24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury

ABIM Critical Care Medicine Study Guide Exam

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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy

1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy

2 Chapter 2: Acute Respiratory Failure & ARDS

2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO

3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies

3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage

4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies

4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome

5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation

5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support

6 Chapter 6: Shock Syndromes & Hemodynamic Principles

6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets

7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support

7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication

8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy

8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI

9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies

9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis

10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders

10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency

11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias

11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing

12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies

12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes

13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies

13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm

14 Chapter 14: Sepsis & Systemic Infectious Diseases

14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU

15 Chapter 15: ICU-Acquired & Severe Focal Infections

15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections

16 Chapter 16: Focal, Special-Host & Systemic Infections

16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses

17 Chapter 17: Neurocritical Care & Coma

17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage

18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States

18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy

19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness

19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination

20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis

20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis

21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies

21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia

22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis

22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes

23 Chapter 23: Trauma, Burns & Perioperative Critical Care

23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients

24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care

24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy

25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care

25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia

26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation

26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics

27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders

27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity

28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings

28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia

29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound

29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound

24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury

Key Takeaways Explain This Topic AI

Tension pneumothorax is a clinical diagnosis treated by immediate decompression; finger or needle thoracostomy precedes imaging.

Blunt aortic injury is managed initially with impulse control (heart rate below 80 bpm, systolic 100 to 120 mmHg) followed by thoracic endovascular repair, which has lower mortality and paraplegia rates than open repair.

Surgical rib fixation reduces ventilator days and pneumonia in selected patients with flail chest, and regional analgesia with an epidural or paravertebral or erector spinae block improves outcomes.

Tracheobronchial injury presents with a large persistent air leak, pneumomediastinum, and a pneumothorax that fails to resolve despite a functioning chest tube, and is confirmed by bronchoscopy.

Blunt cardiac injury is screened with ECG and troponin; a normal ECG and normal troponin effectively exclude clinically significant injury.

Last updated: October 2026

Immediately Life-Threatening Thoracic Injuries

Injury Recognition Immediate action

Tension pneumothorax Hypotension, unilateral absent breath sounds, distended neck veins, tracheal deviation, rising airway pressures on the ventilator Immediate decompression : finger thoracostomy (or needle in the 4th or 5th intercostal space at the anterior axillary line), then a chest tube. It is a clinical diagnosis and must not wait for imaging

Open pneumothorax A sucking chest wound Three-sided occlusive dressing, then a chest tube away from the wound

Massive hemothorax Hypotension with dullness and absent breath sounds; 1,500 mL immediately or more than 200 mL/h for 2 to 4 hours out of the chest tube Resuscitation with blood and thoracotomy

Cardiac tamponade Penetrating or blunt injury with hypotension and distended neck veins; subxiphoid ultrasound Pericardiotomy or thoracotomy; needle drainage as a bridge

Flail chest Paradoxical chest wall movement with multiple segmental rib fractures Analgesia, oxygenation, selective fixation

Tracheobronchial injury Large persistent air leak, pneumomediastinum, subcutaneous emphysema Bronchoscopy and surgical repair

Resuscitative thoracotomy is considered for penetrating thoracic trauma with witnessed loss of vital signs and a short down time; outcomes are poor in blunt arrest. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may temporize subdiaphragmatic hemorrhage but is not a substitute for definitive control.

Rib Fractures and Flail Chest

Significance : rib fractures mark the energy of injury and cause morbidity through pain, splinting, atelectasis, and pneumonia, particularly in older adults (3 or more fractures, or any fracture in a patient over 65, predicts complications).

Flail chest : at least 3 consecutive ribs fractured in 2 places, creating a segment that moves paradoxically. The main physiologic insult is often the underlying pulmonary contusion , not the mechanics alone.

Analgesia is the core therapy , in a stepwise fashion:

Scheduled acetaminophen and, where safe, NSAIDs.

Opioids, titrated and minimized.

Regional techniques : thoracic epidural, paravertebral block, erector spinae plane or serratus anterior plane blocks, or intercostal nerve blocks. Regional analgesia improves ventilation and reduces pneumonia.

Avoid sedating doses of opioids that suppress cough.

Pulmonary toilet : incentive spirometry, early mobilization, chest physiotherapy, and secretion clearance.

Surgical stabilization of rib fractures reduces ventilator days, ICU stay, and pneumonia in selected patients (flail chest, severe displacement, failure to wean, or persistent pain), ideally within about 72 hours.

Noninvasive support : high-flow nasal oxygen or noninvasive ventilation can avert intubation when pain is controlled and secretions are manageable.

Pulmonary Contusion

Alveolar hemorrhage and edema from direct energy transfer, often beneath rib fractures.

It worsens over 24 to 48 hours , so initial imaging underestimates it; CT is more sensitive than chest radiography.

Management : lung-protective ventilation, judicious fluids (avoid overload but do not under-resuscitate a bleeding patient), analgesia, and selective bronchodilators. Steroids and prophylactic antibiotics are not indicated.

Complications include ARDS, pneumonia, and persistent air leak.

Blunt Aortic and Great Vessel Injury

Mechanism : rapid deceleration, with the tear typically just distal to the left subclavian artery at the ligamentum arteriosum.

Clues : a widened mediastinum, an indistinct aortic knob, left apical cap, tracheal or nasogastric tube deviation, first or second rib or scapular fracture, and a pseudocoarctation pattern with upper extremity hypertension.

Diagnosis : CT angiography of the chest.

Management :

Impulse control : a heart rate below about 80 bpm and a systolic pressure of about 100 to 120 mmHg, usually with esmolol, balanced against brain and other injuries.

Thoracic endovascular aortic repair (TEVAR) has lower mortality and paraplegia rates than open repair and is now standard, typically delayed until other life-threatening injuries are addressed, except for free rupture or an expanding hematoma.

Grade I (intimal tear) lesions are often managed medically with repeat imaging.

Great vessel and subclavian injuries present with pulse deficits, expanding hematoma, or brachial plexus signs; most are now treated endovascularly.

Tracheobronchial Injury

Mechanism : blunt deceleration with shearing near the carina, penetrating injury, or iatrogenic from intubation.

Presentation : massive subcutaneous emphysema, pneumomediastinum, hemoptysis, and a large persistent air leak with a pneumothorax that does not resolve despite a well-placed functioning chest tube. The "fallen lung sign" on imaging is characteristic.

Diagnosis and management : bronchoscopy confirms and localizes the tear. Secure the airway distal to the injury (sometimes with a double-lumen tube or single-lung ventilation), minimize positive pressure, and arrange surgical repair for large or symptomatic injuries; small iatrogenic tears can be managed conservatively or with stenting.

Blunt Cardiac Injury

Spectrum : from asymptomatic troponin elevation to arrhythmia, free wall rupture, septal rupture, valve injury, and coronary dissection.

Screening : ECG and troponin . A normal ECG with a normal troponin effectively excludes clinically significant injury; abnormal results warrant monitoring and echocardiography.

Management : telemetry for 24 to 48 hours, treat arrhythmias, echocardiography for structural injury or hemodynamic instability, and surgery for rupture or significant valve injury. Commotio cordis causes arrest from a precordial blow during a vulnerable repolarization window and is treated with immediate defibrillation.

Other Thoracic Problems After Trauma

Retained hemothorax : drain early; video-assisted thoracoscopic evacuation within about 3 to 7 days prevents empyema and fibrothorax. Intrapleural fibrinolytics are an alternative in selected patients.

Diaphragmatic rupture : more often left-sided, with bowel in the chest on imaging; requires surgical repair.

Esophageal injury : see the esophageal emergencies section.

Foreign body aspiration : sudden choking with unilateral wheeze; rigid bronchoscopy for central objects, flexible for peripheral.

Air embolism after penetrating lung injury or positive-pressure ventilation: place the patient head down and left side down, give 100% oxygen, and consider thoracotomy with hilar clamping.

Subcutaneous emphysema itself is rarely dangerous but signals an airway or pleural leak; it is managed by treating the source rather than by incisions.