Staged Multimodal Analgesia in Complex Blunt Thoracoabdominal Trauma at a Resource-Limited Hilly Hospital: A CARE-Compliant Case Report

Background: Complex blunt thoracoabdominal trauma is challenging in resource-limited settings, particularly when severe chest pain, respiratory compromise, hemorrhagic shock, and occult intra-abdominal injuries coexist. We report a 59-year-old male who presented following a road traffic accident with hemorrhagic shock, severe hypoxemia, massive left hemothorax, multiple bilateral rib fractures, and a VAS pain score of 10/10. Initial management included tube thoracostomy, massive transfusion with four units of whole blood, vasopressor support, and resuscitation. Subsequent imaging demonstrated traumatic left diaphragmatic rupture, pulmonary contusion, pneumothorax, hemothorax, and bowel herniation. A staged analgesic strategy comprising a transdermal fentanyl patch, bilateral ultrasound-guided erector spinae plane block, and perioperative thoracic epidural analgesia progressively reduced pain from VAS 10/10 to 1/10. Definitive surgery revealed diaphragmatic rupture and Grade IV splenic injury requiring splenectomy and primary diaphragmatic repair. The patient was extubated on the operating table and subsequently underwent early pulmonary rehabilitation without major postoperative pulmonary complications. He was discharged on hospital day 15. This case highlights the feasibility and potential clinical value of individualized, staged multimodal analgesia integrated with resuscitation and definitive surgical management of complex thoracoabdominal trauma in a resource-limited hilly hospital.

Keywords: blunt thoracoabdominal trauma; multimodal analgesia; erector spinae plane block; thoracic epidural analgesia; traumatic diaphragmatic rupture; rib fractures; hemorrhagic shock.