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The practice of intracardiac injection originated in the 1800s and had been strongly advocated for years before it began to fall out of favor.1-3 It was commonly performed throughout the 1960s, as it was thought to be the most expeditious route of drug delivery during a cardiac arrest.4,5 By the mid-1970s, the practice of intracardiac injection declined. Safer and simpler routes of medication administration (i.e., intravenous, endotracheal, and intraosseous) became available. Experimental data suggested that there was no advantage to intracardiac injection over intravenous administration of medications.6 Cardiopulmonary resuscitation (CPR) must be interrupted to perform an intracardiac injection. The time required for this procedure may be prolonged in difficult patients or in inexperienced hands. Many serious complications may occur from an intracardiac injection.5 Intracardiac injection should be considered when no other access is readily available.7


The technique of an intracardiac injection is similar to a pericardiocentesis (Chapter 48). Both techniques use the same anatomic landmarks and approach and involve the transthoracic insertion of a needle through the pericardium. The tip of the needle is inserted into the pericardial space when performing a pericardiocentesis. Intracardiac injection requires the tip of the needle to be inserted directly through the myocardium and into a cardiac chamber.

Echocardiography or bedside ultrasound may be useful in a pericardiocentesis to avoid the lung or myocardium.8 However, time is of the essence when performing an intracardiac injection. The objective is to quickly enter the myocardial cavity. Ultrasonographic guidance is generally not necessary. Certain comorbidities (e.g., chronic obstructive pulmonary disease [COPD], prior lung resection, or dextrocardia) may benefit from ultrasonographic guidance to avoid puncturing the lung.

The technique of intracardiac injection is rapid, simple to perform, and requires no special equipment. It begins with identification of the anatomic landmarks required to perform the procedure (Figure 49-1). For the subxiphoid approach, identify and palpate the xiphoid process of the sternum and the left costosternal angle. For the left parasternal approach, identify and palpate the left fourth or fifth intercostal spaces immediately adjacent to the sternum.

FIGURE 49-1.

Intracardiac injection. The needle is inserted 1 cm to the left of the xiphoid process and aimed toward the left shoulder. The needle may also be inserted parasternally in the left fourth or fifth intercostal space (as denoted by the ⊗).


Intracardiac injection should be considered when vascular access is not readily available in a patient in cardiac arrest. The goal of the procedure is to administer epinephrine rapidly to improve the likelihood of achieving a return of spontaneous circulation (ROSC).7 This is typically performed on patients in cardiac arrest with dysrhythmias such as asystole, pulseless electrical activity, or ventricular fibrillation....

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