01Approach to the Critical Patient/attcp40

Immediate priorities

›Initial stabilization

›Airway compromise

›If impending airway failure, RSI

›If facial trauma, anticipated difficult airway

›Breathing failure

›If SpO2 < 90% on supplemental oxygen, NIV

›If worsening hypercapnia, intubation

›Circulatory instability

›If SBP < 90 mmHg, hemorrhage evaluation

›If suspected tension pneumothorax, immediate decompression

›Pain driven hypoventilation

›Rapid multimodal analgesia

›Early regional anesthesia pathway

Threats and triggers

›Immediate life threats to exclude

›Pneumothorax

›Unilateral decreased breath sounds

›Pleuritic chest pain

›Hemothorax

›Shock with unilateral decreased breath sounds

›Dullness to percussion

›Pulmonary contusion

›Hypoxemia out of proportion to exam

›Worsening oxygenation over 6 to 24 hours

›Flail chest

›Multiple adjacent segmental fractures

›Respiratory distress

02History/hx40

Mechanism and symptom profile

›Presentation pattern

›Mechanism of injury

›Blunt chest trauma

›Fall

›MVC restraint and airbag deployment

›Pain characteristics

›Focal chest wall pain

›Pleuritic component

›Respiratory symptoms

›Dyspnea

›Cough

›Associated symptoms

›Hemoptysis

›Syncope

Risk factors and modifiers

›Risk stratifiers

›Age

›Age 65 years or older

›Frailty and baseline function

›Comorbid lung disease

›COPD

›Asthma

›OSA and obesity hypoventilation

›Home CPAP use

›Baseline daytime somnolence

›Anticoagulation and antiplatelets

›DOAC use

03Physical Exam/exam37

Chest wall and respiratory exam

›Focused exam domains

›Chest wall findings

›Point tenderness

›Crepitus

›Ecchymosis

›Respiratory mechanics

›Splinting

›Accessory muscle use

›Breath sounds

›Asymmetry

›Reduced air entry

›Percussion

›Hyperresonance

›Dullness

Complication screen

›Associated injury screen

›Flail segment clues

›Paradoxical motion

›Marked respiratory distress

›Pneumothorax clues

›Tracheal deviation

›Subcutaneous emphysema

›Hemothorax clues

›Hypotension

›Tachycardia

›Abdominal injury clues

›LUQ tenderness

04Differential Diagnosis/ddx42

Life threats and important mimics

›High risk differential

›Pneumothorax (J93.9)

›Sudden dyspnea

›Unilateral decreased breath sounds

›Hemothorax (J94.2)

›Hypotension

›Dullness to percussion

›Pulmonary contusion (S27.3)

›Hypoxemia

›Delayed deterioration

›Flail chest (S22.5)

›Paradoxical motion

›Respiratory failure

›Blunt cardiac injury

›Arrhythmia

›Chest pain not reproducible

›Aortic injury (S25.0)

›High speed deceleration

›Widened mediastinum

Alternative causes of chest pain

›Non traumatic causes

›Acute coronary syndrome (I21.9)

›Exertional component

›Diaphoresis

›Pulmonary embolism (I26.99)

›Pleuritic pain without trauma fit

›Tachycardia unexplained

05Laboratory Tests/lt24

Baseline and complication directed labs

›Labs by indication

›CBC for bleeding concern

›Hemoglobin trend for hemothorax concern

›Leukocytosis nonspecific for stress versus infection

›Electrolytes and renal function for analgesic planning

›eGFR for NSAID safety

›Potassium and magnesium for arrhythmia risk if blunt cardiac injury concern

›Coagulation studies for anticoagulation

›INR for warfarin use

›Anti Xa level per local protocol for selected DOAC cases

Respiratory failure assessment

›Gas exchange evaluation

›VBG or ABG for ventilation concern

›PaCO2 in mmHg for hypoventilation concern

›pH for fatigue and impending failure

›Lactate for shock concern

›Trend response to resuscitation

›Persistent elevation triggers occult injury search

Cardiac injury workup

›Blunt cardiac injury screen

›Troponin for suspected blunt cardiac injury

›Interpretation with ECG findings

›Serial testing per local pathway

›Type and screen for suspected hemothorax

›Massive transfusion pathway triggers if unstable

›Crossmatch if chest tube output high

06Diagnostic Tests/dt58

Scoring Systems

›Risk stratification tools

›RibScore

›Six or more ribs fractured

›Bilateral fractures

›Flail chest

›Three or more bicortically displaced fractures

›First rib fracture

›Fractures in three anatomic areas

›STUMBL score

›Age

›Number of rib fractures

›Chronic lung disease

›Pre injury anticoagulants

›SpO2 on room air

›Limitations

›Local validation variability

›Not a substitute for clinical trajectory

MRI

›MRI considerations

›Limited ED role

›Occult costochondral injury

›Soft tissue injury clarification

›Contraindications

›Non MRI compatible implants

›Unstable patient

›Practical limitations

›Time to scan

07Disposition/dispo36

Admission and monitoring criteria

›Higher level care triggers

›Respiratory compromise

›Persistent SpO2 < 92% on room air

›Rising PaCO2 in mmHg

›Multiple rib fractures

›Three or more fractures with symptoms

›Six or more fractures

›Flail chest physiology

›Need for NIV or intubation

›Significant work of breathing

›High risk age and frailty

›Age 65 years or older with two or more fractures

›Poor baseline mobility

›Inadequate analgesia

›Incentive spirometry poor despite escalation

›Inability to cough effectively

Discharge criteria and follow up

›Safe discharge requirements

›Oxygenation stability

›Room air acceptable or stable baseline home oxygen

›No increasing oxygen requirement during observation

›Pain control for function

›Able to deep breathe

›Able to cough

›Low complication risk

›No pneumothorax or hemothorax requiring intervention

›No significant pulmonary contusion

08Treatment/t77

Analgesia strategy

›Multimodal pain control

›Acetaminophen

›1000 mg PO every 6 hours

›Maximum 4000 mg per 24 hours

›NSAID option

›Ibuprofen 400 mg PO every 6 hours

›Naproxen 500 mg PO twice daily

›Opioid option

›Morphine 0.05 mg/kg IV

›Repeat 0.02 to 0.05 mg/kg every 10 to 15 minutes to effect

›Monitor sedation and respiratory rate

›Hydromorphone 0.5 mg IV

›Repeat 0.2 to 0.5 mg every 10 to 15 minutes to effect

›Higher risk in opioid naive elderly

›Oxycodone 5 mg PO

›Repeat every 4 to 6 hours as needed

›Constipation prophylaxis

›Ketamine analgesia

›Initiate 0.1 to 0.3 mg/kg IV bolus

›If inadequate, infusion 0.05 to 0.2 mg/kg/hour

›Avoid in uncontrolled psychosis

Regional anesthesia and advanced analgesia

›Regional options

›Erector spinae plane block

›Unilateral rib fracture pain

›Opioid sparing strategy

›Serratus anterior plane block

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Maintain oxygenation and ventilation

›Avoid hypotension

›Imaging risk balance

›CXR acceptable with shielding

›CT chest when maternal benefit outweighs fetal risk

›Analgesic safety

›Acetaminophen preferred

›NSAIDs avoidance in later pregnancy per obstetric guidance

Geriatric

›Older adult risk amplification

›Higher pneumonia and respiratory failure risk

›Lower threshold for admission

›Early regional anesthesia

›Medication sensitivity

›Opioid dose reduction

›Delirium risk monitoring

›Osteoporosis and fragility

›Low energy mechanism still high risk

›Occult fractures and contusion risk

Pediatrics

›Pediatric considerations

›Non accidental trauma screen

›History inconsistency

›Additional injuries

›Imaging selection

10Background/b30

Epidemiology

›Epidemiology

›Common blunt trauma injury

›MVC and falls common mechanisms

›Higher incidence with older age

›Morbidity drivers

›Pain driven hypoventilation

›Pulmonary contusion co injury

›Risk correlations

›Increasing rib fracture count increases pneumonia risk

›Older age increases mortality risk per trauma registry observations

Pathophysiology

›Pathophysiology

›Pain and mechanics

›Splinting reduces tidal volume

›Atelectasis risk

›Secretion retention

›Impaired cough

›Pneumonia risk

›Co injuries

›Lung parenchymal injury from blunt force

›Pleural space injury causing pneumothorax or hemothorax

Therapeutic Considerations

›Therapeutic principles

›Analgesia improves ventilation

›Reduced atelectasis

›Improved cough effectiveness

›Multimodal approach

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Discharge plan

›Pain control regimen

›Acetaminophen schedule

›NSAID schedule if safe

›Opioid rescue only if needed

›Breathing exercises

›Incentive spirometry while awake

›Deep breathing and coughing routine

›Activity guidance

›Avoid heavy lifting until improving

›Gradual return to activity

›Ice and positioning

›Ice to tender area 15 to 20 minutes several times daily

›Sleep upright if helpful

›Return to ED immediately

›Breathing worsening

›New or increasing shortness of breath

›SpO2 decline if home oximeter

›Chest complications

›New chest tightness not reproducible by pressing on ribs

›Coughing up blood

›Infection signs

›Fever

›Productive cough

›Pain escalation

›Pain preventing deep breathing despite medications

›Confusion or excessive sleepiness after pain meds

12References/r20

Clinical guidelines and evidence sources

›Guideline sources

›ATLS principles for blunt chest trauma evaluation

›ABC prioritization

›Immediate pneumothorax and hemothorax management

›Trauma society guidance for rib fracture analgesia pathways

›Early multimodal analgesia

›Consider regional anesthesia for multiple fractures

›Practice patterns for blunt cardiac injury screening

›ECG plus troponin in selected patients

›Telemetry for abnormal results

›Evidence anchors

›Rib fracture count as risk marker in trauma cohorts

›Increasing fractures associated with pneumonia and mortality

›Age modifies risk at lower fracture counts

›Regional anesthesia benefits in selected patients

›Improved pain scores

›Improved inspiratory capacity

›POCUS for pneumothorax

›Rapid bedside detection

›Operator dependence acknowledged

Evidence & Review

Evidence & Review