Trauma

Patients over the age of 60 with rib fractures are a vulnerable group who often should be admitted to a high level of care for:

• Respiratory monitoring
• Pain management
• Pulmonary hygiene
• Supportive care

Three Vital Components of This Pathway

1. Functional Pain Assessment

• Pain should be assessed not just at rest, but with functional activities (deep breath, cough, movement)
• A pain score of ≤ 4/10 with deep inspiration is often the target
• Assess frequently — pain management is dynamic

2. Multimodal Pain Management

Multimodal analgesia minimizes opioid requirements and their associated risks (respiratory depression, delirium) in elderly patients.

Common multimodal approaches include:

• Non-opioid systemic agents: acetaminophen, NSAIDs (if no contraindication), gabapentinoids
• Regional anesthesia: intercostal nerve blocks, serratus anterior plane block, epidural, paravertebral block
• Opioids: used judiciously, titrated to functional pain scores

Specific agents, doses, and block choices are institution-specific and require attending and anesthesia guidance.

3. Mobilization Protocol

Early and progressive mobilization is a key component:

• Out-of-bed as early as tolerated
• Incentive spirometry
• Physical therapy consultation
• Incentive spirometry use encouraged
• Pulmonary hygiene: deep breathing exercises, cough assistance (pillow splinting)

Why This Population Is High Risk

Elderly patients with rib fractures are at increased risk for:

• Pneumonia (splinting from pain → atelectasis)
• Respiratory failure requiring intubation
• Mortality (especially > 3 rib fractures or bilateral fractures)

Studies have demonstrated that each additional rib fracture increases mortality and pneumonia rates in elderly patients.

Admission Threshold Considerations

Factors supporting ICU/high-acuity admission:

• Age ≥ 65 with multiple rib fractures (≥ 3)
• Bilateral rib fractures
• Pulmonary contusion
• Hemothorax or pneumothorax
• Respiratory distress or hypoxia
• Inadequate pain control
• Comorbidities (COPD, CHF, anticoagulation)

Related Content

• Trauma
• Analgesia & Sedation

• Adapted from SurgCritCare. org pathway content. Specific agents, doses, block techniques, and admission thresholds are institution-specific. Verify with attending guidance and current institutional pathway.*

Content Status

• Guideline-supported example educational content* based on ATLS principles. Always follow your institution's trauma protocols and attending guidance.

The secondary survey begins only after the primary survey is complete and life-threatening injuries have been addressed.

History — AMPLE

Head-to-Toe Examination

Head

Scalp lacerations, skull deformities, facial fractures, raccoon eyes (basilar skull), Battle's sign, hemotympanum, pupil size/reactivity, EOMs

Neck

C-spine tenderness/step-off, tracheal deviation, JVD, subcutaneous emphysema, penetrating wounds

Chest

Chest wall stability, breath sounds bilateral, bowel sounds in chest (diaphragm injury), penetrating wounds

Abdomen

Tenderness, guarding, rigidity, seat belt sign, penetrating wounds, repeat FAST

Pelvis

Pelvic ring stability (single lateral compression — do NOT spring), perineal/genital lacerations, blood at urethral meatus

Extremities

Deformity, neurovascular status (pulses, sensation, motor), open wounds, compartment syndrome signs

Back

Logroll — entire posterior surface, spine tenderness/step-off, flank ecchymosis (Grey Turner sign)

Neurologic

Complete GCS, motor/sensory all extremities, cranial nerve assessment

Adjuncts

• CT imaging (head, C-spine, chest, abdomen/pelvis as indicated)
• Plain films (extremities as indicated)
• Vascular studies for limb-threatening injury
• Urinalysis (hematuria → urologic injury)

• Guideline-supported example educational content based on ATLS principles. Do not use without attending guidance and local institutional review.*

Content Status

• Guideline-supported example educational content* based on ATLS principles. Trauma activation criteria are institution-specific. Always follow your institution's trauma activation protocol and attending guidance.

Trauma Activation Criteria (Common Examples)

Physiologic

• GCS ≤ 13 or loss of consciousness
• SBP < 90 mmHg
• RR < 10 or > 29
• Field intubation required

Anatomic

• Penetrating injury to head, neck, torso, or proximal extremities
• Open or depressed skull fracture
• Flail chest
• Suspected spinal cord injury with deficit
• Amputation proximal to wrist/ankle
• Two or more long bone fractures

Mechanism

• Ejection from vehicle
• Death of same-car occupant
• Vehicle intrusion > 12 inches on patient's side
• Pedestrian/bicyclist thrown or run over
• Fall > 20 feet
• High-risk auto vs. pedestrian (> 20 mph)

Primary Survey — ABCDE

Hemorrhage Control — Damage Control Resuscitation

• Control external hemorrhage (pressure, tourniquet)
• Resuscitate with blood products (1:1:1 — pRBC: FFP: Platelets)
• Activate massive transfusion protocol (MTP) early
• Consider permissive hypotension (SBP 80–90) in penetrating trauma until hemorrhage controlled
• TXA within 3 hours of injury in appropriate patients

Adjuncts to Primary Survey

• CXR, pelvis X-ray
• FAST exam
• Two large-bore peripheral IVs
• Labs: T&S, CBC, BMP, coags, lactate, ABG
• Foley catheter (if no urethral injury)
• 12-lead EKG if cardiac contusion suspected

• Guideline-supported example educational content based on ATLS principles and ACS TQIP guidance. Do not use without attending guidance and local institutional review.*