Quick reference algorithm

Chest Trauma Score (CTS) — Rib Fracture Management

Trauma patients with rib fractures · 2026 edition

Validated Triage Score • Multimodal Pain Management • SSRF Criteria

CTS ≥ 7: ICU admissionSSRF criteria: thoracic surgery consult within 24h

Rib fracture(s) identified

CT chest recommended for accurate fracture count.

Assess pulmonary contusion, pneumo/hemothorax.

High-risk features → consider ICU / step-up

Age > 65
Flail chest
Bilateral fractures
≥ 6 fractures
Respiratory failure
Pre-injury anticoagulation

Chest Trauma Score · Pressley et al., 2012

Age
Criteria	Points
< 45 yrs	1
45–65 yrs	2
> 65 yrs	3

Rib fractures
Criteria	Points
< 3	1
3–5	2
> 5	3

Pulmonary contusion
Criteria	Points
None	0
Mild (unilateral)	1
Severe (≥ 20% lung volume)	2
Bilateral	3

Bilateral rib fractures
Criteria	Points
Present	+2

Maximum score = 11

Total Chest Trauma Score

Score ≤ 4Lower risk ↓Score 5–6Moderate risk ↓Score ≥ 7High risk ↓

Score ≤ 4

Lower risk

Floor admission or discharge

Oral multimodal analgesia
Incentive spirometry + FVC monitoring
Trauma clinic follow-up 3–5 days
Return precautions: dyspnea, fever

Score 5–6

Moderate risk

Ward / step-down admission

Multimodal analgesia ± regional
Pulmonary toilet, early mobilization
Monitor for respiratory decline
Consider regional anesthesia

Score ≥ 7

High risk

ICU admission (↑ mortality, intubation)

Regional / neuraxial block within 12–24h (epidural, paravertebral, ESP, serratus)
Respiratory therapy
Evaluate for SSRF

Multimodal pain management pathway

Tier 1 (All patients)

Acetaminophen 1 g IV/PO q6h (max 4 g/day)
Lidocaine 5% patch to chest wall

Tier 2 (Moderate pain)

Add NSAID if no contraindication — ketorolac(reduce dose / avoid in elderly or renal impairment; ≤ 5 days)
Gabapentin 300 mg PO TID

Tier 3 (Severe / Score ≥ 7)

Regional / neuraxial block within 12–24h (epidural, paravertebral, ESP, serratus)
PCA if regional contraindicated
Minimize IV opioids

SSRF consult criteria

Flail chest with respiratory failure
≥ 3 severely (bicortically) displaced fractures
Failure to wean from mechanical ventilation
Symptomatic non-union / malunion with chronic pain

→ Thoracic surgery consult within 24h

Step-down / discharge criteria

Pain controlled on oral regimen
FVC ≥ ~50% predicted / adequate spirometry
SpO₂ > 92% on room air
Adequate cough, no respiratory distress

Safe home environment

Abbreviations: CTS, Chest Trauma Score; SSRF, surgical stabilization of rib fractures; ESP, erector spinae plane; PCA, patient-controlled analgesia; FVC, forced vital capacity; NSAID, nonsteroidal anti-inflammatory drug.

Age

Criteria

Points

< 45 yrs

45–65 yrs

> 65 yrs

Rib fractures

Criteria

Points

< 3

3–5

> 5

Pulmonary contusion

Criteria

Points

None

Mild (unilateral)

Severe (≥ 20% lung volume)

Bilateral

Bilateral rib fractures

Criteria

Points

Present

Multimodal pain management pathway

Tier 1 (All patients)

Acetaminophen 1 g IV/PO q6h (max 4 g/day)
Lidocaine 5% patch to chest wall

Tier 2 (Moderate pain)

Add NSAID if no contraindication — ketorolac(reduce dose / avoid in elderly or renal impairment; ≤ 5 days)
Gabapentin 300 mg PO TID

Tier 3 (Severe / Score ≥ 7)

Regional / neuraxial block within 12–24h (epidural, paravertebral, ESP, serratus)
PCA if regional contraindicated
Minimize IV opioids