Approach to the Critical Patient

Immediate stabilization

Primary survey priorities

Immediate threats and escalation triggers

Tension pneumothorax

Massive hemothorax

Cardiac tamponade

Flail segment with respiratory failure

Monitoring and targets

Continuous monitoring bundle

Ventilator targets if intubated

Team activation

Trauma surgery

Thoracic surgery if available

Anesthesia or pain service

Respiratory therapy

History

Mechanism and injury context

High-energy trauma mechanisms

Presenting symptoms

Core respiratory symptoms

Associated symptoms suggesting co-injuries

Risk factors and comorbidities

Patient factors increasing mortality

Social history relevant to trauma

Physical Exam

Vital signs and general assessment

Hemodynamic stability snapshot

Chest wall examination

Inspection findings

Palpation

Auscultation

Secondary survey

Head and neurologic exam

Abdominal exam

Extremity exam

PITFALLS

Missed or delayed diagnosis

Differential Diagnosis

Life-threatening diagnoses

Tension pneumothorax

Massive hemothorax

Cardiac tamponade

Traumatic aortic injury

Open pneumothorax

Thoracic injury mimics

Multiple rib fractures without flail segment

Sternal fracture

Pulmonary contusion without flail

Diaphragmatic rupture

Tracheobronchial injury

Myocardial contusion

Extra-thoracic differentials

Traumatic brain injury

Intra-abdominal injury with referred pain

Laboratory Tests

Hemorrhage and resuscitation labs

Complete blood count

Coagulation studies

Type and crossmatch

Lactate

Respiratory function labs

Arterial blood gas

Venous blood gas

Organ function and cardiac labs

Troponin I or T

Basic metabolic panel

Hepatic function panel

Ethanol level and urine drug screen

Diagnostic Tests

Scoring Systems

Rib fracture severity scoring

Pulmonary contusion quantification

MRI

MRI role in chest trauma

CT

CT chest with IV contrast

CT angiography of chest

CT abdomen and pelvis with contrast

Ultrasound

Extended FAST examination

Lung ultrasound for pulmonary contusion

POCUS cardiac

Disposition

Admission criteria

ICU admission

Surgical consultation thresholds

Trauma surgery consultation

Thoracic surgery or orthopedic surgery

Transfer criteria

Transfer to higher level trauma center

Discharge not applicable

Discharge from ED is not appropriate for confirmed flail chest

Treatment

Immediate chest decompression

Chest tube thoracostomy

Pain management

Multimodal analgesia is cornerstone of management

Regional analgesia

Thoracic epidural analgesia

Paravertebral block

Serratus anterior plane block

Erector spinae plane block

Intercostal nerve blocks

Respiratory support

Supplemental oxygen

Non-invasive ventilation CPAP or BiPAP

Mechanical ventilation

Fluid management

Resuscitation strategy

Blood product resuscitation

Surgical stabilization of rib fractures

Indications for SSRF

Operative technique

Contraindications to SSRF

Adjunct and prevention interventions

Pulmonary toilet

Steroids are contraindicated

Bronchoscopy

Special Populations

Pregnancy

Trauma in pregnancy considerations

Geriatric

Older adult specific considerations

Pediatrics

Pediatric flail chest differences

Background

Epidemiology

Incidence and burden

Long-term outcomes

Pathophysiology

Mechanical definition

Paradoxical motion mechanism

Pulmonary contusion pathophysiology

Pain-induced splinting

Therapeutic Considerations

Historical evolution of management

Analgesic-first paradigm

Fluid management principle

Patient Discharge Instructions

copy discharge instructions

Flail chest recovery at home - for patients discharged after inpatient treatment

Warning signs requiring immediate return to emergency department

Follow up appointments

Expected recovery timeline

References

Guidelines and key sources

Major guidelines

Evidence base

Key trials and systematic reviews

Imaging standards

Radiology and imaging guidance