Chest Wall Trauma and Rib InjuryAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

568 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

Motor Vehicle Collision Evaluation Chest Wall Trauma And Rib Injury Blunt Abdominal Trauma Evaluation Penetrating Trauma Evaluation Pediatric Minor Head Trauma Pediatric Head Trauma Facial Lacerations And Dental Trauma Hand Lacerations With Tendon Injury Concern Puncture Wounds And Retained Foreign Body Concern Electrical Injury Burn Injury Fall Evaluation Assault And Interpersonal Violence Evaluation Eye Trauma And Hyphema Concern

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx83

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

02Alarm Features/alarm34

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

03Medications/meds28

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

04Diet/diet10

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

05Review of Systems/ros18

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

06Collateral History and Family History/chafh14

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

07Risk Factors/rf17

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

08Differential Diagnosis/ddx45

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

09Past Medical History/pmh27

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

10Physical Exam/exam53

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

11Lab Studies/labs25

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

12Imaging/img43

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 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

13Special Tests/spec14

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

14ECG/ecg18

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

15Assessment/ax17

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

16Plan/plan50

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

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 February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Chest Wall Trauma and Rib InjuryAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

568 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx83

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

02Alarm Features/alarm34

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

03Medications/meds28

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

04Diet/diet10

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

05Review of Systems/ros18

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

06Collateral History and Family History/chafh14

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

07Risk Factors/rf17

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

08Differential Diagnosis/ddx45

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

09Past Medical History/pmh27

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

10Physical Exam/exam53

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

11Lab Studies/labs25

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

12Imaging/img43

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 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

13Special Tests/spec14

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

14ECG/ecg18

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

15Assessment/ax17

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

16Plan/plan50

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

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 February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.