01Approach to the Critical Patient/attcp58

Immediate life threats

›Tension pneumothorax recognition

›Clinical diagnosis — do not delay for imaging

›Hypotension with tachycardia

›Absent breath sounds ipsilaterally

›Tracheal deviation away from affected side

›JVD and cyanosis

›Immediate needle decompression if tension physiology

›2nd intercostal space midclavicular line or 4th/5th ICS anterior axillary line

›Follow with finger thoracostomy in cardiac arrest

›Patients on positive-pressure ventilation at highest risk for rapid deterioration

›70% develop hemodynamic collapse within minutes without decompression

›Open pneumothorax management

›Three-sided occlusive dressing as temporizing measure

›Allows air egress, prevents ingress

›Commercial chest seal device preferred

›Definitive surgical closure required

›Chest tube placed remote from wound

›Hemodynamic instability evaluation

›SBP < 90 mmHg with chest injury

›Tension pneumothorax first priority

›Hemothorax concurrent evaluation

›Cardiac tamponade FAST assessment

Monitoring and targets

›Monitoring bundle

›Continuous pulse oximetry

›SpO2 target >= 94%

›Supplemental oxygen 15 L/min non-rebreather initially

02History/hx53

Mechanism of injury

›Blunt trauma mechanisms

›Motor vehicle collision

›High-energy deceleration

›Steering wheel impact

›Fall from height

›Estimated height and landing surface

›Assault or crush injury

›Thoracic compression pattern

›Sports injury

›Rib fracture mechanism

›Penetrating trauma mechanisms

›Stab wound

›Weapon type and estimated depth

›Number and location of wounds

›Gunshot wound

›Weapon caliber and distance

›Entry and exit wound location

›Iatrogenic

›Central line insertion

›Pacemaker lead placement

›Positive pressure ventilation

Presenting symptoms

›Respiratory symptoms

›Chest pain

›Sharp, pleuritic, ipsilateral onset

›Radiation to back or shoulder

›Dyspnea

03Physical Exam/exam60

Vitals and general

›Hemodynamic snapshot

›Blood pressure

›SBP < 90 mmHg as shock threshold

›Pulsus paradoxus if tamponade concern

›Heart rate

›Tachycardia in tension, pain, hypovolemia

›Respiratory rate

›>= 30 per minute as severity marker

›Oxygen saturation

›Room air value

›Trend under supplemental oxygen

›Temperature

›Hypothermia from hemorrhagic shock

Chest and respiratory exam

›Inspection findings

›Asymmetric chest wall expansion

›Paradoxical movement in flail chest

›Open chest wound or sucking defect

›Air movement visible with respiration

›Accessory muscle use

›Intercostal retractions

›Supraclavicular retractions

›Cyanosis

›Central cyanosis from hypoxemia

›Palpation findings

›Chest wall tenderness

›Rib fracture localization

04Differential Diagnosis/ddx47

Life-threatening differentials

›Tension pneumothorax

›ICD-10 S27.0XXA

›Requires immediate decompression without imaging

›Clinical triad: absent breath sounds, hypotension, tracheal deviation

›Hemothorax

›ICD-10 S27.1XXA

›Dullness to percussion vs hyperresonance

›FAST or CXR confirms pleural blood

›Often coexists with pneumothorax (hemopneumothorax)

›Cardiac tamponade

›ICD-10 S26.09XA

›Beck triad: hypotension, JVD, muffled heart sounds

›FAST pericardial effusion positive

›Pericardiocentesis or ED thoracotomy

›Aortic injury

›ICD-10 S25.00XA

›Widened mediastinum on CXR

›CT angiography chest diagnostic

›Open pneumothorax

›ICD-10 S21.30XA

›Visible wound with air movement

›Three-sided dressing immediately

Thoracic mimics

›Pulmonary contusion

›ICD-10 S27.321A

›Dyspnea and hypoxia without pleural air

›CT confirms parenchymal opacification without air space

05Laboratory Tests/lt34

Core trauma labs

›Complete blood count

›Hemoglobin baseline for concurrent hemothorax

›Serial trend if ongoing hemorrhage

›Platelets for procedural planning

›Chest tube insertion bleeding risk

›Type and screen or crossmatch

›Hemodynamic instability or hemothorax

›Massive transfusion protocol preparation

›All penetrating injuries

Metabolic and coagulation

›Arterial or venous blood gas

›Hypoxia quantification

›PaO2 below 60 mmHg as critical threshold

›Hypercarbia assessment

›Rising PaCO2 indicating ventilatory failure

›Metabolic acidosis from shock

›Lactate

›Elevated predicts failed observation requiring chest tube

›J Trauma and Acute Care Surgery 2024

›Serial measurement to assess resuscitation

›Target normalization

›Coagulation panel

›PT and INR baseline

›Anticoagulant reversal planning

›Fibrinogen if massive hemorrhage suspected

›Basic metabolic panel

›Renal function for contrast CT planning

06Diagnostic Tests/dt79

Scoring Systems

›Pneumothorax size classification for management decisions

›CT radial measurement

›35-mm rule: pneumothorax <= 35 mm on axial CT — observation eligible in stable patients

›Pneumothorax > 35 mm — tube thoracostomy recommended

›J Trauma Acute Care Surg 2019 and 2022 validate 35-mm rule for blunt and penetrating trauma

›CXR equivalent threshold

›Apex-to-cupola distance ~38 mm correlates with 35-mm CT threshold

›J Trauma Acute Care Surg 2024

›Trauma severity scoring

›Abbreviated Injury Scale chest component

›AIS 3-4 for pneumothorax with rib fractures

›AIS 5 for massive hemopneumothorax

›Injury Severity Score integration

›ISS > 15 associated with increased complication risk

›Rib Fracture Severity Index

›Each additional rib fracture increases pneumothorax incidence by approximately 23%

›European Journal of Medical Research 2025

›>= 4 rib fractures and displaced fractures significantly increase risk

›Younger age paradoxically associated with higher risk per rib fracture

›>= 6 rib fractures — ICU admission and rib fixation consideration

MRI

›MRI chest role in traumatic pneumothorax

›Limited acute utility

›Long acquisition time unsuitable for unstable trauma patient

›Motion artifact degrades image quality

›Potential problem-solving indications

›Spinal injury concurrent evaluation

›Complex pleural disease characterization when CT inconclusive

›Contraindications in trauma context

›Hemodynamic instability

›Metallic foreign body from penetrating wound

›Non-MRI compatible monitoring equipment

CT

›CT chest indications

›Gold standard for pneumothorax diagnosis and sizing

›Identifies occult pneumothorax missed on supine CXR

›J Trauma Acute Care Surg 2025 — CT superior to CXR for all pneumothorax detection

›Associated injury evaluation

›Rib fracture number and displacement

›Pulmonary contusion extent

›Mediastinal injury

›Diaphragmatic injury

›CT measurement protocol

›Axial slice measurement of maximum radial distance from lung edge to chest wall

›35-mm threshold is interobserver reproducible

›Bilateral assessment

›Contralateral occult pneumothorax not uncommon

›CT angiography indications

›Widened mediastinum or clinical aortic injury suspicion

›CT angio sensitivity approaches 100% for aortic injury

›Active hemorrhage from chest wall vessels

›Occult pneumothorax on supine CXR

›Risk factors for missed pneumothorax on supine CXR

›Subcutaneous emphysema OR 25.9

›Lung contusion OR 1.4

›Journal of Thoracic Disease 2023

›Deep sulcus sign on supine CXR should prompt CT

Ultrasound

›E-FAST lung assessment

›Absence of lung sliding

›Sensitive for pneumothorax at anterior probe placement

›Specificity limited when pleurodesis or prior surgery

›Lung point sign

›Transition zone between absent and present lung sliding

›Pathognomonic for pneumothorax when identified

›Allows size estimation

›Performance vs supine CXR

›Ultrasound sensitivity superior to supine CXR

›Cochrane review 2020 — ultrasound sensitivity 78-90%, CXR sensitivity ~47%

›Cardiac and hemodynamic FAST

›Pericardial effusion window

›Subxiphoid and parasternal views

›Distinguishes tamponade from tension pneumothorax

›Right heart strain assessment

›Flattened septum in massive tension

›IVC collapsibility

›Fluid responsiveness estimate in shock

›Guided procedures

›Thoracentesis guidance for hemopneumothorax drainage

›Real-time guidance reduces complications

›Chest tube placement confirmation

›Lung sliding return confirms lung re-expansion

07Disposition/dispo48

Immediate disposition

›Resuscitation bay activation criteria

›Tension physiology present

›Immediate decompression in place before transport

›Open pneumothorax or sucking chest wound

›Hemodynamic instability

›SBP < 90 mmHg

›GCS < 14 with chest injury

›Operating room activation

›Penetrating chest trauma with instability

›> 1500 mL blood from chest tube on insertion

›> 200 mL per hour for 2 to 4 hours ongoing

›Open chest wound requiring definitive closure

›Suspected aortic injury with hemodynamic compromise

Admission criteria

›ICU level care

›Chest tube in situ requiring monitoring

›Ongoing air leak

›Persistent hemothorax drainage

›Associated injuries requiring critical care

›Head injury with GCS < 14

›Hemodynamic instability requiring vasopressors

›Mechanical ventilation

›Bilateral pneumothoraces

›Respiratory failure from contusion

›>= 3 rib fractures with poor pain control

›High risk of splinting and pneumonia

›Inpatient ward

08Treatment/t112

Tension pneumothorax — immediate

›Needle decompression

›Primary site — 2nd intercostal space midclavicular line

›14 gauge or 16 gauge angiocatheter at least 8 cm length

›Insert over superior rib margin to avoid neurovascular bundle

›Alternative site — 4th or 5th intercostal space anterior axillary line

›Higher success rate in obese patients

›NAEMSP 2024 endorses as primary prehospital site

›Immediate needle thoracostomy followed by definitive chest tube

›Do not leave needle in as definitive treatment

›Finger thoracostomy in cardiac arrest

›4th or 5th ICS anterior axillary line

›Blunt dissection through all layers into pleural space

›Finger sweep to confirm and relieve tension

›Indicated in traumatic cardiac arrest before ACLS protocols

Tube thoracostomy

›Indications

›Tension pneumothorax after needle decompression

›Definitive treatment

›Simple pneumothorax > 35 mm by CT in stable patient

›Hemopneumothorax requiring drainage

›Any symptomatic pneumothorax

›Positive-pressure ventilation with pneumothorax

›Absolute indication given tension risk

›Technique

›Site — 4th or 5th intercostal space anterior axillary line or mid-axillary line

›Safe triangle bordered by pectoralis major, latissimus dorsi, and nipple line

›Tube size selection

›28-32 French for pneumothorax alone

›32-36 French for hemopneumothorax

›Blunt dissection with Kelly clamp, finger sweep before tube insertion

›Confirm pleural entry before tube placement

›Water seal drainage initially

›Suction at -20 cmH2O if air leak persists or lung fails to expand

›Post-insertion management

›CXR immediately after placement

›Confirm tube position and lung re-expansion

›Air leak monitoring

›Continuous vs intermittent on water seal trial

›JAMA Surgery 2022 comprehensive review of chest tube management

›Removal criteria

›No air leak for 24 hours

›Drainage < 200 mL per day

›Lung expanded on CXR

Small catheter and observation

›Pigtail catheter option

›8-14 French for isolated simple pneumothorax

›Comparable efficacy to large-bore tube in non-traumatic pneumothorax

›Evidence limited for traumatic pneumothorax specifically

›Not recommended for hemothorax or hemopneumothorax

›Observation protocol

›Eligibility — pneumothorax <= 35 mm, hemodynamically stable, not ventilated

›35-mm rule safe for blunt and penetrating trauma — J Trauma 2019

›Serial CXR or ultrasound at 4-6 hours

›Expand to 12-24 hours if stable

›Meta-analysis 2025 — non-invasive management of blunt traumatic pneumothorax feasible in selected patients

Pain management

›Multimodal analgesia framework

›Scheduled acetaminophen

›1000 mg PO or IV every 6 hours

›Baseline analgesic for all patients

›NSAIDs when not contraindicated

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

›Ketorolac 15-30 mg IV every 6 hours short course

›Avoid if renal impairment, coagulopathy, or COX-2 inhibitor planned for regional block

›Opioids

›IV fentanyl preferred in hemodynamically unstable patients

›1-2 mcg/kg IV titrated

›Minimal hemodynamic effects

›Oral opioids once stable

›Oxycodone 5-10 mg PO every 4-6 hours PRN

›Low-dose ketamine

›0.3 mg/kg IV as opioid-sparing alternative

›Especially in unstable patients

›ACS Best Practices Guidelines 2020

›Muscle relaxants

›Methocarbamol for chest wall spasm

›May reduce length of stay

›Regional analgesia for rib fractures

›Serratus anterior plane block

›Feasible in ED setting

›SABRE RCT — JAMA Surgery 2024 — favorable outcomes

›Single injection provides multilevel coverage T2-T9

›Erector spinae plane block

›Suitable for posterior rib fractures

›Favorable safety profile

›Intercostal nerve block with liposomal bupivacaine

›Up to 72 hours duration

›JACS 2020 — comparable to epidural for selected patients

›Thoracic epidural

›Bilateral rib fractures or flail chest

›Contraindicated with coagulopathy or spinal injury

›Dexmedetomidine adjunct

›For ICU patients with rib fracture pain

›No respiratory depression — JAMA Surgery 2025 RCT

Antibiotic prophylaxis

›Penetrating injury and open pneumothorax

›Cefazolin 1-2 g IV single dose pre-procedure

›WSES-AAST guidelines 2025 recommend prophylaxis for penetrating only

›Duration — 24 hours maximum for penetrating trauma

›Longer courses increase resistance without benefit

›Blunt trauma

›Routine prophylaxis not recommended by WSES-AAST 2025

›No survival benefit demonstrated

›Prophylaxis only if gross contamination from open wound

Surgical management

›Video-assisted thoracoscopic surgery indications

›Persistent air leak > 5-7 days

›Bronchopleural fistula repair

›Retained hemothorax after chest tube

›Ideally within 3-5 days to prevent fibrothorax

›Failed re-expansion

›ED thoracotomy

›Penetrating chest trauma with arrest within 15 minutes

›Cross-clamp descending aorta

›Internal cardiac massage

›Pericardiotomy if tamponade

›Blunt traumatic arrest with signs of life — less survival benefit

09Special Populations/sp86

Pregnancy

›Physiologic considerations

›Elevated diaphragm from uterus

›Chest tube placement higher intercostal space (3rd-4th ICS) to avoid abdominal placement

›Careful anatomical landmark reassessment

›Increased minute ventilation baseline

›Lower PaCO2 normal in pregnancy — 28-32 mmHg

›Hypoxia develops more rapidly than non-pregnant

›Supine hypotension syndrome

›Uterine compression of IVC worsens venous return in tension

›Left lateral tilt or manual uterine displacement

›Imaging approach

›E-FAST and ultrasound preferred initial modality

›No ionizing radiation

›CXR with abdominal shielding when needed

›Radiation risk to fetus from single CXR minimal

›CT chest when injury severity warrants

›Benefits outweigh radiation risk in hemodynamically unstable patient

›Fetal radiation dose from chest CT low (< 1 mGy)

›Fetal monitoring

›Viable gestation (>= 23-24 weeks) — obstetrics consult immediately

›External fetal monitoring after maternal stabilization

›Maternal oxygenation target SpO2 >= 95%

›Fetal oxygen delivery sensitive to maternal saturation

›Medication considerations

›Opioid analgesics — fentanyl preferred short-term

›Neonatal opioid withdrawal risk with prolonged use

›NSAIDs — avoid after 20 weeks

›Premature ductus arteriosus closure risk

›Ketamine — limited data in pregnancy, use with caution in first trimester

Geriatric

›Physiologic vulnerabilities

›Decreased pulmonary reserve

›Small pneumothorax poorly tolerated

›Lower threshold for tube thoracostomy

›Reduced chest wall compliance

›Multiple rib fractures common from lower-energy trauma

›Osteoporosis contribution

›Decreased pain tolerance and analgesic clearance

›Opioid sensitivity increased

›Start low, titrate cautiously

›Rib fracture management in older adults

›WSES 2023 guidelines on elderly trauma

›Each rib fracture associated with 19% increase in pneumonia risk

›Multimodal analgesia critical to prevent splinting

›Regional analgesia priority

›Serratus anterior or erector spinae block preferred over systemic opioids

›Epidural — higher complication risk from anticoagulation

›Anticoagulation management

›High prevalence of anticoagulants in geriatric patients

›Warfarin reversal: 4-factor PCC and vitamin K

›DOAC reversal agents if available

›Withhold anticoagulants until bleeding controlled

›Disposition bias toward admission

›Limited physiologic reserve

›Frailty and functional status

›Social supports often inadequate for home observation

›Higher mortality from delayed treatment

Pediatrics

›Anatomical differences

›More compliant chest wall

›Significant internal injury without rib fractures possible

›Rib fractures in young children suggest high-energy trauma

›Higher respiratory rate baselines

›Age-adjusted normal ranges for assessment

›Tachypnea threshold age-dependent

›Smaller trachea

›Tension physiology causes respiratory failure rapidly

›Management approach

›Needle decompression site

›2nd ICS MCL preferred in children

›Shorter needles appropriate for thinner chest wall

›Chest tube size

›Neonates — 10-12 French

›Infant (1-12 months) — 14-18 French

›Child (1-8 years) — 18-24 French

›Adolescent — 24-32 French

›NEJM 1991 Jaffe and Wesson — blunt pediatric trauma principles

›Non-accidental trauma

›Pneumothorax from significant rib fractures in infants

›Consider child protection evaluation

›Inconsistent history with injury severity — mandatory reporting

›Analgesia considerations

›Weight-based dosing

›Acetaminophen 15 mg/kg IV or PO every 6 hours, max 75 mg/kg/day

›Ibuprofen 10 mg/kg PO every 6-8 hours if > 6 months

›Morphine 0.05-0.1 mg/kg IV titrated

›Regional analgesia in older children

›Serratus anterior plane block feasible in children > 5 years

10Background/b79

Epidemiology

›Incidence and prevalence

›Traumatic pneumothorax in 15-50% of patients with significant thoracic trauma

›Cochrane 2020, WSES-AAST 2025

›One-third of all thoracic trauma patients present with pneumothorax, hemothorax, or both

›J Trauma Acute Care Surg 2025

›Blunt trauma most common mechanism in civilian setting

›MVC accounts for majority

›Penetrating trauma — higher severity per event

›Occult pneumothorax

›Visible on CT but not on supine CXR

›Up to 20-40% of trauma CT series

›Supine CXR sensitivity only ~47% for all pneumothoraces

›Journal of Thoracic Disease 2023

›Subcutaneous emphysema on CXR — OR 25.9 for occult pneumothorax

›Risk factors for increased pneumothorax incidence

›Each additional fractured rib increases pneumothorax risk by ~23%

›European Journal of Medical Research 2025

›Displaced fractures higher risk than non-displaced

›Overall polytrauma pneumothorax risk ~20%; up to 50% in severe chest trauma

›Mortality contribution

›Tension pneumothorax — 70% develop hemodynamic collapse without treatment

›Annals of Surgery 2015 systematic review

›Leading cause of preventable death in trauma

Pathophysiology

›Mechanisms of pleural air accumulation

›Blunt trauma — alveolar rupture from compression-decompression

›Air enters pleural space from disrupted alveoli or bronchi

›Rib fracture lacerating visceral pleura

›Penetrating trauma — direct wound tract to pleural space

›Air enters from outside via chest wall or airway

›Barotrauma — from positive-pressure ventilation

›Alveolar overdistension and rupture

›Tension mechanism

›One-way valve effect at site of pleural injury

›Air enters pleural space with each breath, cannot exit

›Progressive pleural pressure rise

›Lung compression ipsilaterally

›Mediastinal shift contralaterally

›SVC and IVC compression — reduced venous return

›Cardiac output falls precipitously

›Rapid progression in ventilated patients

›Positive end-expiratory pressure accelerates tension development

›Open pneumothorax physiology

›Chest wall defect >= 2/3 tracheal diameter

›Air preferentially enters through wound rather than trachea

›Functional dead space from pendulum air movement

›Hypoxia and hypercapnia from ineffective ventilation

›Resolution physiology

›Pleural air reabsorbed at approximately 1.25% per day passively

›Supplemental oxygen accelerates reabsorption 4-fold

›Small pneumothoraces may resolve over 1-2 weeks with observation

Therapeutic Considerations

›Observation vs intervention philosophy

›35-mm rule has shifted management toward observation in stable patients

›Decreases unnecessary chest tube insertion

›Safe for blunt and penetrating trauma — J Trauma 2019 and 2022

›Meta-analysis 2025 supports non-invasive management of blunt traumatic pneumothorax in selected patients

›Emergency Medicine Australasia 2025

›Failed observation predictors

›Positive-pressure ventilation

›Large initial size

›Elevated lactate

›Oxygen supplementation rationale

›Increases nitrogen washout from pleural space

›Accelerates resolution 4-fold

›Recommended for all patients with pneumothorax under observation

›Chest tube management evolution

›Smaller caliber tubes (pigtail 8-14 French) comparable to large-bore in spontaneous pneumothorax

›Limited traumatic pneumothorax data — large bore still preferred when hemothorax present

›Early removal protocols when air leak ceases

›JAMA Surgery 2022 review supports water seal trial before removal

›Rib fixation consideration

›Surgical rib plating for flail chest or >= 6 fractured ribs

›Reduces ventilator days and pneumonia

›Not standard for pneumothorax management alone

›Prevention of secondary complications

›Multimodal analgesia prevents splinting-induced pneumonia

›Critical in patients with >= 3 rib fractures

›Early mobilization when clinically feasible

›Incentive spirometry

›Antibiotic prophylaxis targeted — penetrating only per WSES-AAST 2025

11Patient Discharge Instructions/pdi34

copy discharge instructions

›Traumatic pneumothorax home care

›Rest and limit physical activity

›No heavy lifting or strenuous exercise for at least 4 weeks

›Gradually return to normal activity as symptoms improve

›Pain management at home

›Take prescribed pain medications as directed

›Acetaminophen and ibuprofen can be alternated as prescribed

›Breathing exercises

›Deep breathing 10 times every hour while awake

›Use incentive spirometer if provided

›Avoid activities that increase chest pressure

›No Valsalva maneuvers (straining, vigorous coughing)

›No scuba diving until cleared by your doctor

›No air travel until confirmed healed by imaging (risk of expansion at altitude)

›Smoking cessation

›Smoking delays healing and increases recurrence risk

›Cessation resources available

›Warning signs to return to emergency department immediately

›Sudden worsening shortness of breath

›Severe or worsening chest pain

›Lightheadedness, dizziness, or fainting

›Rapid or irregular heartbeat

›Bluish color to lips or fingertips

›New or spreading puffiness under the skin (subcutaneous emphysema)

›Fever above 38.5 degrees Celsius

›Follow-up instructions

›Repeat chest X-ray at 24-48 hours if observed in hospital

12References/r35

Guidelines and key sources

›Primary guidelines

›WSES-AAST Thoracic Trauma Guidelines 2025 — Coccolini F et al, World J Emerg Surg

›Comprehensive management recommendations for traumatic pneumothorax

›Antibiotic prophylaxis recommendations

›NAEMSP Traumatic Pneumothorax Position Statement 2024 — Lyng JW et al, Prehospital Emergency Care

›Prehospital decompression site recommendations

›ACS Best Practices for Acute Pain Management in Trauma 2020

›Multimodal analgesia framework

›WSES Guidelines Management of Trauma in Elderly 2024 — De Simone B et al

Key trials and reviews

›Diagnostic evidence

›Chan KK et al, Cochrane Database Syst Rev 2020 — ultrasound vs CXR for pneumothorax in ED trauma

›Ultrasound superior to supine CXR

›Park IH et al, J Thorac Dis 2023 — occult pneumothorax key findings on supine CXR

›Subcutaneous emphysema OR 25.9 for occult pneumothorax

›Aydin S et al, Eur J Med Res 2025 — CT findings and demographics in traumatic pneumothorax

›Treatment evidence

›Figueroa JF et al, J Trauma Acute Care Surg 2022 — 35-mm rule increases appropriate observation

›Bou Zein Eddine S et al, J Trauma Acute Care Surg 2019 — 35-mm rule safe for blunt and penetrating

›Harrison M, Emerg Med Australasia 2025 — meta-analysis of non-invasive management of blunt traumatic pneumothorax

›Banks KC et al, Am J Emerg Med 2023 — observation vs tube thoracostomy for small traumatic pneumothorax

›Anderson D et al, JAMA Surgery 2022 — comprehensive review of chest tube management

›Analgesia evidence

›Partyka C et al, JAMA Surgery 2024 — SABRE RCT serratus anterior plane block for rib fractures

›Nahmias J et al, JAMA Surgery 2025 — dexmedetomidine for rib fracture pain in non-intubated patients

›Sheets NW et al, J Am Coll Surg 2020 — intercostal nerve block with liposomal bupivacaine vs epidural

Evidence & Review