01Approach to the Critical Patient/attcp53

Immediate priorities

›Airway and ventilation threats

›Respiratory failure indicators

›SpO2 < 92% on room air

›Tachypnea > 30 breaths/minute

›Accessory muscle use or paradoxical breathing

›Flail chest recognition

›Paradoxical chest wall motion with respiration

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

›Associated pulmonary contusion in approximately 46% of flail chest

›Tension pneumothorax

›Tracheal deviation away from affected side

›Absent breath sounds with hypotension

›Immediate needle decompression then chest tube

›Massive hemothorax

›> 1500 ml blood on initial drainage

›Hemodynamic instability with dullness to percussion

›Immediate chest tube and surgical consultation

Hemodynamic monitoring and targets

›Hemodynamic targets

›SBP > 90 mmHg

›MAP > 65 mmHg

›SpO2 92 to 96%

›Heart rate < 100 beats/minute

›Monitoring bundle

›Continuous pulse oximetry

›Waveform quality assessment

›Trending over first 4 to 6 hours

02History/hx60

Mechanism and presentation

›Mechanism of injury

›Blunt thoracic trauma

›Motor vehicle collision

›Fall from height or ground-level fall in elderly

›Crush injury or assault

›Low-energy mechanism

›CPR-related fractures

›Repetitive stress from coughing (COPD, athletes)

›Pathologic fracture from minimal trauma in osteoporosis

›Pain characterization

›Sharp, well-localized pleuritic chest pain

›Worsening with deep breathing, coughing, and sneezing

›Point tenderness over fracture site

›Dyspnea and splinting

›Inability to take deep breaths

›Voluntary reduction of tidal volume

Symptom timeline

›Onset and progression

›Acute onset with trauma

›Pain typically peaks days 2 to 3 after injury

›Worsening dyspnea or pain may signal delayed hemothorax

›Delayed presentation

›Stress fractures may present days to weeks after inciting activity

›Occult fractures missed on initial CXR may be identified later

›Associated symptoms

›Dyspnea

›Exertional limitation

03Physical Exam/exam66

Vitals and general appearance

›Vital signs assessment

›Respiratory rate

›Greater than 30 breaths per minute as severity marker

›Rising trend as early fatigue indicator

›SpO2 on room air

›Below 95% requires supplemental oxygen

›Below 90% critical threshold

›Blood pressure

›Hypotension with hemothorax or tension pneumothorax

›Heart rate

›Tachycardia with hemodynamic instability

›General appearance

›Splinting and guarding

›Voluntary breath-holding behavior

›Reluctance to cough or move

›Accessory muscle use

›Sternocleidomastoid recruitment

›Intercostal retractions

Chest wall exam

›Inspection

›Paradoxical chest wall movement

›Inward movement during inspiration

›Diagnostic of flail chest with appropriate mechanism

›Ecchymosis and abrasions

›Seat belt sign indicating deceleration injury

›Point of impact location

›Asymmetric chest expansion

04Differential Diagnosis/ddx50

Life-threatening diagnoses

›Immediately life-threatening

›Tension pneumothorax

›Tracheal deviation, absent breath sounds, hypotension

›ICD-10 J93.0

›Massive hemothorax

›Dullness to percussion, shock physiology

›ICD-10 J94.2

›Aortic injury

›High-energy mechanism, mediastinal widening

›First/second rib fractures with 4.4 times higher association

›Flail chest with respiratory failure

›ICD-10 S22.5

›Paradoxical motion with hypoxemia

Chest pain mimics

›Musculoskeletal and soft tissue

›Costochondritis or Tietze syndrome

›Tenderness at costochondral junctions without fracture

›No mechanism of trauma

›Muscle strain or contusion

›No bony tenderness on palpation

›Normal imaging

›Slipping rib syndrome

›Hypermobility of lower costal cartilages

›Positive hooking maneuver

›Cardiac and vascular

›Myocardial infarction or ACS

›12% of patients with chest wall tenderness in ED had AMI

05Laboratory Tests/lt31

Core trauma labs

›Hematologic assessment

›Complete blood count

›Baseline hemoglobin and hematocrit

›Serial measurement if hemothorax suspected

›Decreased hematocrit as independent risk factor for intra-abdominal injury

›Type and screen

›Significant hemothorax anticipation

›Surgical intervention planning

›Coagulation studies PT/INR

›Anticoagulant use or suspected coagulopathy

›Hemothorax management planning

›Metabolic panel

›Basic metabolic panel

›Renal function for NSAID safety determination

›Electrolytes for resuscitation guidance

›Liver enzymes

›Lower rib fractures with hepatic injury concern

›Elevated AST/ALT indicating solid organ injury

Perfusion and respiratory labs

›Lactate

›Hemodynamic instability or shock physiology

›Lactate above 2 mmol/l as tissue hypoperfusion marker

›Repeat within 2 hours if elevated

›Arterial blood gas or venous blood gas

›Respiratory compromise or hypoxia assessment

›PaO2 below 60 mmHg indicating respiratory failure

›PaCO2 elevation indicating ventilatory failure

06Diagnostic Tests/dt69

Scoring Systems

›STUMBL Score

›Validated tool for rib fracture triage and ICU referral

›Parameters include age, number of fractures, COPD, SpO2, pain scores

›Score of 26 or higher associated with ICU-level care requirement

›Guides acute pain management intensity decisions

›Clinical utility

›Prospectively validated across trauma centers

›Reduces unnecessary ICU admissions and improves triage efficiency

Chest Radiograph

›Chest X-ray initial imaging

›Standard initial imaging for suspected rib fractures

›PA and lateral views as first-line per ACR Appropriateness Criteria

›Sensitivity limited to 50 to 50% for rib fractures

›Up to 66% of rib fractures visible only on CT in large cohorts

›Primary value in detecting complications

›Pneumothorax identification

›Hemothorax identification

›Pulmonary contusion pattern

›Mediastinal widening suggesting aortic injury

CT

›CT chest indications

›Gold standard for rib fracture detection and characterization

›Most sensitive and specific for fractures and associated injuries

›3D reconstructions valuable for surgical planning

›Specific CT indications

›Three or more rib fractures on CXR

›Lateral or posterior fracture locations

›Oxygen requirement or hypoxia

›High-energy mechanism

›Elderly with any rib fracture

›Suspected vascular injury or clinical deterioration

›CT protocol considerations

›IV contrast for vascular injury assessment

›CT abdomen and pelvis if lower rib fractures with abdominal tenderness

›CT angiography if great vessel injury suspected (first or second rib fracture)

›CT findings and grading

›Fracture characterization

›Number, location, and displacement of fractures

›Bilateral fracture pattern as intra-abdominal injury risk factor

›Associated injury identification

›Pulmonary contusion extent and distribution

›Pneumothorax size and location

›Hemothorax volume estimation

›Solid organ injury grading

MRI

›MRI role in rib fractures

›Limited primary role in acute trauma setting

›Not first-line for acute rib fracture evaluation

›Longer acquisition time limits acute utility

›Selective indications

›Occult fracture detection when CT is non-diagnostic

›Pathologic fracture evaluation for marrow infiltration

›Bony edema pattern identifying acute versus chronic fractures

›Bone marrow edema on STIR sequences

›Detects fractures not visible on CT or plain film

›Useful in low-trauma or stress fracture evaluation

›Distinguishes acute from chronic pathologic process

Ultrasound

›Point-of-care ultrasound applications

›Pneumothorax detection

›Sensitivity superior to supine CXR (86% vs 28% per Cochrane 2020 meta-analysis)

›Lung sliding present rules out pneumothorax at that probe location

›M-mode barcode sign indicating absent sliding

›Hemothorax detection

›Anechoic or complex fluid in costophrenic angle

›Sensitivity 92 to 96% compared to CT

›Rib fracture direct visualization

›Cortical disruption visible on high-frequency linear probe

›Useful when radiation avoidance desired

›Sensitivity approximately 78 to 90% for non-displaced fractures

›FAST exam integration

›Abdominal free fluid detection with lower rib fractures

›Free fluid with lower rib fractures mandates CT or operative evaluation

07Disposition/dispo43

Discharge criteria

›Safe for discharge

›Patient profile for discharge

›Young healthy patient with one to two non-displaced fractures

›Adequate pain control with oral medications

›Normal respiratory status with SpO2 above 95%

›No associated injuries on imaging

›Reliable follow-up and social support

›Discharge analgesic plan

›Scheduled acetaminophen and NSAID prescription

›Opioid prescription for breakthrough pain if needed

›Clear return precautions and follow-up timing

Admission criteria

›Floor admission indications

›Fracture count and patient factors

›Three or more rib fractures

›Age 65 years or older with any rib fracture

›Significant comorbidities affecting pulmonary reserve

›Clinical status

›Inadequate pain control on oral medications

›Supplemental oxygen requirement

›Associated pneumothorax or hemothorax requiring chest tube

›ICU admission indications

›High-acuity criteria

›Flail chest with respiratory compromise

›Respiratory failure or impending respiratory failure

›Hemodynamic instability

›STUMBL score of 26 or higher

08Treatment/t108

Analgesic strategy

›Multimodal analgesia

›ACS Best Practices Guidelines cornerstone approach

›Scheduled acetaminophen 1g orally every 6 hours

›Scheduled NSAIDs as first-line adjunct

›Ibuprofen 400 to 600 mg every 6 to 8 hours

›Ketorolac 15 to 30 mg IV for inpatient setting

›Use COX-2 inhibitor if regional block planned

›Muscle relaxants as adjunct

›Methocarbamol or cyclobenzaprine

›Evidence suggests reduced length of stay and respiratory complications

›NSAID contraindications

›Renal impairment

›GI bleeding risk

›Planned epidural or paravertebral block

Opioid management

›Opioid analgesics

›Opioid escalation pathway

›Start with oral opioids for moderate to severe pain

›Escalate to IV PRN if oral inadequate

›PCA consideration for refractory pain

›Opioid cautions

›Minimize in elderly due to delirium and respiratory depression risk

›Risk of falls in elderly with opioid use

›Monitor for respiratory depression with frequent doses

›Opioid dose targets

›Lowest effective dose for shortest duration

›Reassess pain control every 4 to 6 hours

Regional analgesia

›Regional nerve blocks

›Serratus anterior plane block (SAPB)

›Covers lateral chest wall ribs 2 to 9

›Ultrasound-guided injection in emergency department

›SABRE RCT 2024 demonstrating efficacy for acute rib fracture pain

›Academic EM RCT 2026 confirming ED feasibility and pain reduction

›Erector spinae plane block (ESPB)

›Covers posterior and anterior chest wall

›Feasible for non-specialized emergency physician with ultrasound

›Injury 2025 study confirming ED applicability

›Systematic review 2025 showing comparable efficacy to SAPB

›Intercostal nerve block

›Single-level or multilevel injection

›Shorter duration compared to plane blocks

›Useful when plane block not available

›Paravertebral block

›Covers unilateral chest wall comprehensively

›Typically performed by anesthesia or pain service

›Thoracic epidural

›Gold standard for bilateral or extensive rib fractures

›Contraindicated in coagulopathy or hemodynamic instability

›Typically managed by anesthesia or pain service

Adjunct analgesics

›Adjunct agents

›Low-dose ketamine

›0.3 mg/kg IV over 15 minutes

›Non-inferior to morphine in trials

›Opioid-sparing effect

›Higher psycho-perceptual side effects requiring monitoring

›Dexmedetomidine

›Selective alpha-2 agonist with analgesic and anxiolytic properties

›No respiratory depression advantage

›JAMA Surgery 2025 evidence for non-intubated rib fracture patients

›Emerging role in non-ICU settings

›Lidocaine patch 5%

›Topical application over fracture sites

›Useful when regional block cannot be administered

›Limited evidence base but low harm profile

Respiratory management

›Pulmonary toilet

›Incentive spirometry

›Hourly use during waking hours

›Volume targets based on predicted values

›Failure to meet targets indicates need for escalation

›Deep breathing exercises

›Every 1 to 2 hours to prevent atelectasis

›Coached breathing with pillow splinting technique

›Early ambulation

›As soon as pain control permits

›Reduces pneumonia risk

›Rib belts or binders

›Contraindicated due to restriction of ventilation

›Increases pneumonia and atelectasis risk

›Supplemental oxygen

›Titrated oxygen delivery

›Target SpO2 92 to 96%

›High-flow nasal cannula for increased demand

›NIV CPAP or BiPAP for impending respiratory failure

›Mechanical ventilation indications

›Failure of NIV

›GCS deterioration

›Flail chest with progressive respiratory failure

Chest tube management

›Chest tube indications

›Pneumothorax

›Moderate to large pneumothorax requiring drainage

›Any pneumothorax on positive pressure ventilation

›Tension pneumothorax after needle decompression

›Hemothorax

›Clinically significant hemothorax on CT or ultrasound

›Tube size 28 to 32 French for trauma hemothorax

›Massive hemothorax over 1500 ml requiring surgical evaluation

›Monitoring after chest tube

›Output tracking every 4 to 8 hours

›Criteria for operative intervention: initial output over 1500 ml or ongoing bleeding over 200 ml/hour

Surgical stabilization

›Surgical stabilization of rib fractures (SSRF)

›WSES-CWIS 2024 position paper indications

›Flail chest with respiratory failure not responsive to non-operative management

›Severely displaced or comminuted fractures with chest wall instability

›Pain refractory to multimodal analgesia

›Failed extubation thought to be due to chest wall instability

›SSRF outcomes

›Cochrane 2015 review: reduced ICU days and ventilator days vs non-operative for flail

›Reduced pneumonia incidence compared to prolonged ventilation

›Titanium rib plating most common technique

09Special Populations/sp84

Pregnancy

›Physiologic considerations

›Anatomic and respiratory changes

›Elevated diaphragm shifting rib position superiorly

›Increased minute ventilation and oxygen consumption

›Lower functional residual capacity reducing hypoxia tolerance

›Radiation exposure considerations

›CXR acceptable with abdominal shielding

›CT chest preferred over CT abdomen for rib characterization

›MRI as alternative if radiation avoidance strongly preferred

›Analgesic safety in pregnancy

›Acetaminophen

›Safest first-line analgesic in pregnancy

›Use at lowest effective dose for shortest duration

›NSAIDs

›Avoid after 20 weeks gestation due to premature ductus arteriosus closure risk

›Short course before 20 weeks if benefit outweighs risk

›Opioids

›Short course acceptable with close monitoring

›Neonatal opioid withdrawal syndrome risk with prolonged use

›Coordinate with obstetrics for fetal monitoring

›Regional analgesia preferred

›Intercostal block, SAPB, or ESPB safe in pregnancy

›Avoids systemic medication exposure

›Fetal monitoring

›Trauma assessment follows standard trauma protocols

›Kleihauer-Betke test if placental injury suspected

›Obstetric consultation for all significant thoracic trauma in pregnancy

›Continuous fetal monitoring for viable gestations

Geriatric

›Age-related vulnerability

›Mortality and morbidity burden

›Patients age 65 or older have twice the mortality of younger patients with similar injuries

›Higher rate of pneumonia, ARDS, and prolonged hospitalization

›Even single rib fracture in elderly warrants hospital admission consideration

›Physiologic vulnerability

›Reduced chest wall compliance and respiratory reserve

›Lower threshold for respiratory failure with pain-induced splinting

›Reduced cough effectiveness increasing pneumonia risk

›Bone density considerations

›Osteoporosis prevalent making low-trauma fractures common

›Ground-level falls sufficient for multiple rib fractures

›DXA scan referral for low-trauma mechanism

›Medication management in elderly

›Analgesic adjustments

›Minimize opioids due to delirium, respiratory depression, and fall risk

›Scheduled acetaminophen preferred first-line

›NSAIDs with caution due to renal impairment risk

›Regional analgesia strongly preferred to reduce systemic analgesic burden

›Anticoagulant considerations

›Higher prevalence of anticoagulant use in elderly

›Warfarin associated with decreased bone mineral density with long-term use

›Hemothorax management complicated by anticoagulation

›Disposition thresholds

›Lower threshold for admission

›Any rib fracture in elderly age 65 with comorbidities warrants admission

›Floor or ICU based on respiratory status and STUMBL score

›Family meeting early regarding goals and functional recovery

Pediatrics

›Epidemiology and significance

›Rib fractures uncommon in children due to elastic chest wall

›Rib fractures in children indicate significant force transmission

›Associated with major intrathoracic injury in up to 50%

›Non-accidental trauma screening

›Posterior rib fractures in infants highly specific for non-accidental trauma

›Multiple fractures at various healing stages

›Mandatory child protective services notification and skeletal survey

›Physiologic differences

›Flexible chest wall transmits force to underlying organs

›Pulmonary contusion may occur without rib fractures

›Mediastinal structures more mobile increasing injury risk

›Higher respiratory rate baselines

›Normal respiratory rate varies by age

›Tachypnea definition age-dependent

›Analgesic dosing in pediatrics

›Acetaminophen

›15 mg/kg orally every 4 to 6 hours

›Maximum 75 mg/kg per day

›Ibuprofen

›10 mg/kg orally every 6 to 8 hours

›Maximum 40 mg/kg per day

›Opioids

›Morphine 0.1 mg/kg IV every 2 to 4 hours titrated to effect

›Close respiratory monitoring required

›Regional analgesia

›Feasible with pediatric anesthesia involvement

›Intercostal blocks or plane blocks under sedation

10Background/b82

Epidemiology

›Incidence and prevalence

›Frequency in trauma

›Rib fractures occur in up to 40% of blunt thoracic trauma patients

›Among the most common injuries from blunt chest trauma

›Overall mortality approximately 10% in blunt chest trauma patients

›Morbidity burden

›Morbidity and mortality primarily from pain-induced hypoventilation

›Leading to pneumonia, atelectasis, ARDS, and respiratory failure

›Pulmonary complications in 31 to 68% depending on severity and age

›Age distribution

›Bimodal distribution with peaks in young adults from high-energy trauma

›Second peak in elderly from low-energy falls and osteoporosis

›Patients age 65 or older represent majority of low-trauma rib fractures

›Risk stratification epidemiology

›High-risk patient characteristics

›Age 65 or older with highest morbidity per WSES 2023 guidelines

›Three or more fractures independently predictive of complications

›Underlying cardiopulmonary disease multiplying risk

Pathophysiology

›Mechanism of injury

›Direct impact mechanism

›Force concentrated at point of contact causing cortical failure

›Higher ribs protected by shoulder girdle and musculature

›Lower ribs exposed with less muscle protection

›Indirect mechanism

›Anteroposterior compression forcing lateral rib angulation

›Common in CPR and crush injuries

›Stress fractures

›Repetitive loading exceeding bone remodeling capacity

›Cough fractures typically occur at posterolateral angle

›Pain and respiratory failure cascade

›Hypoventilation cycle

›Pain causes splinting and reduced tidal volume

›Atelectasis develops in dependent and injured zones

›Secretion retention leading to pneumonia

›Progressive hypoxemia and hypercapnia

›Inflammatory response

›Pulmonary contusion causing alveolar hemorrhage and edema

›Cytokine release contributing to ARDS in severe cases

›Flail chest physiology

›Mechanical instability

›Loss of chest wall rigidity causing paradoxical movement

›Increased work of breathing with inefficient ventilation

›Underlying pulmonary contusion in approximately 46% contributing to hypoxemia

›Respiratory failure pathway

›Combined mechanical instability and parenchymal injury

›Progressive respiratory muscle fatigue

›Escalating oxygen requirement and hypercapnia

Therapeutic Considerations

›Analgesic evidence base

›Multimodal analgesia superiority

›ACS Best Practices Guidelines 2020 recommend scheduled acetaminophen and NSAIDs

›Combination reduces opioid requirements by 30 to 50%

›Adherence to evidence-based practices associated with reduced mortality across US trauma centers (JAMA Network Open 2020)

›Regional analgesia evidence

›Serratus anterior plane block vs sham (SABRE trial JAMA Surgery 2024)

›Significant reduction in pain scores at rest and with movement

›Reduced opioid consumption in first 48 hours

›Erector spinae plane block systematic review 2025

›Comparable efficacy to SAPB with wider posterior coverage

›Feasible for emergency physicians with ultrasound training

›Dexmedetomidine evidence

›JAMA Surgery 2025 RCT in non-intubated patients

›Improved pain scores and reduced opioid use

›No significant respiratory depression

›Surgical stabilization evidence

›SSRF for flail chest

›Cochrane 2015 systematic review supporting SSRF over prolonged ventilation

›Reduced ICU length of stay

›Reduced pneumonia incidence

›Reduced duration of mechanical ventilation

›Patient selection for SSRF

›WSES-CWIS 2024 position paper guidance

›Benefit greatest when performed within 72 hours of injury

›Classification systems

›Anatomic classification

›Simple fracture: single fracture line without displacement

›Displaced fracture: cortical step-off with fragments separated

›Comminuted fracture: multiple fragments

›Flail chest: three or more consecutive ribs fractured in two or more places

›Functional severity classification

›Minor: one to two fractures, young patient, no complications

›Moderate: three or more fractures or elderly with any fracture

›Severe: flail chest, respiratory failure, or hemodynamic instability

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Rib Fracture Discharge Instructions

›Your diagnosis

›You have been diagnosed with rib fractures from your injury

›Pain typically peaks at 2 to 3 days after injury and gradually improves

›Most rib fractures heal fully in 6 to 8 weeks

›Pain medications

›Take acetaminophen (Tylenol) as prescribed every 6 hours around the clock

›Take ibuprofen or naproxen as prescribed with food to reduce stomach irritation

›Use opioid pain medication only for severe breakthrough pain not controlled by other medications

›Do not skip doses of scheduled medications even if pain seems better

›Breathing exercises

›Use your incentive spirometer every 1 to 2 hours while awake

›Take 10 deep breaths per session even if it is uncomfortable

›Deep breathing prevents pneumonia which is a serious complication of rib fractures

›Hugging a pillow while coughing or taking deep breaths reduces pain (pillow splinting)

›Activity restrictions

›Avoid heavy lifting over 4.5 kg for 4 to 6 weeks

›Avoid strenuous exercise, sports, and contact activities for 4 to 6 weeks

›Light walking encouraged as tolerated beginning immediately

›Do not use rib belts or chest binders as these restrict breathing and increase pneumonia risk

›Follow-up appointments

›Return for follow-up in 1 to 2 weeks as directed

›Repeat chest X-ray may be needed to check for delayed fluid around the lung

›Contact your doctor if you need osteoporosis evaluation

›Return to emergency department immediately for

›Red flag symptoms requiring urgent return

›Increasing shortness of breath or difficulty breathing

12References/r38

Guidelines and key sources

›Primary guidelines

›ACS Best Practices Guidelines for Acute Pain Management in Trauma Patients 2020

›Bernard A et al., American College of Surgeons

›Multimodal analgesia framework and regional block recommendations

›WSES Thoracic Trauma Guidelines 2025

›Coccolini F, Cremonini C, Moore EE et al.

›World Journal of Emergency Surgery

›WSES Guidelines on Management of Trauma in Elderly and Frail Patients 2023

›De Simone B, Chouillard E, Podda M et al.

›World Journal of Emergency Surgery 2024

›ACR Appropriateness Criteria Rib Fractures 2019

›Henry TS, Donnelly EF, Boiselle PM et al.

›Journal of the American College of Radiology

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

›Sermonesi G, Bertelli R, Pieracci FM et al.

›World Journal of Emergency Surgery

Landmark trials and studies

›Key clinical trials

›SABRE RCT 2024

›Partyka C et al., JAMA Surgery 2024

›Serratus anterior plane block vs sham for acute rib fracture pain

›Dexmedetomidine RCT 2025

›Nahmias J et al., JAMA Surgery 2025

›Dexmedetomidine for analgesia in non-intubated rib fracture patients

›Serratus Anterior Plane Block ED RCT 2026

›Perice L et al., Academic Emergency Medicine 2026

›Serratus anterior plane block for acute rib fractures in the emergency department

Evidence & Review