University School of Medicine, Department of
100 at rest, and 0–40/100 during deep inhalation. In addition to the
Anesthesiology and Reanimation, 25100 Yakutiye, Erzurum, Turkey. block, the patient received dexketoprofen trometamol 50 mg every
E-mail address: [email protected] (A. Ahiskalioglu). 12 h intravenously.
2 A.M. Yayik et al. / American Journal of Emergency Medicine xxx (xxxx) xxx

2.2. Case-2 sagittal plane orientation, 1–2 cm medial to the medial scapula at the
T5–T6 level. The trapezius muscle, rhomboid major muscle, ribs, inter-
A 65 year-old-woman with multiple left-sided postero-lateral rib costal muscle and pleura were visualized respectively using ultrasound.
fractures (3rd–9th) after a motor vehicle accident was admitted to the A sonovisible 50 mm needle was inserted from the cranial to the caudal
emergency intensive care unit. A left sided chest tube was previously direction using the in-plane technique. The needle was advanced be-
placed for pneumothorax and the patient did not have adequate pain tween the rhomboid major and intercostal muscle fascia. The location
control with dexketoprofen 50 mg twice daily and 50 mg tramadol of the needle was confirmed with 2 mL saline solution, after which
every 8 h. A RISS block was performed. Prior to the procedure, the pa- 20 mL local anesthetic mixture was administered. Then the probe was
tient reported a VAS score of 80/100. Twelve hours after the procedure, advanced caudally and laterally to identify the plane between the
the patient reported a VAS score of 0–40/100. In addition to the RISS serratus and intercostal muscle for the sub-serratus block at T9 level
block, the patient received dexketoprofen trometamol 50 mg twice (Fig. 1). To confirm the position of the needle, a 2 mL saline injection
daily and paracetamol 10 mg/kg every 6 h intravenously. Forty eight was made and 10 mL local anesthetic mixture was injected between
hours after the procedures, the patient reported a VAS score of 0–40/ the serratus and intercostal muscle fascia.
100.
3. Discussion
2.3. The RISS block technique
Effective analgesia is essential in patients with multiple rib fractures
A total mixture of 30 mL was made using 15 mL 0.5% bupivacaine, to reduce respiratory complications. Multiple analgesia modalities have
2 mL 8 mg dexamethasone as an adjuvant to prolong the block duration, been utilized for the pain control in patients with multiple rib fractures
and 13 mL normal saline. The patient was placed in the lateral decubitus including systemic opioids, ketamine, epidural placement, and regional
position with the ipsilateral arm adducted across the chest, allowing for anesthesia including paravertebral, interpleural and serratus-erector
lateral scapula movement thus opening up the thoracic cavity. The pro- spinaea blocks [4,5]. We describe the RISS block for pain control in pa-
cedure was performed using a high frequency linear ultrasound probe tients with multiple rib fractures. In the case reports described above,
under sterile conditions. The ultrasound probe was placed in the oblique the RISS block resulted in adequate pain control. In this block, the

Fig. 1. A, B. Ultrasound, patient set up and sonographic image for rhomboid intercostal plane block Fig. 1 C, D. Ultrasound, patient set up and sonographic image for sub-serratus block. TRM:
Trapezius Muscle, RM: Rhomboid Muscle, LDM: Latissimus Dorsi Muscle, SAM: Serratus Anterior Muscle.
 A.M. Yayik et al. / American Journal of Emergency Medicine xxx (xxxx) xxx 3

injection is performed between the intercostal muscles and, the serratus block has been provided for superior analgesia over routine care. The
and rhomboid muscles. The local anesthetic solution is spread in the fa- RISS block may be a good alternative or addition in the management
cial plane and its blocks the ventral and dorsal radii of the thoracic inter- of pain control in multiple rib fractures as a part of multimodal analge-
costal nerves to provide effective analgesia in patients with rib fractures sia. Further studies evaluating the RISS block are needed to explore the
and those requiring chest tubes. The RISS block is more superficial and efficacy and appropriate volume and concentration of medications used.
easier to perform compared to paravertebral block. As a result, this
block could be used with increasing frequency in the emergency
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