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
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.
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.
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.
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.
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
- 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
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 ...