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The practice of intracardiac injection seems to have originated in the 1800s. It was quite common throughout the 1960s, as it was thought to be the most expeditious route of drug delivery during a cardiac arrest.1,2 By the mid-1970s, the practice of intracardiac injection declined. Safer and simpler routes of medication administration (intravenous, endotracheal, intraosseous) became available. Experimental data suggested that there was no advantage to intracardiac injection over intravenous administration of medications. Cardiopulmonary resuscitation (CPR) must be interrupted to perform an intracardiac injection. In difficult patients or in inexperienced hands, the time required for this procedure may be too prolonged. Finally, many serious complications may occur as a result of an intracardiac injection.2

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The technique of intracardiac injection is similar to that of a pericardiocentesis (Chapter 25). Both techniques use the same anatomic landmarks, the same anatomic approach, and the transthoracic insertion of a needle through the pericardium. In performing a pericardiocentesis, the tip of the needle is inserted into the pericardial space. Intracardiac injection requires the tip of the needle to be inserted through the myocardium and into a cardiac chamber.

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The technique of intracardiac injection is easy to teach, is rapid and simple to perform, and requires no special equipment. It begins with identification of the anatomic landmarks required to perform the procedure.

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For the subxiphoid approach, palpate the xiphoid process of the sternum and the left costosternal angle. For the left parasternal approach, palpate the left fourth or fifth intercostal spaces immediately adjacent to the sternum.

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The primary indication for an intracardiac injection is when vascular access is not readily available or unobtainable in an arrested patient with asystole, pulseless electrical activity, pulseless ventricular tachycardia, or ventricular fibrillation. If the endotracheal route of medication administration has failed to achieve resuscitation, the intracardiac injection of resuscitative medications may be warranted and can be attempted as a last effort to resuscitate the patient.

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As candidates for this route of medicinal delivery have undergone cardiac arrest, there are no absolute or relative contraindications to performing this procedure. A few clinical conditions may make the procedure more difficult to perform. Chronic obstructive pulmonary disease can shift the heart from its normal position and increase the risk of a pneumothorax (with or without tension). Therapeutic or overanticoagulation may result in a hemopericardium and cardiac tamponade. Dextrocardia will require some alterations in needle positioning.

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  • Povidone iodine solution or swabs
  • 18 gauge spinal needle or 18 gauge 3½ inch needle (for adults)
  • 22 gauge spinal needle (for children)
  • Syringes, 5 and 10 mL
  • Nasogastric tube
  • Epinephrine, 1:1000 and 1:10,000

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Epinephrine is the only resuscitative medication that should be administered by intracardiac injection. Administer 1 mg of epinephrine as the initial and subsequent doses in an adult patient. Administer 0.01 mg/kg (or 0.1 mL/kg) of the 1:10,000 concentration of epinephrine as the initial dose ...

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