Chest tube thoracostomy (CTT) is essential for lung expansion, but protocol discrepancies exist across trauma centers. This prospective study compared CTT protocols between an urban (center 1) and rural (center 2) level 1 trauma center in East Tennessee from June to August 2023. 66 trauma patients required CTT (51 from center 1 and 15 from center 2). Diagnostic practices and post-pull chest X-rays (CXR) differed significantly. Center 1 favored CXR for diagnosis ( P = 0.012), while center 2 relied more on clinical presentation ( P = 0.012). Post-pull CXR was less common at center 2 ( P = 0.012). Center 2 had lower Glasgow Coma Scale scores ( P = 0.028), shorter tube duration ( P = 0.044), and more needle thoracostomy use ( P = 0.393). These findings underscore the need for regional protocols considering pre-arrival factors, hospital practices, and injury patterns. Protocol adjustments aim to improve adherence and patient outcomes, with ongoing data collection exploring factors influencing protocol evolution.