Thoracic Trauma: Flail Chest, Contusion, Cardiac and Aortic Injury

Four injuries often arrive together. Each runs on its own clock, so this page takes them one at a time.

• Flail chest: a loose segment of chest wall that moves the wrong way, because adjacent ribs are broken in several places. Sources disagree on the rib-count threshold. A common one is two or more adjacent ribs, each broken in two or more places. The segment shifts with every breath, and that movement cuts into ventilation and cough.
• Pulmonary contusion: bruised, bleeding lung tissue under the impact. Blood moves past air it can't reach, and hypoxemia follows. It can keep getting worse after the first injury.
• Blunt cardiac injury (BCI): a range from a hidden bruise to rupture. Most patients look fine at first. The injury can still bring on sudden arrhythmia, heart block or pump failure.
• Blunt traumatic aortic injury (BTAI): a tear in the aortic wall, usually at the ligamentum arteriosum, caused by rapid deceleration. Severity runs from an intimal defect to rupture. The Society for Vascular Surgery (SVS) system grades it.

Open chest wounds, tracheobronchial injury and commotio cordis get their own sections below. Tension pneumothorax, hemothorax and tamponade are separate topics, covered elsewhere.

Flail Chest

• Paradoxical chest wall movement, rib pain, crepitus and splinting, often with hypoxemia or hypoventilation.
• Watch for the segment pulling inward on each breath in. Count the fractures on imaging. Palpation alone won't get you the count.

Pulmonary Contusion

• Hypoxemia out of step with the mechanical findings is the clue. Repeat chest imaging when the course changes.

Blunt Cardiac Injury

• Chest impact with ECG change, new arrhythmia, heart block or unexplained hypotension.
• A sternal fracture on its own doesn't predict BCI. The EAST 2012 guideline says so.

Blunt Aortic Injury

• High-energy deceleration (frontal crash, fall from height, crush) with chest or back pain, a blood-pressure difference between arms, or a mediastinal finding on chest imaging.

Commotio Cordis

• Sudden collapse after a blow to the precordium (chest), during the cardiac repolarization phase. Typically, the chest wall shows no structural damage. Survival depends on immediate CPR and defibrillation.

Red Flags

• SpO₂ falling, rising work of breathing, or inability to speak in full sentences
• Paradoxical movement, absent breath sounds on one side, or subcutaneous emphysema
• Sucking or bubbling chest wound
• New arrhythmia, heart block or ECG change after blunt impact
• Hypotension without a clear source, or hypotension with distended neck veins (see the tamponade page)

For suspected aortic or cardiac injury, CT angiography and echocardiography are the usual tests. Need to separate an acute infarction from BCI? The 2012 EAST guideline says cardiac CT or MRI can do it in trauma patients.

• Acute myocardial infarction: A non-traumatic ACS can happen alongside a fall or crash. Cardiac CT or MRI can tell infarction from BCI in the trauma setting. The ECG pattern alone may not.
• Tension pneumothorax: One side with absent breath sounds, low blood pressure and distended neck veins. Needle decompression comes first. See Needle Decompression.
• Hemothorax: Dullness and quiet breath sounds, with blood loss. Treatment is chest tube drainage. See Chest Tubes.
• Hemorrhagic shock from abdominal or pelvic bleeding: The chest injury can be the visible one, while the shock comes from bleeding somewhere else. See Hemorrhagic Shock.

1. Scene safety and mechanism: note the deceleration, impact or blast mechanism and the time of injury.
2. Oxygen: titrate to the target SpO₂ on the oxygen page; continue assisted ventilation if the patient cannot maintain oxygenation.
3. Open chest wound: cover the wound with a vented chest seal. If none is available, use an occlusive dressing and watch for tension. If tension develops, lift the seal per protocol and decompress if tension persists.
4. Splint and position: support the chest wall with a hand or pillow for comfort; avoid circumferential binding of the chest.
5. Hemorrhage and spine: control external bleeding; apply spinal motion restriction when the mechanism warrants it (see Spinal Motion Restriction).
6. Commotio cordis: pulseless? Start CPR and apply an AED immediately. In traumatic cardiac arrest from chest injury, work the reversible causes alongside CPR. For infants and children, the 2025 AHA guidelines say to evaluate and treat hemorrhage, tension pneumothorax and pericardial tamponade (2025 AHA Guidelines for CPR and ECC, Part 8, COR 1, LOE C-EO; this recommendation was carried over from 2020). For adults, the 2025 AHA cardiac arrest algorithm puts hypovolemia, tension pneumothorax and cardiac tamponade on the list of reversible causes. The Part 8 supportive text for traumatic arrest says to do airway opening, hemorrhage control, volume restoration and relief of tension pneumothorax at the same time as CPR.
7. Transport priority: chest trauma with hypoxemia, shock or an abnormal ECG is a priority patient from scene to ambulance.

Doses vary by protocol; follow local protocols and medical direction.

• IV or IO access (Paramedic/RN/CCT): two large-bore lines when shock is present. See IV Insertion and IO Access.
• Analgesia (Paramedic/RN/CCT): morphine 0.1 mg/kg IV/IO slowly (adult max 10 mg initial dose), reassessed at the peak (about 15 to 20 min) and titrated. See Morphine. Fentanyl 1 mcg/kg IV/IO (adult max initial 100 mcg) is an alternative per protocol. See Fentanyl. Hold opioids for SBP below 90 mmHg or for respiratory depression.
• Ketamine for analgesia: sub-dissociative pain dose 0.1 to 0.3 mg/kg IV over 10 to 15 min. Ketamine raises heart rate and blood pressure; many clinicians avoid it when a rise would be dangerous, such as suspected aortic injury (clinical judgment, not a guideline recommendation). For induction dosing, see Ketamine and RSI.
• Noninvasive ventilation (Paramedic/RN/CCT, ED): only in patients without a risk of losing their airway, and only when the patient can protect the airway. In older adults with multiple rib fractures, the 2023 EAST and CWIS guideline conditionally recommends it in that group. Before or with positive-pressure ventilation, have a plan for decompression or chest tube when a pneumothorax is present or suspected. See Noninvasive Ventilation.
• Airway (Paramedic/RN/CCT): intubate for respiratory failure or a failing airway with RSI. Reassess after each intubation and positive-pressure breath for a new or worse pneumothorax.
• Suspected aortic injury, anti-impulse (ED or Paramedic per protocol): add anti-impulse therapy only after hemorrhage is excluded or controlled. Reduce heart rate with esmolol 500 mcg/kg IV over 1 min (optional load), then 50 mcg/kg/min. Titrate in 50 mcg/kg/min steps, repeating the load per protocol, to a maximum of 200 mcg/kg/min. See Esmolol. Commonly used targets are heart rate below 80 bpm and systolic pressure about 100 to 120 mmHg, titrated to the lowest pressure that keeps end-organ perfusion; targets vary by protocol, so confirm them with medical direction. Hold or reduce the drug and reassess if systolic pressure falls below target, or if hemorrhage or traumatic brain injury is present. Labetalol is an alternative: 20 mg IV over 2 min, then 40 or 80 mg every 10 min to a cumulative maximum of 300 mg, or an infusion of 1 to 2 mg/min per protocol. See Labetalol. Both drugs are contraindicated in heart block beyond first degree, severe bradycardia and cardiogenic shock. Treat hemorrhage first; do not lower pressure in a bleeding patient. The 2026 SVS focused update discusses anti-impulse therapy for medical management.
• Hemorrhage (Paramedic/RN/CCT): tranexamic acid 1 g IV/IO over 10 min, then 1 g over 8 hr, within 3 hr of injury. See Tranexamic Acid. Blood products per the trauma protocol.
• Arrhythmia (Paramedic/RN/CCT): treat per ACLS. For VF or pulseless VT, defibrillate immediately. For unstable bradycardia or heart block after BCI, see Transcutaneous Pacing. For unstable tachyarrhythmia, see Cardioversion.
• Tension physiology (Paramedic/RN/CCT): needle decompression, see Needle Decompression.

• Imaging: chest CT covers rib fractures, contusion and the mediastinum. CT angiography of the aorta is for when mechanism and imaging point to BTAI.
• Flail chest: the 2017 EAST guideline conditionally recommends rib fixation in adults with flail chest. In that guideline, fixation is associated with lower mortality, shorter ventilator and ICU stay, and less pneumonia and tracheostomy. Refer to thoracic surgery. Not every fracture needs fixing.
• Pain control: multimodal analgesia, with opioids titrated. EAST 2023 makes no recommendation for or against epidural or other locoregional blocks in older adults with rib fractures. Choose per local expertise.
• Pulmonary contusion: If the patient needs mechanical ventilation, use lung-protective settings. Keep tidal volume low (4 to 8 mL/kg predicted body weight, often 6 mL/kg) and plateau pressure below 30 cm H₂O, per the 2017 ATS/ESICM/SCCM ARDS guideline. The evidence comes from ARDS and is applied here by extension.
• Blunt cardiac injury: admit for monitoring if the ECG is abnormal or troponin is elevated. Echo is for hypotension or arrhythmia. Heart block after BCI can happen, so watch for conduction changes, per the 2017 systematic review of heart block after BCI.
• Blunt thoracic aortic injury: definitive repair is endovascular or open surgery with vascular surgery, per the SVS 2026 focused update. While the patient waits for repair, continue beta-blockade or nicardipine and clevidipine per protocol. See Nicardipine.
• Open chest wound: a chest tube goes in at a separate site, and surgical closure follows. See Chest Tubes.
• Tracheobronchial injury: consider it when a chest tube keeps leaking air, subcutaneous emphysema extends, or there is hemoptysis. Confirm with bronchoscopy or CT, then refer to thoracic surgery.
• Post-arrest care: after commotio cordis or any other arrest, follow the post-arrest pathway. See Post-Cardiac Arrest Care.

• Destination: the highest-level trauma center available. For aortic injury, that means a center with vascular and cardiac surgery.
• Continue in transit: SpO₂ and ETCO₂ monitoring, continuous ECG, and reassessment of breath sounds and chest seal at a protocol interval (often every 5 minutes). Keep the chest seal vented.
• Air transport: a trapped or untreated pneumothorax keeps growing as altitude climbs. Confirm decompression or a chest tube before flight, per protocol.
• Watch for: recurrent tension, falling pressure after anti-impulse drugs, arrhythmia, and hemorrhage progression.
• Handoff: mechanism and time of injury, SpO₂ and ventilation settings, ECG and troponin results, TXA time and dose, opioid and beta-blocker doses and times.

• Pediatrics: dose by weight, and judge vital signs against age-specific thresholds. A child's chest wall flexes more, so serious pulmonary contusion or cardiac injury can happen with no rib fractures. Pneumothorax and tension physiology differ from adults too, so keep a low threshold for imaging and for trauma-center transfer. This page doesn't set pediatric thoracic-injury management. Follow pediatric trauma and PALS protocols. Morphine is off-label in children: 0.05 to 0.1 mg/kg IV/IO slowly, with per-dose caps set by local pediatric protocol. The Morphine page has the pediatric dosing table. Fentanyl and ketamine are weight-based in children too. See Fentanyl and Ketamine. Esmolol isn't established in children. Use specialist or pediatric critical care protocols only. See Weight-Based Dosing and Vital Signs.
• Pregnancy: past about 20 weeks, the gravid uterus presses on the great vessels. Resuscitate the mother first. During CPR, add manual left lateral uterine displacement to chest compressions when the fundal height is at or above the umbilicus (2025 AHA Guidelines for CPR and ECC, Part 10, COR 1, LOE C-LD). Manual displacement keeps the patient supine, because a meta-analysis found better chest compression technique in the supine position than with left lateral tilt (Part 10). Don't tilt during compressions. If ROSC isn't achieved with standard resuscitation, resuscitative delivery is indicated at the same fundal height. Start preparing for delivery when arrest is recognized, and plan to finish delivery by 5 minutes (Part 10, COR 1, LOE B-NR). For a pregnant patient who is not in arrest but is hypotensive, a 25 to 30 degree left tilt or left-lateral positioning is an option per protocol. After stabilization, monitor the fetus with tocodynamometry for at least 4 hours, per the AAFP 2014 review. Bring in obstetrics early. Obstetrics and medical direction should guide any labetalol or esmolol use in pregnancy.
• Older Adults: Rib fractures in older adults raise the risk of pneumonia and respiratory failure. The 2023 EAST and CWIS guideline recommends incentive spirometry to guide ICU admission. Noninvasive ventilation is conditionally recommended for patients who are not at risk of losing the airway, per the 2023 EAST and CWIS guideline.
• Patients on Anticoagulants: Bleeding risk is higher. Reverse warfarin per protocol with 4F-PCC. DOAC reversal per local protocol and current product labeling (for example andexanet alfa or 4F-PCC). Check for delayed hemorrhage.

• Error: ruling out blunt cardiac injury with a normal ECG alone. EAST 2012 also requires a normal troponin I. An ECG alone isn't enough.
• Error: diagnosing BCI from a sternal fracture. A sternal fracture on its own doesn't predict BCI.
• Error: sealing an open chest wound with no vent. Use a vented chest seal. If tension develops, lift the seal per protocol, and decompress if tension persists.
• Error: starting anti-impulse drugs before the bleeding is controlled. The low pressure may be the bleeding, not the aorta.
• Error: starting esmolol or labetalol into bradycardia, heart block or cardiogenic shock, including BCI with conduction disease. Check the rhythm and the pacing plan first.
• Error: using noninvasive ventilation in a patient who might lose the airway. It's limited to patients without that risk.
• Error: giving opioids or positive-pressure breaths and not rechecking breath sounds and blood pressure afterward.