- Chest Tube
- Dual Sequence Defibrillation
- Needle Decompression
- Pacemaker/ICD Reset with Magnet
- Pericardiocentesis
- Synchronized Cardioversion
- Transcutaneous Cardiac Pacing
- Transvenous Cardiac Pacing
- Thoracentesis
- Thoracotomy
Chest Tube
Rapid Review
- 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.
Pearls
- Lower the risk of injury to the diaphragm/abdominal organs by elevating the head of the bed to 30-60 degrees
- When in doubt about your landmarks, stay within the “triangle of safety” (within the nipple line, lateral edge of latissmus dorsi, and lateral edge of pectoralis major)
Dual Sequence Defibrillation
Rapid Review
- Background
- Administration of electrical currents from two separate defibrillator devices in rapid succession for treatment of cardiac arrest.
- Indications
- Refractory ventricular fibrillation (does not convert or respond to three or more single defibrillation attempts)
- Contraindications
- No absolute or relative contraindications
- Complications
- Risk of damaging defibrillators if any pads are touching one another
Pearls
- Avoid any overlap of the defibrillation pads, as this pay cause significant damage to one or both defibrillators.
- The shocks from both monitors can be delivered simultaneously or one right after the other.
Needle Decompression
Rapid Review
- 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
Pearls
- Avoid the neurovascular bundle by inserting the needle above the ribs, as opposed to under.
- Needle decompression is useful in cases of tension pneumothorax, but is not sufficient for hemothorax. In these cases, a chest tube is often needed.
Pacemaker/ICD Reset with Magnet
Rapid Review
- Background
- Placement of a magnet over a malfunctioning pacemaker or ICD to reset the device into a manufacturer specific setting.
- Magnet over a pacemaker will set the device to a predetermined heart rate (ex. 70-110). Magnet over an ICD will disable the defibrillator entirely.
- Indications
- Pacemaker mediated tachycardia (PMT), inappropriate shocks.
- May be used diagnostically with pacemakers to identify oversensing or battery failure.
- Contraindications
- Do not reset an ICD delivering appropriate shocks to patient
- Complications
- May prevent ICD from cardioverting lethal arrhythmia
Pearls
- The reset of the ICD or pacemaker will only work as long as the magnet is placed over top of the device.
- All ICDs are also pacemakers. Placing a magnet over an ICD will disable the defibrillation function, but still allow it to pace.
Pericardiocentesis
Rapid Review
- Background
- Aspiration of fluid from the pericardial space for the treatment of cardiac tamponade. May be performed with blind-insertion or under ultrasound guidance.
- Indications
- Hemodynamically unstable cardiac tamponade
- May also be used diagnostically to determine cause of effusion
- Contraindications
- No absolute contraindications
- Relative contraindications include aortic dissection, anticoagulation, platelets < 50K.
- Complications
- Complications vary based on access route.
- Subcostal route (liver laceration, pneumothorax), Apical route (ventricular laceration), Parasternal route (pneumothorax, right ventricular laceration)
Pearls
- If ultrasound is unavailable, you can use an EKG to guide you during the procedure. Attach one alligator clip to the needle and the other to an anterior lead on a continuous EKG. If you notice ST-elevations, that means that the myocardium is being touched and you’ll need to retract the needle.
- Avoid redirecting the needle in lateral motions during the procedure, as this can cause tissue lacerations.
Deep Dive
Synchronized Cardioversion
Rapid Review
- 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.
Pearls
- It is imperative to press the “sync” button prior to defibrillation. Additionally, you must ensure the defibrillator correctly matches with the QRS complexes, as opposed to T-waves (may be difficult to distinguish in pre-excitation syndromes such as WPW)
- In stable patients, consider appropriate analgesia/sedation (ex. fentanyl, etomiate)
Transcutaneous Cardiac Pacing
Rapid Review
- 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.
Pearls
- Transcutaneous pacing has high failure rates and should only be used as a bridge to tranvenous pacing.
- Pace rates can be set to 60-80 bpm. Start the mA at 70 and titrate up by 5-10 until mechanical capture is achieved. Once threshold is met, increase by an additional 5-10 mA.
Transvenous Cardiac Pacing
Rapid Review
- Background
- Insertion of a pacing electrode catheter into the right ventricle for the treatment of unstable bradycardia. Often placed after initial transcutaneous pacing for more reliable pacing and increased patient comfort.
- Indications
- Unstable bradycardia. Bridge between transcutaneous pacing and application of permanent pacemaker.
- Contraindications
- Stable bradycardia (ex. first-degree AV block or mobitz 1)
- Complications
- Most complications related to central venous access (pneumothorax, infection, air embolism)
- Pacing may cause valvular or myocardial tears/ruptures
Pearls
- The right internal jugular vein is the preferred location due to it’s direct path to the right ventricle.
- Transvenous pacing is more reliable and more comfortable for the patient than transcutaneous pacing.
Deep Dive
Thoracentesis
Rapid Review
- 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.
Pearls
- If the fluid is of unknown origin, thoracentesis should be performed diagnostically (20-30cc). If fluid is causing significant clinical symptoms, it should be performed therapeutically (Max 1500cc to prevent reexpansion pulmonary edema)
- Reexpansion pulmonary edema is rare, but can be treated simply with BiPAP.
Thoracotomy
Rapid Review
- Background
- Emergency surgical procedure to gain access into the pleural space of the chest and manage intrathoracic injuries, decompress pericardial tamponade, or control aorta to prevent exsanguination
- Indications
- Penetrating or blunt thoracic trauma with refractory hypotension or recent cardiac arrest
- Contraindications
- Signs of prolonged death (rigor mortis) or non-survivable injuries
- CPR > 15 minutes for penetrating trauma, > 10 minutes for blunt trauma
- Complications
- Structural damage to organs or adjacent vessels. Infection.
Pearls
- Survival rates following thoracotomy are markedly higher in patients with penetrating trauma (16%), as opposed to blunt trauma (2%)
- Avoid damaging the phrenic nerves, which run parallel to the lateral walls of the pericardial sac.
Emergency Medicine Physician Assistant. Duke University Graduate. Army National Guard PA/Combat Medic. Former Paramedic. Devoted to learning and sharing evidence-based medicine.