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Chest Emergency Checklist (On-Call)

Rapid checklist for the acute chest study: pulmonary embolism with right-heart strain, acute aortic syndrome (dissection / intramural hematoma / penetrating ulcer), pneumothorax sizing, and support-device positioning. Aims to standardize the findings that change immediate management.
reviewed 2026-07-01

Pulmonary embolism & RV strain (CTPA)

  • Central/saddle vs segmental/subsegmental clot burden and laterality
  • RV strain: RV/LV short-axis diameter ratio ≥1.0 (measure on axial)RV/LV ≥1.0 predicts adverse outcome; report the ratio explicitly.
  • Interventricular septal bowing toward the LV
  • Reflux of contrast into the IVC/hepatic veins and dilated main pulmonary artery
  • Right heart thrombus in transit — a surgical/thrombolysis emergency
  • Pulmonary infarct, effusion, and any chronic clot signs (webs, calcified/eccentric thrombus)

Acute aortic syndrome (CTA — dissection / IMH / PAU triad)

  • Dissection: intimal flap and true vs false lumen — classify Stanford A (any ascending involvement) vs BType A is a surgical emergency. Track the flap from root to iliacs.
  • Intramural hematoma (IMH): crescentic high-attenuation wall thickening on non-contrast, no flap
  • Penetrating atherosclerotic ulcer (PAU): focal ulcer projecting beyond the intima into the wall
  • Branch-vessel involvement / malperfusion: coronaries, arch vessels, celiac/SMA/renals, iliacs
  • Pericardial effusion/tamponade, aortic regurgitation, and mediastinal/pleural hematoma (rupture)
  • Maximal aortic diameter and the proximal/distal extent for surgical or endovascular planning

Pneumothorax & pleura

  • Tension physiology: mediastinal shift, deep sulcus sign, flattened/inverted hemidiaphragm — decompress, do not wait
  • Size estimate on CXR (interpleural distance) or supine anterior distribution on CTCollins method: interpleural distances estimate size; report apical and lateral distances.
  • Hemothorax / hydropneumothorax and loculation

Tubes & lines (quick check)

  • ETT tip 3–5 cm above the carina; not endobronchial (right main-stem) or too high
  • Central venous catheter tip at cavoatrial junction / lower SVC; exclude arterial or aberrant course and post-line pneumothoraxA left-sided line crossing midline or a vertical mediastinal course suggests arterial or persistent left SVC placement.
  • Enteric tube below the diaphragm with tip in the stomach; NOT coiled in the esophagus or in a bronchus/pleuraA feeding tube in the airway/pleura is a critical, actionable finding — hold feeds and report immediately.
  • Chest tube position and side-hole location relative to the pleural space
  • Pacemaker/ICD lead positions and any post-procedure pneumothorax

Support-device target positions (quick reference)

Endotracheal tube

Tip 3–5 cm above carina with neutral neck; avoid right main-stem intubation.

Central venous catheter

Tip in lower SVC / cavoatrial junction; not in RA/RV, not arterial.

Enteric (NG/OG/feeding) tube

Follows esophagus midline, tip in stomach below diaphragm; never in airway or pleura.

Chest tube

All side holes within the pleural space; posterobasal for fluid, apical for air.

PICC

Tip in lower SVC / cavoatrial junction.

RV strain markers on CTPA (context)

RV/LV ratio ≥1.0

Right-heart strain; associated with worse outcome.

Septal bowing toward LV

Elevated RV pressure.

IVC/hepatic vein contrast reflux

Elevated right-heart pressure.

Right heart thrombus in transit

Emergency — consider thrombolysis/embolectomy.

  • Communicate critical results (type A dissection, saddle PE with strain, tension pneumothorax, tube in airway/pleura) directly and document per ACR communication guidance.
  • IMH and PAU are part of the acute aortic syndrome spectrum and are managed with the same urgency as dissection based on location (ascending vs descending) and complications.

Sources

  • Konstantinides SV, et al. 2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism. Eur Heart J. 2020;41(4):543-603.source
  • Creager MA, et al. 2026 AHA/ACC Multisociety Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. J Am Coll Cardiol. 2026;87(13):1626-1710.source
  • Lee WA, et al. Endovascular Repair of Traumatic Thoracic Aortic Injury: Clinical Practice Guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192.
  • Collins CD, et al. Quantification of Pneumothorax Size on Chest Radiographs Using Interpleural Distances. AJR Am J Roentgenol. 1995;165(5):1127-1130.

Educational reference for clinicians — not medical advice. Verify against the primary source before acting on it; guidelines change. Final decisions rest with the interpreting physician and your institution's protocols.