01Approach to the Critical Patient/attcp34

Immediate priorities

›Initial stabilization

›Airway patency

›If impending airway compromise, RSI with cervical spine precautions

›Breathing

›Oxygen saturation target 94% to 98%

›If respiratory distress, escalate to noninvasive ventilation or intubation

›Circulation

›IV access x 2 large bore

›Cardiac monitor

›If hypotension, trauma hemorrhage protocol and bedside ultrasound

›Disability

›GCS trend

›If altered mental status, broaden traumatic differential

›Exposure

›Full trauma exam

›Hypothermia prevention

High-risk triggers

›Immediate escalation triggers

›Hemodynamic instability

›If persistent hypotension, consider pericardial tamponade, tension pneumothorax, hemorrhage

›New arrhythmia

›If ventricular arrhythmia or high-grade block, blunt cardiac injury pathway and critical care consult

›Respiratory compromise

›If rising work of breathing, evaluate for pulmonary contusion, pneumothorax, flail chest

›Severe uncontrolled pain

›If splinting and hypoventilation, regional analgesia or IV opioid strategy

02History/hx42

Mechanism and timeline

›Injury context

›High-energy blunt chest trauma

›MVC with steering wheel impact

›Seatbelt sign

›Fall from height

›Time since injury

›Early worsening dyspnea

›Delayed chest wall pain progression

›Impact location

›Midline anterior chest

Symptoms and red flags

›Symptom profile

›Chest pain

›Pleuritic component

›Pain with palpation or movement

›Dyspnea

›Exertional limitation

›Orthopnea

›Palpitations

›New irregular heartbeat

›Presyncope or syncope

›Hemoptysis

›Concern for pulmonary contusion or airway injury

›Neurologic symptoms

›Neck or back pain

›Weakness or paresthesias

03Physical Exam/exam36

Primary thoracic assessment

›Chest wall findings

›Sternal tenderness

›Focal midline pain

›Step-off or crepitus

›Soft tissue injury

›Seatbelt ecchymosis

›Anterior chest wall hematoma

›Respiratory mechanics

›Splinting

›Pain-limited inspiration

Cardiopulmonary exam

›Cardiovascular

›Heart rate and rhythm

›Irregular rhythm

›Bradycardia with block concern

›Perfusion

›Capillary refill

›Peripheral pulses

›JVP

›Elevated with tamponade concern

›Pulmonary

›Breath sounds

›Decreased unilateral sounds

›Crackles suggesting contusion

›Work of breathing

›Accessory muscle use

›Hypoxia

04Differential Diagnosis/ddx31

Life-threatening thoracic conditions

›Immediate threats

›Tension pneumothorax (J93.0)

›Severe dyspnea

›Hypotension

›Massive hemothorax (J94.2)

›Shock

›Unilateral decreased breath sounds

›Cardiac tamponade (I31.4)

›Hypotension

›Elevated JVP

›Blunt cardiac injury

›Myocardial contusion (SNOMED CT concept)

›Dysrhythmia

›Traumatic aortic injury (S25.0)

›High-energy mechanism

›Mediastinal widening

Mimics and co-injuries

›Other causes of anterior chest pain

›Rib fractures (S22.3)

›Lateral chest wall tenderness

›Costochondral injury

›Localized parasternal pain

›Manubriosternal dislocation

›Visible deformity

›Sternoclavicular injury

›Upper anterior chest pain

›Pulmonary contusion (S27.3)

05Laboratory Tests/lt21

Cardiac and trauma labs

›Screening labs

›High-sensitivity troponin for blunt cardiac injury risk

›Normal troponin with normal ECG supports low likelihood of clinically significant blunt cardiac injury

›Elevated troponin warrants monitoring and echocardiography pathway

›CBC for anemia or occult bleeding

›Hemoglobin trend with associated injuries

›Leukocytosis nonspecific stress response

›Electrolytes for dysrhythmia contributors

›Potassium

›Magnesium

›Coagulation profile if anticoagulants or bleeding concern

›INR

›PT

›aPTT

Respiratory and perfusion assessment

›Physiologic labs

›Venous blood gas for ventilation and perfusion snapshot when indicated

›pH

›Lactate mmol/l for shock screening

›Arterial blood gas when severe hypoxia or ventilation failure

›PaO2 mmHg

›PaCO2 mmHg

06Diagnostic Tests/dt49

Scoring Systems

›Decision tools for imaging and risk

›NEXUS Chest criteria for selective chest imaging in blunt trauma

›Age greater than 60 years

›Rapid deceleration mechanism

›Chest pain

›Intoxication

›Abnormal alertness

›Distracting painful injury

›Chest wall tenderness

›Blunt cardiac injury low-risk screen concept

›Normal ECG

›Normal troponin

›Low risk for clinically significant blunt cardiac injury

›Canadian C-spine Rule for cervical imaging consideration

›High-risk features

›Range of motion assessment pathway

MRI

›MRI roles

›Rare indications

›Persistent pain with negative CT and high suspicion of occult fracture

›Suspected sternal osteomyelitis or chronic nonunion in subacute setting

›Limitations

›Not first-line in acute trauma resuscitation

›Time and monitoring constraints in unstable patients

CT

›CT chest considerations

›CT chest with IV contrast for high-risk mechanism or abnormal CXR

07Disposition/dispo30

Level of care selection

›Disposition pathway

›Discharge criteria for isolated sternal fracture

›Hemodynamically stable

›Oxygenation stable on room air or baseline requirement

›Pain controlled with oral regimen

›Normal ECG

›Normal troponin at appropriate interval per local protocol

›No significant associated injuries on imaging and exam

›Observation or admission indications

›Abnormal ECG

›Elevated troponin

›Arrhythmia

›Syncope

›Significant displacement or unstable fracture pattern

›Retrosternal hematoma with concerning features

›Hypoxia or pulmonary contusion

›Poor pain control or inadequate ventilation

›ICU indications

›Hemodynamic instability

›Significant dysrhythmia requiring infusion or pacing

›Respiratory failure or escalating oxygen needs

›Multi-system trauma with ongoing resuscitation

Consultation and follow-up

›Specialty involvement

›Trauma surgery for polytrauma or unstable fracture

›Operative fixation consideration for severe displacement or nonunion risk

›Cardiology for suspected blunt cardiac injury with significant findings

08Treatment/t68

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

09Special Populations/sp33

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Standard trauma ABCs

›Left uterine displacement in later pregnancy

›Imaging approach

›Ultrasound favored when appropriate

›CT when clinically indicated for maternal evaluation

›Medication safety

›Acetaminophen preferred first-line

›NSAIDs avoidance in third trimester

›Fetal considerations

›If viable gestational age and significant trauma, obstetric consultation

Geriatric

›Older adult considerations

›Higher risk of pulmonary complications

›Lower reserve

›Earlier admission threshold for pain control and pulmonary hygiene

›Comorbidity burden

›Higher baseline CAD and conduction disease

›Lower threshold for telemetry with symptoms

›Medication risks

›Opioid sensitivity

›NSAID renal and GI risk

Pediatrics

›Pediatric considerations

›Lower incidence of true sternal fracture

›Flexible chest wall

10Background/b33

Epidemiology

›Epidemiologic features

›Typical mechanism high-energy blunt anterior chest trauma

›MVC with restraint use

›Direct impact

›Association with other injuries

›Rib fractures

›Thoracic spine fractures

›Pulmonary contusion

›Blunt cardiac injury in a minority of cases

Pathophysiology

›Injury mechanisms

›Direct compression fracture

›Anterior to posterior force transmission

›Manubrium and sternal body involvement

›Indirect flexion injury

›Force transfer through clavicles and ribs

›Complication pathways

›Pain-induced hypoventilation leading to atelectasis

›Contusion-related gas exchange impairment

›Myocardial injury leading to dysrhythmia

Therapeutic Considerations

›Treatment principles

›Pain control as primary therapy for isolated fractures

›Improved ventilation

›Reduced pneumonia risk

›Cardiac screening rationale

›Clinically significant blunt cardiac injury uncommon

11Patient Discharge Instructions/pdi21

Copy discharge instructions

›Discharge care plan

›Pain control plan

›Acetaminophen as directed

›NSAID as directed if safe for patient

›Opioid only if needed for breakthrough pain

›Breathing exercises

›Incentive spirometry hourly while awake

›Cough and deep breathing several times daily

›Activity guidance

›Avoid heavy lifting and contact sports until cleared

›Gradual return to activity as pain improves

›Follow-up

›Primary care or trauma clinic within 3 to 7 days

›Earlier follow-up if pain uncontrolled

›Return to ED immediately

›New or worsening shortness of breath

›Fainting or near-fainting

›Palpitations or new irregular heartbeat

›Chest pain not controlled with medications

›Fever or productive cough

›Worsening swelling or expanding chest wall bruising

12References/r13

Guidelines and key sources

›Core references

›ATLS principles for blunt chest trauma evaluation and resuscitation

›ABC-first stabilization and associated injury search

›Trauma society guidance on blunt cardiac injury screening

›ECG screening in suspected blunt cardiac injury

›Troponin adjunct to risk stratification

›Telemetry for abnormal screening tests

›ACLS algorithms for dysrhythmia management

›Stable and unstable tachycardia pathways

›Symptomatic bradycardia pathway

›Trauma imaging decision instruments

›NEXUS Chest selective imaging framework

›Canadian C-spine Rule framework

Evidence & Review

Evidence & Review