01Approach to the Critical Patient/attcp55

Immediate stabilization

›Primary survey priorities

›Airway patency and protection

›Inability to protect airway mandates definitive airway

›Rapid sequence intubation preparation

›Breathing adequacy

›SpO2 target >= 94%

›Supplemental oxygen via high-flow mask or non-rebreather

›Tachypnea > 30 per minute as escalation trigger

›Circulation and hemorrhage control

›Two large-bore IV access

›Permissive hypotension SBP 80-90 mmHg until surgical hemorrhage control if active bleeding

›Massive transfusion protocol activation for refractory hypotension

›Disability

›GCS documentation

›Concurrent TBI in approximately 66% of flail chest patients

›Exposure

›Full trauma exposure

›Associated injuries in approximately 90% of patients

Immediate threats and escalation triggers

›Tension pneumothorax

›Absent breath sounds with tracheal deviation and hypotension

›Immediate needle decompression second intercostal space mid-clavicular line

›Followed by chest tube thoracostomy

›Massive hemothorax

›Dullness to percussion with hypotension

›Chest tube thoracostomy fifth intercostal space anterior axillary line

›Activate massive transfusion protocol

02History/hx47

Mechanism and injury context

›High-energy trauma mechanisms

›Motor vehicle collision most common

›Speed and vector

›Unrestrained occupant risk

›Steering wheel deformity

›Airbag deployment

›Falls from height

›Particularly elderly patients

›Landing surface and distance

›Crush injuries

›Thoracic compression force

›Duration of entrapment

›Assaults and occupational trauma

›Blunt force to chest

›Industrial machinery

Presenting symptoms

›Core respiratory symptoms

›Severe pleuritic chest wall pain

›Worsens with inspiration

›Splinting behavior reducing tidal volume

›Dyspnea

›Inability to take deep breath

›Inability to cough effectively

›Paradoxical motion may be delayed

›Early splinting and muscle guarding masks motion

›Edema and subcutaneous emphysema may obscure

›Associated symptoms suggesting co-injuries

03Physical Exam/exam60

Vital signs and general assessment

›Hemodynamic stability snapshot

›Heart rate

›Tachycardia > 100 as hemorrhage marker

›Bradycardia with hypotension suggesting cardiac injury

›Blood pressure

›SBP < 90 mmHg suggesting hemothorax or cardiac injury

›Widened pulse pressure if tamponade

›Respiratory rate

›> 30 per minute as severity and escalation marker

›Trend more important than single value

›Oxygen saturation

›< 90% requiring immediate intervention

›Correlates poorly with early pulmonary contusion severity

›Temperature

›Hypothermia worsening coagulopathy in polytrauma

Chest wall examination

›Inspection findings

›Paradoxical movement pathognomonic

›Segment moves inward on inspiration

›Segment moves outward on expiration

›May be masked early by splinting edema or subcutaneous emphysema

›Chest wall asymmetry

›Unilateral vs bilateral involvement

›Anterior lateral or posterior flail location

›Subcutaneous emphysema

›Suggests pneumothorax or tracheobronchial injury

›Bilateral tracking suggests significant barotrauma

04Differential Diagnosis/ddx51

Life-threatening diagnoses

›Tension pneumothorax

›ICD-10 S27.0XXA

›Absent breath sounds tracheal deviation hypotension

›Immediate clinical diagnosis without waiting for imaging

›Massive hemothorax

›ICD-10 S27.1XXA

›Dullness to percussion with hypotension and shock

›> 1500 mL blood or > 200 mL per hour output post tube

›Cardiac tamponade

›ICD-10 S26.01XA

›Beck triad in penetrating more than blunt

›FAST confirms pericardial fluid

›Traumatic aortic injury

›ICD-10 S25.00XA

›Widened mediastinum on CXR

›CT angiography mandatory for high mechanism

›Open pneumothorax

›Sucking chest wound

›Three-sided occlusive dressing immediately

Thoracic injury mimics

›Multiple rib fractures without flail segment

›ICD-10 S22.40XA

›No paradoxical motion

›Managed without mechanical ventilation typically

›Sternal fracture

›ICD-10 S22.20XA

›Midline anterior tenderness

05Laboratory Tests/lt50

Hemorrhage and resuscitation labs

›Complete blood count

›Baseline hemoglobin for hemorrhage monitoring

›Serial measurements every 4-6 hours if active bleeding

›Threshold for transfusion 70 g/L hemodynamically stable

›Platelet count

›Transfusion trigger < 100 x 10^9/L in active bleeding

›Operative planning if < 50 x 10^9/L

›Coagulation studies

›Prothrombin time and INR

›Reversal agents if anticoagulated and bleeding

›Operative planning for SSRF timing

›Partial thromboplastin time

›Fibrinogen

›< 1.5 g/L requires cryoprecipitate in massive hemorrhage

›Type and crossmatch

›All hemodynamically unstable patients

›Massive transfusion protocol threshold

›Lactate

›Tissue perfusion adequacy

›> 2 mmol/L as organ hypoperfusion marker

›Serial measurement every 2-4 hours until normalized

›Clearance >= 10% per hour as resuscitation target

Respiratory function labs

›Arterial blood gas

›Oxygenation assessment

›PaO2 < 60 mmHg as mechanical ventilation threshold

›A-a gradient correlates with contusion severity

06Diagnostic Tests/dt84

Scoring Systems

›Rib fracture severity scoring

›Rib Fracture Severity Score

›Incorporates number and location of fractures

›Bilateral fractures higher score

›Score guides ICU triage decisions

›Chest Trauma Score

›Age plus rib fracture count plus pulmonary contusion extent

›Predicts pneumonia ventilator days and mortality

›Abbreviated Injury Scale thorax component

›AIS 3 or greater indicates severe thoracic trauma

›Correlates with ICU need and mortality

›Pulmonary contusion quantification

›CT volumetric assessment

›> 20% lung volume contused predicts ARDS risk

›> 28% lung volume contused predicts need for mechanical ventilation

›Correlates with ARDS development in approximately 27% of flail chest patients

MRI

›MRI role in chest trauma

›Acute utility is limited

›Long acquisition times incompatible with unstable trauma patients

›Motion artifact degrades image quality

›CT remains gold standard in acute setting

›Delayed or subacute indications

›Suspected spinal cord injury at thoracic level

›Characterizing diaphragmatic injury when CT equivocal

›Brachial plexus assessment in high upper thoracic trauma

›Contraindications

›Unstable hemodynamic status

›Incompatible metallic implants

›Intubated and ventilated patients with incompatible equipment

CT

›CT chest with IV contrast

›Indications

›Gold standard for defining injury extent in hemodynamically stable patients

›All suspected flail chest with mechanism supporting significant injury

›Pre-operative planning for SSRF mandatory

›Diagnostic yield versus CXR

›Detects up to 50% more rib fractures than plain radiography

›Identifies occult pneumothorax not seen on CXR

›Quantifies pulmonary contusion volume accurately

›Specific findings to document

›Number location and displacement of rib fractures

›Bilateral versus unilateral involvement

›Pulmonary contusion volume as percentage of total lung volume

›Pneumothorax and hemothorax size

›Mediastinal hematoma or vascular injury

›Sternal fracture pattern

›3D reconstruction

›Essential for surgical planning of SSRF

›Identifies optimal fixation sites

›CT angiography of chest

›Aortic injury evaluation

›High mechanism with mediastinal widening on CXR

›Sensitivity and specificity approaching 100% for aortic injury

›ACR Appropriateness Criteria support for major blunt trauma

›Pulmonary vasculature assessment

›Traumatic pulmonary pseudoaneurysm

›Active hemorrhage in hemothorax

›CT abdomen and pelvis with contrast

›Concurrent abdominal injury in 34%

›Combined thoracoabdominal CT reduces time to diagnosis in polytrauma

Ultrasound

›Extended FAST examination

›Role in unstable patients

›Rapid bedside assessment without transport

›Pericardial fluid hemopericardium detection

›Pleural fluid hemothorax detection

›Pneumothorax detection

›Absence of lung sliding at anterior chest wall

›Absence of B-lines in pneumothorax zone

›Sensitivity comparable to CT for anterior pneumothorax

›Limitations

›Operator dependent

›Subcutaneous emphysema degrades image quality

›Cannot quantify contusion volume

›Lung ultrasound for pulmonary contusion

›B-line pattern indicates alveolar interstitial syndrome

›Multiple confluent B-lines in contused zone

›Evolves over first 24 hours

›Serial assessment of contusion progression

›Expanding B-line pattern correlates with worsening

›Complements serial ABG monitoring

›POCUS cardiac

›Ventricular function gross estimate

›Volume status assessment

›IVC collapsibility with limitations in positive pressure ventilation

›Integration with clinical exam

07Disposition/dispo41

Admission criteria

›ICU admission

›All confirmed flail chest requires ICU or monitored bed

›Pulmonary deterioration risk peaks at 24-72 hours

›Continuous monitoring mandatory

›Mandatory ICU indications

›Respiratory failure requiring mechanical ventilation

›Non-invasive ventilation requirement

›Hemodynamic instability

›High-flow oxygen requirement

›Regional analgesia catheter management

›ICU-level monitoring criteria

›SpO2 trending downward despite supplemental oxygen

›Serial ABG every 4-6 hours requirement

›Epidural or paravertebral catheter in situ

Surgical consultation thresholds

›Trauma surgery consultation

›All confirmed flail chest

›SSRF evaluation within 24 hours

›Operative versus nonoperative decision

›SSRF candidate criteria

›Hemodynamically stable

›Anterolateral flail with respiratory failure without severe pulmonary contusion

›Failing to wean from mechanical ventilation

›Non-intubated with deteriorating respiratory function

›Thoracic surgery or orthopedic surgery

›SSRF operative planning and execution

›Plate and screw fixation technique selection

08Treatment/t157

Immediate chest decompression

›Chest tube thoracostomy

›Pneumothorax or hemothorax indications

›Fifth intercostal space anterior axillary line

›28-36 Fr tube preferred for hemothorax

›Connect to water seal with suction -20 cmH2O

›Output thresholds for surgical intervention

›Initial output > 1500 mL

›Ongoing output > 200 mL per hour for 2-4 hours

›Surgical consultation for thoracotomy

Pain management

›Multimodal analgesia is cornerstone of management

›Scheduled acetaminophen

›1000 mg PO or IV every 6 hours

›Maximum 4000 mg per 24 hours

›Reduce to 3000 mg per 24 hours in hepatic dysfunction

›Scheduled NSAIDs

›Ibuprofen 400-600 mg PO every 6-8 hours with food

›Ketorolac 15-30 mg IV every 6 hours maximum 5 days

›Avoid if renal impairment or active bleeding

›Low-dose ketamine opioid-sparing adjunct

›0.3 mg/kg IV over 15 minutes

›Particularly beneficial in elderly patients

›Reduces opioid requirement

›Opioids for breakthrough

›Oral opioids first-line for moderate pain

›IV breakthrough for severe uncontrolled pain

›Patient-controlled analgesia for inpatient if IV route needed

›Minimize dose to avoid respiratory depression and delirium

Regional analgesia

›Thoracic epidural analgesia

›Gold standard for severe flail chest

›Bilateral injury indication

›Significantly reduces mechanical ventilation duration

›Reduces pneumonia and tracheostomy rates

›Placement level

›T4-T6 for midthoracic injuries

›T6-T8 for lower thoracic injuries

›Contraindications

›Coagulopathy INR > 1.5

›Thoracic spine fractures at insertion level

›Hemodynamic instability

›Paravertebral block

›Alternative to epidural when contraindicated

›Coagulopathy relative contraindication less stringent than epidural

›Spine fractures making epidural unsafe

›Continuous catheter technique preferred

›Bupivacaine 0.25% at 4-8 mL per hour

›Duration 3-5 days typical

›Serratus anterior plane block

›Emerging technique feasible in ED

›Ultrasound guided lateral chest approach

›Safe in anticoagulated patients

›Safe in patients with spinal precautions

›SABRE trial 2024 JAMA Surgery evidence

›Coverage lateral chest ribs 2-9

›Bupivacaine 0.25% 20-30 mL

›Liposomal bupivacaine single-shot option for extended duration

›Erector spinae plane block

›Promising safety and ease profile

›Posterior approach T5-T8 level

›Bilateral blocks possible

›Evidence from multiple case series and trials

›Intercostal nerve blocks

›Option when other regional techniques contraindicated

›Liposomal bupivacaine 266 mg total dose divided per rib

›Single injection duration up to 72 hours

›Limitation

›Does not cover posterior rib fractures

›Requires repeated injections for standard bupivacaine

Respiratory support

›Supplemental oxygen

›Titrate to SpO2 >= 94%

›Nasal cannula for mild hypoxemia

›Non-rebreather mask for moderate hypoxemia

›High flow nasal cannula

›SpO2 < 92% despite simple mask

›Flow rates 40-60 L per minute with FiO2 titrated

›Non-invasive ventilation CPAP or BiPAP

›Alert cooperative patients with marginal respiratory status

›CPAP 5-10 cmH2O starting point

›BiPAP IPAP 10-16 cmH2O EPAP 5-8 cmH2O

›Combined with regional analgesia for best effect

›Trial 1-2 hours with close monitoring

›Contraindications to NIV

›Inability to protect airway

›Persistent vomiting

›Active hemoptysis

›GCS < 10

›Mechanical ventilation

›Intubation indications

›Respiratory failure with PaO2 < 60 mmHg despite supplemental oxygen

›PaCO2 > 50 mmHg with pH < 7.30 rising trend

›Failure of NIV trial

›Airway protection required

›Do NOT intubate solely for chest wall instability

›Ventilator settings

›Tidal volume 6-8 mL/kg ideal body weight

›PEEP 5-10 cmH2O to recruit contused lung

›FiO2 titrate to SpO2 94-98%

›Pressure support or SIMV as patient weans

›Ventilator weaning

›Daily spontaneous breathing trials when criteria met

›Adequate analgesia mandatory for successful extubation

Fluid management

›Resuscitation strategy

›Initial resuscitation to adequate perfusion

›Isotonic crystalloid 500-1000 mL bolus for hypotension

›Reassess after each bolus

›Target MAP >= 65 mmHg

›Avoid fluid overload

›Unnecessary fluids worsen pulmonary contusion

›Once perfusion adequate restrict additional fluid

›Vasopressors preferred over excessive fluid for hemodynamic support

›Blood product resuscitation

›Massive hemorrhage

›Packed red blood cells plasma platelets 1:1:1 ratio

›Tranexamic acid 1 g IV over 10 minutes within 3 hours of injury

›Second dose 1 g IV over 8 hours

›Target hemoglobin 70-80 g/L

Surgical stabilization of rib fractures

›Indications for SSRF

›Hemodynamically stable patients with flail chest

›WSES-AAST guidelines moderate grade of recommendation

›Anterolateral flail with respiratory failure

›Failing to wean from mechanical ventilator

›Non-intubated with deteriorating respiratory function

›Optimal timing

›Within 48-72 hours of injury preferred

›Strong grade of recommendation WSES-AAST

›If early contraindicated perform within 3-7 days

›Outcomes evidence

›Mortality 4.2% with SSRF versus 10.1% with nonoperative management

›Approximately 4.5 fewer ventilator days

›Lower pneumonia and tracheostomy rates

›Shorter ICU stay

›Operative technique

›Plate and screw fixation most common

›Precontoured titanium plates

›Typically 2-3 fractures fixed per operative session

›3D CT reconstruction for preoperative planning mandatory

›Contraindications to SSRF

›Absolute contraindication

›Hemodynamic instability

›Relative contraindications

›Advanced age with significant cardiopulmonary comorbidities

›Active malignancy

›Severe pulmonary contusion where surgery adds risk

Adjunct and prevention interventions

›Pulmonary toilet

›Incentive spirometry every 1-2 hours when awake

›Target tidal volume trending toward baseline

›Documents respiratory effort

›Chest physiotherapy and percussion

›Nasotracheal suction if unable to clear secretions

›Early mobilization when hemodynamically stable

›Steroids are contraindicated

›Do NOT use steroids in pulmonary contusion or flail chest

›Not beneficial and potentially harmful

›Bronchoscopy

›Tracheobronchial injury suspected

›Persistent air leak after chest tube

›Massive subcutaneous emphysema

›90% sensitivity for tracheobronchial injury

09Special Populations/sp74

Pregnancy

›Trauma in pregnancy considerations

›Physiologic changes affecting assessment

›Elevated diaphragm displaces thoracic contents

›Increased blood volume may mask hemorrhagic shock

›Tachycardia common in pregnancy may mask hemorrhage response

›SpO2 target >= 95% for fetal oxygenation

›Fetal considerations

›Uterine displacement left lateral tilt if >20 weeks

›Fetal monitoring when viable gestation

›Obstetric consultation immediately

›Placental abruption risk even without direct abdominal trauma

›Imaging

›CXR with abdominal shielding when indicated

›CT chest when life-threatening injury suspected benefits outweigh radiation risk

›Fetal radiation dose from chest CT is low and acceptable for maternal life-threatening injury

›Analgesic safety

›Acetaminophen safe in pregnancy

›NSAIDs avoid after 20 weeks premature ductus arteriosus closure risk

›Opioids short-term use acceptable with neonatal monitoring plan

›Regional techniques preferred to minimize systemic opioid exposure

›SSRF in pregnancy

›Individual risk-benefit discussion with trauma and obstetric teams

›General anesthesia risk assessment for gestational age

Geriatric

›Older adult specific considerations

›Injury risk at lower energy

›Osteoporosis allows flail segment from lesser mechanism

›Lower velocity falls can produce significant flail chest

›Reduced respiratory reserve means earlier decompensation

›Mortality significantly higher

›Doubled mortality and morbidity versus younger patients with similar injuries

›Age > 65 as independent mortality predictor

›Medication considerations

›Anticoagulants requiring reversal if bleeding

›Beta-blockers masking tachycardia from hemorrhage

›Baseline cognitive status establishment critical

›Analgesic adjustments

›Opioids at lower doses due to delirium and respiratory depression risk

›Low-dose ketamine 0.2-0.3 mg/kg particularly useful

›Regional analgesia strongly preferred to minimize systemic opioids

›WSES 2024 guidelines prioritize regional techniques in frail elderly

›Ventilator weaning challenges

›Muscle weakness

›Underlying COPD common

›Earlier tracheostomy consideration if prolonged ventilation expected

›SSRF in elderly

›Benefits may be greater due to reduced physiologic reserve

›Careful patient selection and perioperative optimization

›Cardiopulmonary comorbidities increase operative risk

Pediatrics

›Pediatric flail chest differences

›Relative rarity

›Pediatric chest wall more compliant

›Higher cartilage content reduces fracture rate

›When flail occurs it implies massive force and high mortality risk

›Physiologic differences

›Higher baseline respiratory rate makes tachypnea threshold age-dependent

›Respiratory reserve lower than adults proportionally

›Tidal volume 6-8 mL/kg by ideal weight same target

›Non-accidental trauma consideration

›Multiple rib fractures in varying stages of healing

›Mechanism inconsistent with stated history

›Child protective services consultation mandatory

›Analgesic dosing weight-based

›Acetaminophen 15 mg/kg PO or IV every 4-6 hours maximum 75 mg/kg per day

›Ibuprofen 10 mg/kg PO every 6-8 hours maximum 40 mg/kg per day

›Opioids 0.05-0.1 mg/kg morphine IV with careful respiratory monitoring

›Ketamine 0.2-0.3 mg/kg IV adjunct

›Regional analgesia

›Paravertebral blocks feasible in children

›Requires pediatric anesthesia expertise

›Serratus anterior block increasingly used

›SSRF in pediatrics

›Very limited data

›Pediatric trauma surgical consultation

›Generally reserved for refractory respiratory failure

10Background/b84

Epidemiology

›Incidence and burden

›Occurs in 5-10% of patients with significant blunt chest trauma

›Most severe form of blunt chest wall injury

›Marker of high kinetic energy absorption

›Mechanism distribution

›Motor vehicle collision most common etiology

›Falls from height second most common

›Crush injuries and occupational trauma

›Mortality

›Overall mortality 10-20% for isolated flail chest

›Rises significantly with associated injuries

›Bilateral flail chest extremely high mortality

›Associated injury burden

›Extrathoracic injuries in approximately 90%

›Concurrent TBI in approximately 66%

›Skeletal fractures in approximately 64%

›Abdominal injuries in approximately 34%

›Pulmonary contusion coexists in 40-60%

›Pneumothorax or hemothorax in approximately 70%

›Long-term outcomes

›Significant morbidity after nonoperative management

›46% have abnormal chest wall expansion at follow-up

›24% obstructive changes on spirometry

›20% restrictive changes on spirometry

›Chronic pain and dyspnea on exertion common

›ARDS develops in approximately 27% of flail chest patients

Pathophysiology

›Mechanical definition

›Diagnostic criteria

›Three or more consecutive ribs fractured in two or more places

›Creates free-floating chest wall segment

›Loss of bony continuity with thoracic cage

›Types by location

›Anterolateral most common

›Posterior less apparent clinically due to muscle mass

›Bilateral worst prognosis

›Paradoxical motion mechanism

›During spontaneous breathing

›Negative intrapleural pressure on inspiration pulls flail segment inward

›Positive pressure on expiration pushes segment outward

›Opposite to normal chest wall movement

›Effect on ventilation

›Reduced tidal volume

›Increased work of breathing

›Inefficient gas exchange

›Pulmonary contusion pathophysiology

›Primary driver of respiratory failure

›More important than mechanical flail itself

›Alveolar hemorrhage and edema in contused zone

›Inflammatory cascade peaks 24-72 hours after injury

›Physiologic consequences

›Intrapulmonary shunt

›Ventilation-perfusion mismatch

›Decreased compliance

›ARDS pathway if severe

›Pain-induced splinting

›Secondary contributor to respiratory failure

›Voluntary reduction in tidal volume to avoid pain

›Reduced cough effectiveness

›Retained secretions

›Atelectasis and secondary pneumonia

Therapeutic Considerations

›Historical evolution of management

›Internal pneumatic stabilization now preferred over external sandbag

›Positive pressure ventilation provides splinting from inside

›Trend away from routine intubation toward analgesic-focused management

›Surgical stabilization evidence base

›Multiple RCTs and meta-analyses support SSRF benefit

›Cochrane review 2015 supports surgical intervention

›WSES-AAST 2025 guidelines recommend SSRF consideration for all hemodynamically stable flail chest

›Analgesic-first paradigm

›Pain control is independent treatment target

›Inadequate analgesia leads to splinting atelectasis and pneumonia

›Regional analgesia reduces need for mechanical ventilation

›ACS 2020 Best Practices Guidelines multimodal approach

›Regional analgesia hierarchy

›Thoracic epidural gold standard for bilateral injuries

›Paravertebral block for unilateral injuries or epidural contraindicated

›Serratus anterior or erector spinae plane as alternatives

›Fluid management principle

›Resuscitate to perfusion then restrict

›Over-resuscitation worsens pulmonary contusion

›Vasopressors preferred over volume for post-resuscitation hypotension

›Avoid crystalloid excess

›Increased extravascular lung water in contused lung

›Colloid consideration in selected patients

11Patient Discharge Instructions/pdi48

copy discharge instructions

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

›Pain management

›Take prescribed pain medications exactly as directed

›Do not skip doses as pain control is essential for breathing

›Use incentive spirometer 10 breaths every hour while awake

›Splinting a pillow against your chest when coughing or moving

›Activity

›Gradually increase walking each day as tolerated

›Avoid lifting anything heavier than 2-3 kg until cleared by surgeon

›No driving while taking opioid pain medications

›Avoid contact sports or activities with fall risk for 6-12 weeks

›Breathing exercises

›Deep breathing exercises 10 times per hour while awake

›Incentive spirometry as instructed

›Cough regularly to clear secretions despite pain

›Wound care if surgical stabilization performed

›Keep incision dry for first 48-72 hours

›Inspect daily for redness swelling or discharge

›No submersion in water until surgeon cleared

›Warning signs requiring immediate return to emergency department

›Breathing

›Shortness of breath that is worsening or not improved from discharge

›Feeling unable to take a full breath

›Breathing faster than normal at rest

›Oxygen levels if prescribed pulse oximeter

›Oxygen saturation below 92% at rest

›Oxygen saturation below 88% with activity

12References/r33

Guidelines and key sources

›Major guidelines

›WSES-AAST Thoracic Trauma Guidelines 2025 Coccolini et al World Journal of Emergency Surgery

›Recommends SSRF consideration for all hemodynamically stable flail chest

›Strong grade of recommendation for operative timing within 48-72 hours

›WSES-CWIS Surgical Stabilization of Rib Fractures Position Paper 2024 Sermonesi et al

›Defines SSRF indications contraindications and operative approach

›Eastern Association for the Surgery of Trauma Practice Management Guideline Simon et al 2012 Journal of Trauma and Acute Care Surgery

›Management of pulmonary contusion and flail chest

›ACS Best Practices Guidelines Acute Pain Management in Trauma 2020 Bernard et al

›Multimodal analgesia framework for rib fractures and flail chest

›WSES Guidelines Management of Trauma in Elderly and Frail Patients 2024 De Simone et al

›Special considerations for older patients with chest wall injury

Evidence base

›Key trials and systematic reviews

›Cochrane Review Surgical Versus Nonsurgical Interventions for Flail Chest Cataneo et al 2015

›Supports surgical intervention benefit

›JAMA Surgery Operative vs Nonoperative Treatment Acute Unstable Chest Wall Injuries RCT Dehghan et al 2022

›RCT evidence for SSRF benefit

›Annals of Surgery Systematic Review Meta-Analysis Operative Management Rib Fractures Flail Chest Leinicke et al 2013

›Mortality 4.2% SSRF versus 10.1% nonoperative management

›JAMA Surgery SABRE Trial Serratus Anterior Plane Blocks Rib Fracture Pain Partyka et al 2024

›Randomized trial supporting serratus anterior plane block efficacy

›Journal of Trauma Acute Care Surgery Early SSRF Multiple Rib Fractures Flail Chest Kwon et al 2025

›Nationwide data outcomes comparison

›Journal of American Academy Orthopaedic Surgeons Management Chest Wall Injuries Updated Review Dehghan et al 2026

Imaging standards

›Radiology and imaging guidance

Evidence & Review