›Cardiac monitoring if significant trauma or ECG concern
›Oxygen
›Supplemental oxygen if SpO2 less than 92 percent
›Target SpO2 local protocol dependent
›IV access
›Two large bore IV if shock concern
›One IV if stable but analgesia needed
›Immediate interventions
›If tension pneumothorax suspected then immediate decompression per local protocol
›If massive hemothorax suspected then tube thoracostomy per local protocol
Analgesia strategy
›Multimodal pain control
›Acetaminophen
›1000 mg PO every 6 to 8 hours
›Maximum 3000 mg per day in older adults or liver disease risk
›NSAID option if appropriate
›Ibuprofen 400 mg PO every 6 to 8 hours
›Avoid with CKD or high GI bleed risk
›Opioid for breakthrough pain
›Hydromorphone 0.5 mg IV
›Repeat every 10 to 20 minutes to effect with monitoring
›Regional analgesia pathway
›Consider serratus anterior plane block
›Consider erector spinae plane block
›Consider thoracic epidural for severe injury per local protocol
Respiratory support and pulmonary hygiene
›Prevention of atelectasis and pneumonia
›Incentive spirometry
›Scheduled use while awake
›Track volumes for trend
›Early mobilization
›Sit upright
›Ambulation as tolerated
›Secretion management
›Cough encouragement after analgesia
›Suction if needed
Diagnostic sequencing and reassessment loop
›Reassessment cycle
›After analgesia within 30 to 60 minutes
›Pain at rest
›Pain with deep breath
›SpO2 and RR
›Repeat imaging triggers
›Increasing dyspnea
›Increasing crepitus
›New hypoxia
›Consult triggers
›Flail chest or respiratory failure
›Multiple rib fractures with hypoxia
›Need for regional anesthesia service
17Disposition/dispo34
ICU and high acuity criteria
›ICU level care indicators
›Respiratory failure
›Need for noninvasive ventilation
›Need for intubation
›Hemodynamic instability
›Vasopressors
›Ongoing transfusion
›Flail chest with hypoxia
›Persistent SpO2 less than 92 percent despite oxygen
›Rising CO2 on blood gas
Inpatient admission criteria
›Ward admission indicators
›Hypoxia requiring oxygen
›Inadequate pain control on oral regimen
›Poor pulmonary mechanics
›Low incentive spirometry volumes
›Inability to cough
›High risk patient
›Age 65 years or more
›Significant COPD
›Anticoagulant use
Observation pathway criteria
›Observation candidates
›One to two rib fractures suspected
›Mild hypoxia resolved with analgesia
›Stable imaging
›No pneumothorax
›No large effusion
Discharge criteria and follow up timing
›Safe discharge requirements
›Stable vitals
›SpO2 92 percent or more on room air
›Pain controlled on oral medications
›Able to deep breathe and cough
›Reliable follow up
›PCP within 48 to 72 hours if high risk
›Return visit plan for worsening symptoms
18Discharge Instructions/di26
Copy discharge instructions
›Diagnosis and expectations
›Chest wall injury with suspected rib injury
›Pain can last days to weeks and should slowly improve
›Medications
›Acetaminophen as directed on the label
›Ibuprofen as directed on the label if safe for you
›If opioid prescribed
›No alcohol or sedatives
›No driving
›Constipation prevention plan
›Breathing exercises
›Deep breathing and coughing every hour while awake
›Incentive spirometer if provided
›Activity
›Avoid heavy lifting until pain improving
›Walking encouraged as tolerated
›Follow up
›Primary care or clinic follow up within 2 to 3 days
›Earlier follow up if older age or lung disease
›Return to ED now for
›Worsening shortness of breath
›New chest tightness not reproducible with pressing on the ribs
›Fainting
›Fever with worsening cough
›Coughing blood
›Increasing chest wall swelling or spreading crackling under the skin
19References/r12
Guidelines and key sources
›Evidence based sources
›American College of Surgeons
›ATLS Student Course Manual 10th edition 2018
›Best Practices Guidelines Chest Wall Injury 2025
›Eastern Association for the Surgery of Trauma
›Blunt thoracic trauma pain management practice management guideline 2005
›Thoracic trauma blunt pain management of update 2016
›BOAST
›The Management of Blunt Chest Wall Trauma 2018
›NEXUS Chest decision instrument validation
›Rodriguez et al JAMA Surgery 2013
›Project instructions
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.