Early treatment goal uncertainty as a barrier to regional analgesia and respiratory deterioration in traumatic rib fractures: a propensity-weighted analysis.

PURPOSE: Patients with multiple rib fractures (≥ 3) admitted to the intensive care unit (ICU) are at high risk of early respiratory deterioration, for which timely and effective analgesia is essential. Although multimodal analgesic strategies are widely recommended, their real-world implementation may be influenced by variability in early clinical decision-making, including treatment goal uncertainty (TGU). We aimed to investigate the association between early TGU, analgesic strategy selection, and respiratory outcomes in critically injured patients with rib fractures. METHODS: This single-center observational cohort study included 236 adult ICU patients with ≥ 3 radiologically confirmed rib fractures who did not require invasive mechanical ventilation at admission (2020-2024). TGU within the first 48 h was assessed using blinded electronic medical record review as a process-level marker of variability in early care prioritization. Analgesic strategies were categorized as regional-based analgesia (RA), systemic-dominant analgesia (SA), or multimodal conservative management. The primary outcome was respiratory deterioration, defined as a composite of escalation of respiratory support, endotracheal intubation, or pulmonary complications requiring intervention. Associations were evaluated using propensity score overlap weighting and adjusted regression models. RESULTS: High TGU was identified in 39.8% of patients and was associated with a higher likelihood of respiratory deterioration (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.35-4.58; P = 0.004). Patients with high TGU were less likely to receive RA (P = 0.01). In the weighted cohort, RA was associated with a lower likelihood of respiratory deterioration compared with systemic-dominant analgesia (aOR 0.44; 95% CI 0.23-0.85; P = 0.01). CONCLUSIONS: Early TGU is common in ICU patients with multiple rib fractures and, in this observational cohort, was associated with lower use of regional analgesia and a higher likelihood of respiratory deterioration. These findings may reflect the clinical relevance of early care-prioritization variability and support further evaluation of multidisciplinary goal clarification and more standardized RA pathways in this setting. Causal inferences cannot be drawn from this study.