Cardiothoracic

  • 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

Video Credit: EM:RAP


Dual Sequence Defibrillation

Rapid Review

Pearls

Deep Dive

Video Credit: Core EM


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

Video Credit: Trauma Pro


Pacemaker/ICD Reset with Magnet

Rapid Review

Pearls

Deep Dive

Video Credit: Core EM


Pericardiocentesis

Rapid Review

Pearls

Deep Dive

Video Credit: Ken Strong


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

Video Credit: Pat Vaughn
Video Credit: Larry Mellick


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

Video Credit: Chris Touzeau


Transvenous Cardiac Pacing

Rapid Review

Pearls

Deep Dive

Video Credit: EMRAP



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

Video Credit: Sarel Gaur MD


Thoracotomy

Rapid Review

Pearls

Deep Dive

Video Credit: Larry Mellick
Video Credit: Essentials of Emergency Medicine


Brandon Simpson, PA-C
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