Emergency Thoracotomy: Indications

When does a trauma patient in the ED need an emergent thoracotomy?

Accepted/relative indications
ANY  Penetrating thoracic injury
-Traumatic arrest, with or without previously witnessed cardiac activity
-Unresponsive hypotension (BP < 70mmHg)

Blunt thoracic injury
-Unresponsive hypotension (BP < 70mmHg)
-Rapid exsanguination from placed chest tube (>1500ml)
-Traumatic arrest with previously witnessed cardiac activity (relative indication)

Contraindications

- Blunt thoracic injuries with no witnessed cardiac activity

- Multiple blunt trauma

- Severe head injury

 

Source: http://trauma.org/archive/thoracic/EDTindications.html

Acute MI? w/ LBBB- Sgarbossa's Criteria

It's hard to tell if a patient with LBBB  has an acute MI because ST segments are "appropriately discordant" with the terminal portion of the QRS

• i.e., if  QRS is - (downgoing), the ST will normally be + (upgoing), and vice versa

In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI --> derived 3 criteria to help dx "hidden" AMI:

1. ST elevation ≥ 1 mm concordant with QRS complex (most predictive of AMI of the 3 criteria)
2. ST depression ≥ 1 mm in lead V1, V2, or V3
3. ST elevation ≥ 5 mm where discordant with QRS complex

 

Sources:

• http://academiclifeinem.blogspot.com/2010/11/paucis-verbis-sgarbossas-criteria-with.html?m=1 
• http://www.ems12lead.blogspot.com

Internal Auditory Canal Anatomy

• 7-up: facial n
• coke down: cochlear n
• SVN: sup vestibular n (superior & lateral semicircular canal; utricle)
• IVN: inf vestibular n (posterior semicircular canal; saccule)
• BB: Bill's bar (bony protrusion, separates ant/post)

Source: http://roentgenrayreader.blogspot.com/

Semicircular canal anatomy:

Source: http://www.answers.com/topic/semicircular-canal