Cardiothoracic

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)

Deep Dive

• Cutting Through the Triangle: A Review of Tube Thoracostomy in the ED

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.

Deep Dive

• Double Sequential Defibrillation – The DOSE VF trial (First10EM)

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. 

Deep Dive

• How To Do Needle Thoracostomy (Merck Manual)

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.

Deep Dive

• Pacemaker and AICD management in the Emergency Department (emDocs)

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

• Pericardiocentesis (NUEM)

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)

Deep Dive

• Electrical Cardioversion in the ED: Who Crashes and How to Improve (emDOCs)

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.

Deep Dive

• Transcutaneous Pacing (Downeast Emergency Medicine)

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

• Transvenous Pacemakers (EMCrit)

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.

Deep Dive

• Considerations When Performing ED Thoracentesis (EMRA)

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.

Deep Dive

• Unlocking Common ED Procedures: Rresuscitative Thoractomy in the ED (emDocs)