Cardiothoracic

• Synchronized Cardioversion
• Transcutaneous Cardiac Pacing
• Needle Thoracostomy
• Tube Thoracostomy
• Thoracentesis

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Synchronized Cardioversion

• Background
  • Defibrillation that is synced to the R or S wave of the QRS complex to avoid energy delivery near the apex of the T wave, which is a vulnerable period for induction of ventricular fibrillation. 
• Indications
  • SVT, atrial tachycardia, new-onset (or unstable) atrial fibrillation
• Contraindications
  • Rhythms requiring unsynchronized defibrillation (pulseless V-tach, V-fib). Caution using for A-fib in patients not anticoagulated (risk of stroke)
• Complications
  • Severe bradycardia/asystole. Burns.

*Deep Dive: Electrical Cardioversion in the ED: Who Crashes and How to Improve (emDOCs)

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Transcutaneous Cardiac Pacing

• Background
  • Temporary, non-invasive means of providing ventricular stimulation to the patient’s heart using pads 
• Indications
  • Symptomatic bradyarrhythmias (AV blocks, sinus node dysfunction, malfunction of implanted pacemaker, etc.)
• Contraindications
  • Stable, asymptomatic patients. Bradyarrythmias secondary to hypothermia. 
• Complications
  • Failure to capture, pain/discomfort, skin burns.

*Deep Dive: Transcutaneous Pacing (Downeast Emergency Medicine)

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Needle Thoracostomy

• Background
  • Insertion of a needle (typically 14 gauge) into the pleural space to decompress tension pneumothorax. Typically inserted in the 2nd intercostal space (above the 3rd rib) in the midclavicular line, or the 4th/5th intercostal space in the anterior axillary line.
• Indications
  • Suspected tension pneumothorax (progress shortness of breath, asymmetric lung sounds, tracheal deviation, jugular venous distension, hypotension)
• Contraindications
  • No absolute contraindications
• Complications
  • Lung laceration, kinking of catheter, dislodgement

*Deep Dive: How To Do Needle Thoracostomy (Merck Manual)

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Tube Thoracostomy

• Background
  • Insertion of a chest tube into the pleural cavity to drain blood, air, bile, pus, or other fluids. Allows for continuous, large volume drainage compared to needle thoracostomy.
• Indications
  • Hemothorax, pneumothorax, empyema, pleural effusion
• Contraindications
  • No absolute contraindication. Relative contraindications include coagulopathy, overlying skin infection, and pulmonary/pleural adhesions.
• Complications
  • Misplaced tube (kinked or too deep), infection, damage to nerves/vessels. 

*Deep Dive: Cutting Through the Triangle: A Review of Tube Thoracostomy in the ED

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Thoracentesis

• Background
  • Procedure performed to remove fluid from the pleural space for both diagnostic and/or therapeutic purposes. 
• Indications
  • pleural effusion
• Contraindications
  • No absolute contraindications; relative contraindications include coagulopathy or inability to place patient in a safe position.
• Complications
  • Pneumothorax, cough, infection, re-expansion pulmonary edema.

*Deep Dive: Considerations When Performing ED Thoracentesis (EMRA)

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