Emergency Medicine · Medical Literature
Effect of early analgesia with erector spinae plane block to reduce ventilation after severe chest trauma: the multicentre randomised controlled TARGET study protocol
Abstract
Introduction Blunt chest trauma is frequently associated with rib fractures, and inadequate pain control may lead to respiratory complications and prolonged ventilatory support. In spontaneously breathing patients, pain impairs coughing and secretion clearance, promoting atelectasis and respiratory failure, while in mechanically ventilated patients, it may delay weaning. Current French guidelines recommend intravenous multimodal analgesia as first-line therapy followed by thoracic epidural or paravertebral block if pain remains uncontrolled. However, these techniques have limited applicability in the trauma setting. The erector spinae plane (ESP) block is a simpler ultrasound-guided regional analgesia technique with fewer contraindications. Although retrospective data suggest potential respiratory benefits, its efficacy has not been evaluated in randomised controlled trials. This study aims to assess whether early initiation of a continuous ESP block reduces ventilatory support duration after blunt chest trauma. Methods and analysis The EffecT of eARly analGesia with ErecTor spinae plane block (TARGET) trial is a multicentre, superiority, randomised controlled trial including adult patients (≥18 years) with blunt chest trauma and at least three rib fractures on thoracic CT scan requiring intensive care unit admission. Participants are randomised to receive either early continuous ESP block initiated within 6 hours of admission or standard intravenous multimodal analgesia with escalation to thoracic epidural or paravertebral block if indicated. The primary outcome is the number of days alive and free from invasive or non-invasive curative ventilation within 30 days after randomisation or hospital discharge. Randomisation is stratified by centre and age ( Ethics and dissemination The study has been approved by the ethics committee CPP Sud-Ouest IV on 17 April 2023 (approval number 23.00675.000144). The study began on 22 October 2023. Results will be disseminated
Clinical relevance
Blunt chest trauma with rib fractures represents a high-acuity emergency medicine and critical care challenge in which inadequate analgesia directly drives respiratory failure, prolonged mechanical ventilation, and ICU morbidity. Current French guidelines endorse thoracic epidural or paravertebral block as escalation therapy, yet both techniques carry significant contraindications and technical barriers in the acute trauma setting, leaving a meaningful gap in evidence-based regional analgesia options. The TARGET trial addresses this gap by rigorously evaluating the erector spinae plane (ESP) block—a simpler, ultrasound-guided technique with a more favorable safety profile—as an early intervention to reduce ventilatory support burden in this population.
Key findings
NOTE: The abstract describes a study protocol (not yet completed results); therefore, no primary efficacy or safety outcome data are available. The following represent key methodological and design parameters as reported: 1. Study design: Multicentre, superiority, randomised controlled trial (RCT) — the highest level of interventional evidence design. 2. Target population: Adult patients (≥18 years) with blunt chest trauma and ≥3 rib fractures confirmed on thoracic CT scan requiring ICU admission. 3. Intervention: Early continuous ESP block initiated within 6 hours of ICU admission versus standard intravenous multimodal analgesia (with escalation to thoracic epidural or paravertebral block if pain remains uncontrolled). 4. Primary outcome: Number of days alive and free from invasive or non-invasive curative ventilation within 30 days post-randomisation or hospital discharge — a clinically meaningful, patient-centered composite endpoint. 5. Randomisation stratification: By centre and age (threshold not fully specified in the provided abstract), reflecting important prognostic variables in chest trauma outcomes. 6. Ethics approval and initiation: Approved by CPP Sud-Ouest IV on 17 April 2023 (approval number 23.00675.000144); trial commenced 22 October 2023. Quantitative outcome data (effect sizes, CIs, p-values, NNT/NNH) are not yet available as this is a protocol publication.
Practice implications
Clinicians managing blunt chest trauma with ≥3 rib fractures in the ICU should recognize that the ESP block represents a promising, technically accessible alternative to thoracic epidural or paravertebral block, particularly in patients where coagulopathy, spinal injury, or hemodynamic instability limits conventional regional techniques. Until TARGET trial efficacy and safety results are published, practice should align with current guidelines—multimodal IV analgesia as first-line with escalation to neuraxial or paravertebral block when feasible—while considering ESP block in patients with contraindications to standard regional approaches given its more favorable risk profile. Institutions should monitor TARGET trial results, as positive findings could support early protocolized ESP block initiation (within 6 hours of admission) as a standard-of-care intervention to reduce ventilator days and associated ICU morbidity in this patient cohort.