Shot Through the Heart

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.