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.
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.
Rhythms requiring unsynchronized defibrillation (pulseless V-tach, V-fib). Caution using for A-fib in patients not anticoagulated (risk of stroke)
Severe bradycardia/asystole. Burns.
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)
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.
Unstable bradycardia. Bridge between transcutaneous pacing and application of permanent pacemaker.
Stable bradycardia (ex. first-degree AV block or mobitz 1)
Most complications related to central venous access (pneumothorax, infection, air embolism)
Pacing may cause valvular or myocardial tears/ruptures
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.
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.