Shot Through the Heart

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Rachel Rafeq
Rachel Rafeq
Emergency medicine pharmacist and toxicology enthusiast. Trained in medication safety and I apply that to everything. I love photography and world schooling my kids.

The Pre-brief

Modern-day medicine doesn’t quite utilize intracardiac epinephrine, however, every now and then it resurfaces during cardiopulmonary resuscitation. Intracardiac injection was first reported in the early 1920’s in patients that underwent chloroform anesthesia who sustained cardiac arrest. Today it is generally utilized in cardiac arrest with open thoracotomy.  

Introduction

In patients with asystole, pulseless electrical activity (PEA), or pulseless ventricular tachycardia or ventricular fibrillation, epinephrine is considered the standard of care. The preferred route of epinephrine is intravenous or intraosseous when intravenous is not available. However, when vascular access is not available or in patients undergoing open cardiac massage (emergent thoracotomy), intracardiac epinephrine should be utilized. 

The 2000 ACC guidelines for advanced cardiac life support recommend that intracardiac administration should only be used during open cardiac massage or when other routes of administration are unavailable.  This is likely because intracardiac injections increase the risk of coronary artery laceration, cardiac tamponade, and pneumothorax. Intracardiac injections also cause interruption of external chest compression and ventilation.

Closed Chest Administration Techniques 

In the rare event that intracardiac administration is required during closed-chest compressions, there are two primary methods to administer. 

1)  Subxiphoid 

  • Stop CPR and stop ventilating the patient to allow the lungs to passively deflate
  • Identify the spot 1 cm to the left of the patients xiphoid process in the costosternal angle 
  • Insert the needle (bevel up) at a 30-40 degree angle to the skin of the abdominal wall and aimed towards the patients left shoulder
  • Advance the needle until blood flows freely into the syringe (be sure to apply negative pressure to the syringe while advancing it). Once this occurs it means the tip of the needle is in the cardiac chamber and epinephrine can quickly be injected. 
  • Resume CPR and ventilation. 
  • If for any reason the attempt is unsuccessful (for example the needle is plugged with subcutaneous fat) resume CPR and ventilation until another dose can be prepared and administered. 
  1. Left Parasternal 
  • Stop CPR and stop ventilating the patient to allow the lungs to passively deflate
  • Insert the needle perpendicular to the chest wall (approximately 1 cm lateral to the left sternal border). Stabilize the needle with one hand and the syringe with the other 
  • Advance the needle until blood flows freely into the syringe (be sure to apply negative pressure to the syringe while advancing it). Once this occurs it means the tip of the needle is in the cardiac chamber and epinephrine can quickly be injected. 
  • Resume CPR and ventilation.

Administration Technique during Open Chest Thoracotomy 

During open chest thoracotomy, the medication may be directly injected into the ventricle. There is not enough data to support the left ventricle over the right ventricle although left is preferred. 

Needle Size

For a closed chest, an 18 gauge spinal needle or 18 gauge 3 ½ inch needle should be utilized. This length allows for the appropriate depth required to reach the pericardium- the tip of the needle should go through the myocardium and into the cardiac chamber. 

In an open chest, a long spinal needle is not required. 

Dose

The dose of intracardiac Eepinephrine remains the same as standard intravenous or intraosseous epinephrine which is 1 mg.  

Epinephrine Concentration 

There is no clear guidance on which concentration of epinephrine should be used.  Historically, intracardiac epinephrine was manufactured as epinephrine 1 mg/10 mL with a 3.5 inch needle for intracardiac use, which is not removable nor compatible with needleless tubing/systems. However, there have been articles which have demonstrated the safe use of epinephrine 1 mg/1 mL. Ultimately this means that if you are at the phase of using intracardiac epinephrine in your patient, then use what you have available. 

The Debrief

  • While antiquated and no longer recommended in closed chest cardiac arrest, intracardiac epinephrine remains to be an appropriate method of administration during open chest thoracotomy cardiac arrest.  
  • The dose of intracardiac epinephrine is 1 mg which can be prepared as 1 mg/mL or 1 mg/10 mL based on availability. 
  • Needle length should be 3.5 inches in closed-chest cases, however this is not necessary in the case of an open chest. 
  • Administration technique varies, but during open chest, aim for the left ventricle and inject the medication quickly followed by cardiac massage immediately after. 

References

  1. Chapter 37. Intracardiac Injection. In: Reichman EF. Eds. Emergency Medicine Procedures, 2e. McGrawHill; 2013. Access October 27, 2021. Chapter 37. Intracardiac Injection | Emergency Medicine Procedures, 2e | AccessEmergency Medicine | McGraw Hill Medical (mhmedical.com)
  2. Lamberg JJ, Malhotra AK, McAlevy ME (2013) Intracardiac Epinephrine Injection during Open Thoracotomy and Circulatory Arrest. J Anesthe Clinic Res 4: 341. doi:10.4172/2155-6148.1000341

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