This module has not been signed off by a clinician other than its author.
It implements the NICE NG39 chest-trauma recommendations and the published STUMBL score, and quotes them where the wording decides the case. But the implementation — which answers lead to which outcome — has been checked only by the person who wrote it. Until an independent clinical review is complete, check anything you intend to act on against NG39 itself, the STUMBL derivation paper, and your local chest-wall-injury pathway.
On a previous ResusDoc tool, an external reviewer found a serious error in a page that had already passed internal audit. That is the specific risk this banner exists to flag.
The stable patient with rib fractures — STUMBL
NICE NG39 does not stratify the isolated blunt chest-wall injury — the patient with a few rib fractures, breathing comfortably, whom you are deciding whether to admit. The STUMBL score (Battle et al., 2014) is a UK-derived, externally validated prognostic model for exactly this decision. It is not NICE guidance; use it alongside your local chest-wall-injury pathway, not instead of clinical judgement.
The reference
The tension pneumothorax — decompression (NG39 1.3–1.4)
- “Use clinical assessment to diagnose pneumothorax for the purpose of triage or intervention.” (1.3.1)
- Pre-hospital: “Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise.” (1.3.4) “Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously.” (1.3.5)
- In hospital: “In patients with tension pneumothorax, perform chest decompression before imaging only if they have either haemodynamic instability or severe respiratory compromise.” (1.4.1) “Perform chest decompression using open thoracostomy followed by a chest drain in patients with tension pneumothorax.” (1.4.2)
- “Observe patients after chest decompression for signs of recurrence of the tension pneumothorax.” (1.3.6)
The through-line: the threshold to decompress is physiology (instability or severe respiratory compromise), and the method is a thoracostomy, not a needle, wherever the expertise exists. NICE gives no landmark; follow your local guidance for thoracostomy technique.
The open pneumothorax
In patients with an open pneumothorax (1.3.7):
- “cover the open pneumothorax with a simple occlusive dressing and”
- “observe for the development of a tension pneumothorax.”
A simple occlusive dressing — the older “three-sided” teaching is not what NG39 specifies; it says a simple occlusive dressing with observation for tension, which is the practical point, since any dressing can convert an open pneumothorax to a tension one.
Imaging, by severity and age (NG39 1.4.3–1.4.7)
| Situation | What NICE says |
|---|---|
| Any chest imaging | “Imaging for chest trauma… should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area” (1.4.3). |
| Adult, severe respiratory compromise | “Consider immediate chest X‑ray and/or eFAST… as part of the primary survey… in adults (16 or over) with severe respiratory compromise” (1.4.4). |
| Adult, not severely compromised, responding or normal | “Consider immediate CT for adults (16 or over) with suspected chest trauma without severe respiratory compromise who are responding to resuscitation or whose haemodynamic status is normal” (1.4.5). |
| Child (under 16) | “Consider chest X‑ray and/or ultrasound for first‑line imaging” (1.4.6). “Do not routinely use CT for first‑line imaging to assess chest trauma in children (under 16s)” (1.4.7). |
| eFAST caveat | “Be aware that a negative eFAST of the chest does not exclude a pneumothorax” (1.3.3). |
| Blunt thoracic aortic injury | “Use an endovascular stent graft in patients with blunt thoracic aortic injury” (1.5.43). |
The STUMBL score in full
STUMBL (STUdy of the Management of BLunt chest wall trauma) is a prognostic model for the risk of in-hospital complications after blunt chest-wall trauma, derived and externally validated in the UK. It was the first such score to add clinical variables — chronic lung disease and pre-injury anticoagulation — to the anatomical variables and age used by earlier scores.
Composition
| Variable | Points |
|---|---|
| Age | 1 point per decade (10–19 = 1, 20–29 = 2, and so on) |
| Rib fractures | 3 points per fracture |
| Chronic lung disease | 5 points |
| Pre-injury anticoagulants | 4 points |
| SpO₂ | 0 (100–95%), 2 (94–90%), 4 (89–85%), 6 (84–80%), 8 (79–75%), 10 (74–70%) |
Interpretation, as reported
- ≥11 — significant risk of developing complications, suggesting hospital admission.
- ≥26 — sufficiently high risk to warrant critical-care admission.
The complications the model predicts are lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury, and 30-day mortality.
This is not a NICE recommendation. STUMBL is a research-derived score; NICE NG39 does not endorse a specific chest-wall-injury score. Cut-offs and local pathways vary between trauma networks — use your own network's chest-wall-injury guideline, which STUMBL commonly informs rather than replaces.
Analgesia (NG39 1.7)
- “Use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.” (1.7.4)
- No IV access: “consider the intranasal route for atomised delivery of diamorphine or ketamine” (1.7.5) — off-label in 2016.
- “Consider ketamine in analgesic doses as a second‑line agent.” (1.7.6)
Pain control is not a comfort measure in rib fractures — it is what prevents the splinting, hypoventilation and pneumonia that STUMBL is predicting. Regional techniques (for example a serratus anterior or erector spinae plane block, or an epidural for multiple fractures) are beyond NG39 and are a decision for your acute pain or anaesthetic team. NG39 gives no doses; use the drug monographs and the paediatric tool.
What this module deliberately does not do
- It does not give a thoracostomy or chest-drain technique. NG39 names the intervention, not the landmark or the tube size; those are your local guideline and the procedures tool.
- It does not manage traumatic cardiac arrest or resuscitative thoracotomy. Those are a separate algorithm.
- It does not endorse a specific rib-fracture score as national guidance. STUMBL is shown because it is UK-derived and validated, and clearly labelled as not-NICE.
- It does not decide surgical rib fixation. That is a specialist decision made after admission.
- It does not give drug doses. NG39 gives none; the drug and paediatric tools do.
Sources in full
- NICE NG39. Major trauma: assessment and initial management. Published 17 February 2016. The full Recommendations chapter was parsed; the chest and imaging recommendations used here are in sections 1.3, 1.4 and 1.5.43, and the pain recommendations in section 1.7. Recommendations apply to both children (under 16s) and adults (16 or over) unless otherwise specified.
- STUMBL / Battle CE et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care 2014;18(3):R98. The score composition, thresholds and predicted complications are as reported for the STUMBL model. Not a NICE recommendation.
Every NG39 quotation on this page is verbatim from the recommendation named beside it. STUMBL is reproduced as a described calculator with attribution; it is flagged as not-NICE wherever it appears.
Related
Bleeding & anticoagulation reversal · Pelvic trauma · Silver trauma · CT head & C-spine · Procedures