Browse categories and answer follow-up questions to refine your symptom profile.
History
Mechanism and context
Injury context
Mechanism
Blunt impact
Fall
MVC
Assault
Sports
Energy and direction
High energy
Lateral compression
Anterior compression
Time course
Time since injury
Progression since injury
Co-injuries suspected
Head injury
Abdominal injury
OPQRST
OPQRST framework
Chest wall pain focus
Alternative visceral chest pain screen
Onset
Onset features
Immediate after trauma
Delayed onset
Sudden worsening
After cough
After movement
Provocation/Palliation
Provoking and relieving factors
Worse with
Inspiration
Cough
Movement
Palpation
Relief with
Splinting
Analgesics
Rest
Quality
Pain quality
Sharp
Pleuritic
Aching
Pressure like
Consider cardiac mimic
ECG and troponin pathway dependent
Region/Radiation
Location and radiation
Focal tenderness over rib
Diffuse chest wall tenderness
Radiation pattern
Shoulder tip
Back
Jaw
Consider ACS mimic
ECG and troponin pathway dependent
Severity
Severity characterization
Pain score trajectory
Functional limitation
Shallow breathing
Unable to cough
Timing
Temporal pattern
Constant
Intermittent
Night pain
Sleep disruption
Ongoing opioid need
Associated symptoms
Associated symptoms
Dyspnea
Cough
Hemoptysis
Syncope
Fever
Palpitations
Abdominal pain
Prior episodes and baseline
Baseline and recurrence
Prior rib fractures
Chronic chest wall pain
Baseline respiratory status
COPD baseline dyspnea
Home oxygen
Functional impact
Function and safety
IS use baseline
Ability to deep breathe
Work and driving safety
Sedating analgesics
Fall risk
Alarm Features
Immediate life threats
Time critical complications
Tension pneumothorax
Severe respiratory distress
Hypotension
Tracheal deviation
Massive hemothorax
Shock
Absent breath sounds
Blunt cardiac injury
Dysrhythmia
Hemodynamic instability
Great vessel injury
High energy deceleration
Chest pain with shock
Vital sign danger thresholds
High risk vitals
SpO2 less than 92 percent on room air
RR 30 or more
SBP less than 90 mmHg
HR 120 or more
Temperature 38.0 C or more with respiratory symptoms
High risk exam findings
High risk physical findings
Flail segment
Paradoxical chest wall motion
Multiple adjacent rib fractures suspected
Subcutaneous emphysema
Crepitus
Rapidly expanding
Severe chest wall deformity
Marked instability
Severe focal point tenderness with guarding
Escalation triggers
Escalate level of care
If worsening oxygen requirement then resuscitation bay
If declining mental status then airway preparedness
If persistent hypotension then massive transfusion protocol per local protocol
Medications
Current medication profile
Medication inventory
Anticoagulants
Warfarin
DOAC
LMWH
Antiplatelets
ASA
Clopidogrel
Chronic opioids
Tolerance risk
Withdrawal risk
Sedatives
Benzodiazepines
Z drugs
Recent analgesic use
Pre-arrival pain control
Acetaminophen exposure
NSAID exposure
Opioid exposure
Timing of last dose
Contraindications and interaction traps
Therapy constraints
NSAID caution
CKD
GI bleed history
Anticoagulation
Opioid caution
OSA
COPD
Concomitant sedatives
Diet
Intake and hydration
Recent intake pattern
Poor oral intake due to pain
Dehydration risk
Vomiting
Exposures affecting symptoms
Relevant exposures
Caffeine and stimulants
Alcohol
Illicit substances
Cocaine
Methamphetamine
Review of Systems
Cardiopulmonary
Cardiopulmonary symptoms
Chest pain
Dyspnea
Orthopnea
Palpitations
Syncope
Leg swelling
Respiratory infection and inflammation
Infection and inflammatory symptoms
Fever
Chills
Productive cough
Pleurisy beyond focal tenderness
Neurologic and general
Neuro and systemic symptoms
Headache
Confusion
Weakness
Dizziness
Fatigue
Collateral History and Family History
Collateral and reliability
Additional sources
Witness account
EMS report
Family report
Reliability concerns
Intoxication
Amnesia
Family history
Relevant family history
Early coronary disease
MI before age 55 in first degree male
MI before age 65 in first degree female
Bleeding disorders
Hemophilia
von Willebrand disease
Risk Factors
Patient factors for complications
High risk patient features
Age 65 years or more
COPD
OSA
Heart failure
Frailty
Bleeding and thrombosis risks
Hemorrhage risk modifiers
Anticoagulant use
Antiplatelet use
Liver disease
Thrombocytopenia history
Mechanism and exposure risks
High energy mechanism features
Rapid deceleration
Ejection
Rollover
Fall from height
Direct blow with object
Differential Diagnosis
Life threatening
Cannot miss
Pneumothorax (S27.0)
Dyspnea
Unilateral decreased breath sounds
Hemothorax (S27.1)
Shock
Dullness to percussion
Pulmonary contusion (S27.3)
Hypoxia out of proportion
Delayed respiratory decline
Flail chest (S22.5)
Paradoxical chest wall motion
Respiratory failure risk
Blunt cardiac injury (S26.9)
Dysrhythmia
Unexplained hypotension
Traumatic aortic injury (S25.0)
High energy deceleration
Shock
Common
Common diagnoses
Rib fracture (S22.3)
Focal bony tenderness
Pain with inspiration
Chest wall contusion (S20.2)
Soft tissue tenderness
Ecchymosis
Intercostal muscle strain
Pain with movement
Normal imaging
Costochondral injury
Anterior chest wall pain
Reproducible tenderness
Less common and mimics
Less common and mimics
Sternal fracture (S22.2)
Anterior midline tenderness
High energy mechanism
Diaphragm injury (S27.8)
Abdominal pain
Abnormal CXR
Splenic injury (S36.0)
Left lower rib fractures
LUQ pain
ACS mimic
Nonreproducible pressure
Exertional component
Past Medical History
Relevant chronic conditions
Baseline health factors
COPD (J44.9)
Prior exacerbations
Baseline SpO2
OSA (G47.33)
CPAP use
Sedation risk
Osteoporosis (M81.0)
Low energy fractures
Vertebral fractures
Coronary artery disease (I25.10)
Prior MI
Stents
Prior procedures and devices
Surgical and device history
Prior thoracic surgery
Cardiac devices
Pacemaker
ICD
Anticoagulation indication
AF
VTE history
Baseline function
Functional baseline
Mobility aids
Home supports
Baseline ADLs
Independent
Assistance required
Physical Exam
General and vitals
General assessment
Work of breathing
Speech
Full sentences
Single words
Mental status
Alert
Confused
Vital sign interpretation
Trend over time
Response to analgesia
Chest wall and lungs
Thoracic exam
Inspection
Bruising
Deformity
Paradoxical movement
Palpation
Focal rib tenderness
Crepitus
Step off
Auscultation
Unilateral decreased breath sounds
Crackles
Percussion
Hyperresonance
Dullness
Cardiovascular
Cardiac exam
Heart sounds
New murmur
Muffled heart sounds
Perfusion
Cap refill
Cool extremities
JVP
Elevated
Normal
Abdomen and spine
Associated injury screen
Abdomen
Tenderness
Guarding
Distension
Spine
Midline tenderness
Neuro deficits
Extremities and skin
Peripheral assessment
Long bone tenderness
Neurovascular status
Pulses
Sensation
Motor
Skin
Seatbelt sign
Lacerations
Lab Studies
Baseline trauma labs when indicated
Core labs based on severity
CBC
Anemia and hemorrhage screen
Leukocytosis context
Electrolytes and renal function
NSAID safety context
Contrast safety context
Coagulation studies
Warfarin use
Liver disease
Targeted tests for complications
Complication directed labs
Troponin
Blunt cardiac injury concern
Persistent nonreproducible chest pain
VBG or ABG
Hypoxia
Hypercapnia concern
Type and screen
Suspected hemothorax
Shock
Pitfalls and limitations
Test limitations
Normal hemoglobin early bleeding
Troponin interpretation context
Baseline elevation
Renal dysfunction
Imaging
Scoring Systems
Decision instruments for imaging selection
NEXUS Chest decision instrument
Age greater than 60 years
Rapid deceleration mechanism
Chest pain
Intoxication
Altered mental status
Distracting painful injury
Tenderness to chest wall palpation
NEXUS Chest CT decision instrument
Major and minor criteria framework
Consider when CXR normal but high suspicion
MRI
MRI considerations
Indications
Brachial plexus injury concern
Spinal cord injury concern
Limitations
Not first line for rib fractures
Time and monitoring constraints
CT
CT chest strategy
Indications for CT chest
High energy mechanism
Abnormal CXR
Hypoxia unexplained
Multiple rib fractures suspected
Contrast considerations
Renal dysfunction risk
Allergy history
Findings to track
Pneumothorax size
Hemothorax
Pulmonary contusion
Vascular injury signs
Ultrasound
POCUS and eFAST
Lung ultrasound
Pneumothorax evaluation
Pleural effusion evaluation
Cardiac ultrasound
Pericardial effusion
Global function
eFAST abdominal views
Free fluid screen
Diaphragm adjacent injury concern
Special Tests
Pulmonary function and bedside monitoring
Ventilation risk assessment
Incentive spirometry volume trend
Low volumes suggest splinting
Use for response to analgesia
Peak cough effectiveness
Weak cough risk
Secretion retention risk
Bedside maneuvers and focused assessments
Focused bedside tests
Palpation for crepitus progression
Expanding subcutaneous emphysema
Trigger for repeat imaging
Pain control adequacy test
Deep breath tolerated
Cough tolerated
ECG
Indications and timing
ECG use cases
Chest pain not clearly reproducible
Syncope
Palpitations
Significant anterior chest trauma
High risk patterns
Concerning ECG findings
New ischemic changes
ST elevation
ST depression
T wave inversion new
Dysrhythmias
Atrial fibrillation with RVR
Ventricular ectopy
Heart block
Serial ECG logic
Repeat ECG triggers
Persistent symptoms despite analgesia
Troponin elevation or rising
Clinical deterioration
Assessment
Working diagnosis and severity
Primary problem formulation
Chest wall trauma with suspected rib fracture (S22.3)
Chest wall contusion (S20.2)
Complications to exclude
Pneumothorax (S27.0)
Hemothorax (S27.1)
Pulmonary contusion (S27.3)
Risk stratification
High risk features for deterioration
Age 65 years or more
Three or more rib fractures suspected
Baseline lung disease
Anticoagulant use
Hypoxia
Alternative diagnoses and uncertainty
Diagnostic uncertainty handling
Nontraumatic chest pain pathways if atypical features
Reassessment after analgesia
Repeat imaging if evolving symptoms
Plan
First 5 minutes and stabilization
Immediate priorities
Monitoring
Continuous pulse oximetry if dyspnea or hypoxia
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.