The practice of intracardiac injection originated in the 1800s. It was quite commonly performed 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 (i.e., intravenous, endotracheal, and 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
The technique of intracardiac injection is similar to that of a pericardiocentesis (Chapter 36). 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. Echocardiography or bedside ultrasound may be useful in pericardiocentesis to avoid the lung or myocardium.
Time is of the essence when performing an intracardiac injection. Since the objective is to quickly enter the myocardial cavity, ultrasonographic guidance is generally not necessary. Keeping this in mind, certain situations such as COPD, a prior lung resection, or dextrocardia may benefit from ultrasonographic guidance to avoid puncturing the lung.
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 (Figure 37-1). 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.
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 symbol “⊗ ”).
The primary indication for an intracardiac injection is when vascular access is not readily available or unobtainable in a patient with asystole, pulseless electrical activity, pulseless ventricular tachycardia, or ventricular fibrillation. The intracardiac injection of resuscitative medications may be warranted and can be attempted as a last effort to resuscitate the patient if other routes of medication administration have failed.
As candidates for this route of medicinal delivery have undergone a cardiac arrest, there are no absolute or relative contraindications to performing this procedure. A few clinical conditions may make the procedure more difficult ...