Analgesia and respiratory support
›Core management
›Multimodal analgesia
›Acetaminophen PO 1000 mg every 6 hours
›Maximum 4000 mg per 24 hours
›Lower maximum with liver disease or chronic alcohol use
›Ibuprofen PO 400 mg every 6 hours
›Avoid with significant bleeding risk, renal injury, or high GI risk
›Maximum 2400 mg per 24 hours
›Naproxen PO 250 mg every 12 hours
›Avoid with significant bleeding risk, renal injury, or high GI risk
›Maximum 1000 mg per 24 hours
›Hydromorphone PO 1 mg every 4 to 6 hours as needed
›If opioid naive, start low dose
›Constipation prophylaxis
›Morphine IV 0.05 mg/kg
›Repeat every 10 to 15 minutes to effect
›Monitor respiratory rate and sedation
›Fentanyl IV 0.5 to 1 mcg/kg
›Repeat every 5 to 10 minutes to effect
›Preferred with hemodynamic lability
›Regional analgesia options
›Parasternal block
›If severe midline pain limiting ventilation, anesthesia consult when available
›Erector spinae plane block
›If associated rib fractures and splinting
›Pulmonary hygiene
›Incentive spirometry
›Hourly while awake
›Goal progression by patient baseline
›Cough and deep breathing
›Splinting technique education
Blunt cardiac injury management
›Cardiac injury pathway
›Monitoring strategy
›If abnormal ECG or elevated troponin, telemetry monitoring
›Duration based on institutional protocol and clinical course
›Repeat ECG for evolving changes
›Echocardiography
›If hemodynamic instability, urgent bedside echocardiography
›Pericardial effusion
›Ventricular dysfunction
›Dysrhythmia management
›If atrial fibrillation with RVR, rate control per ACLS
›Metoprolol IV 2.5 to 5 mg
›Repeat every 5 minutes
›Maximum 15 mg
›Diltiazem IV 0.25 mg/kg
›Second dose 0.35 mg/kg after 15 minutes if needed
›Infusion 5 to 15 mg/hour if ongoing rate control needed
›If symptomatic bradycardia, ACLS bradycardia algorithm
›Atropine IV 1 mg
›Repeat every 3 to 5 minutes
›Maximum 3 mg
›If refractory, transcutaneous pacing
›If refractory, epinephrine infusion 2 to 10 mcg/min
›Evidence framing
›Normal ECG and normal troponin consistent with low risk of clinically significant blunt cardiac injury
›Abnormal ECG or elevated troponin supports telemetry and echocardiography consideration
Fracture-specific considerations
›Sternal fracture management
›Nonoperative care for most isolated fractures
›Pain control to prevent atelectasis
›Activity modification
›Operative fixation considerations
›Severe displacement with respiratory compromise
›Flail anterior chest wall segment
›Symptomatic nonunion in subacute course
›Anticoagulation considerations
›VTE prophylaxis during admission based on trauma risk
›If significant hematoma expansion risk, individualized plan