Opioid-Tolerant Trauma Patient with Rib Fractures

You are the consultant covering acute pain and you are asked to assist with the analgesic management of a 50-year-old man in the emergency department who has been brought in after a motor vehicle accident. He has been stabilised and has the following injuries: Segmental rib fractures bilaterally with anterolateral flail segments, right rib fractures 4 – 7, left rib fractures 5 – 7, associated mild bilateral pulmonary contusions Non-displaced fracture right femoral shaft, non-displaced left medial malleolar ankle fracture, right radius and ulnar non-displaced fractures He is mildly confused and agitated. He has been commenced on high flow nasal oxygen at 50 L/min FiO2 0.5, and intravenous infusions of ketamine 10 mg/hour and morphine 10 mg/hour. Medical History L 1 – 2 lumbar laminectomy with redo surgery and L 2 – 5 discectomy Anxiety/depression Chronic back pain Current smoker 15 pack-year history Medications Morphine 8 mg/24 hours via implanted continuous intrathecal infusion pump Medical cannabis daily Citalopram 20 mg once daily Observations HR 110 bpm BP 150/85 mmHg RR 30 breaths per minute SpO2 92% on HFNP 50 L/min FiO2 0.5 Weight 110 kg height 178 cm BMI 35 kg/m2