Cardiothoracic

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

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.
Video Credit: Pat Vaughn
Video Credit: Larry Mellick

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



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.
Video Credit: Chris Touzeau

*Deep Dive: Transcutaneous Pacing (Downeast Emergency Medicine)



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
Video Credit: Trauma Pro

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



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. 
Video Credit: EM:RAP

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



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.
Video Credit: Sarel Gaur MD

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


Brandon Simpson, PA-C
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