A recent study based on Royal College of Emergency Medicine (RCEM) audit data concluded that it was not possible to identify an ED in the UK that performed consistently well in the assessment and management of pain.1 Acute pain following rib fractures leads to a number of potential pulmonary complications, as a result of reduced inspiratory effort, weak cough and immobility.2 Without prompt and effective analgesia, first-line interventions to reduce the risk of pulmonary complications such as chest physiotherapy are unachievable. These complications are often further compounded by the side effects of the pain management regimens employed in emergency and acute care settings. In the older adult with rib fractures, reported side effects of oral analgesia include acute onset delirium, reduced respiratory drive and nausea, vomiting and constipation. Regional analgesic techniques have been demonstrated to provide superior pain relief; however, in the older adult with rib fractures, a number of contraindications and complications have been reported.3 High-quality evidence is also not yet available to support the use of pain blocks in this patient cohort. For …