intracardiac epi?

[Hamhock]

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anyone ever done this? seen it? think it is a good idea?

how to do it? RV vs. LV?

supposedly it is not such a crazy idea for young folks with a sliver of chance to make it after ED thoracotomy

HH

 

[deleted109597]

I guess you could rent Pulp Fiction.

The theoretical basis would infer that LV injection would get it into the cardiac vessels faster. You're unlikely to harm them anymore than they're already harmed.

 

[EMS5]

pardon my non-MD interjection, but if you're performing an emergent thoracotomy aren't you basically saying "this guy is as good as dead"? trauma codes have a low survival rate anyway, and ACLS meds have little effect on them regardless of the route (IV, IO, intracardiac)

 

[deleted109597]

pardon my non-MD interjection, but if you're performing an emergent thoracotomy aren't you basically saying "this guy is as good as dead"? trauma codes have a low survival rate anyway

No, there have been cases where people survive the thoracotomy, if done in the right populations. That being said, it is probably done 100x for every one appropriate one

and ACLS meds have little effect on them regardless of the route (IV, IO, intracardiac)

ACLS meds have little effect on patient oriented outcomes regardless of route or reason for giving.

 

[xaelia]

Epinephrine adminstration is an independent predictor of negative outcome in cardiac arrest.
PMID: 12104107

Epinephrine increases post-resuscitation myocardial dysfunction and decreased post-arrest survival in rats.
PMID: 7586280

Epinephrine administration decreases cerebral perfusion during CPR.
PMID: 19242339

Everything we do in cardiac arrest is probably wrong except the compressions, shocking vfib, and the post-ROSC cooling.

 

[Hamhock]

Everything we do in cardiac arrest is probably wrong except the compressions, shocking vfib, and the post-ROSC cooling.

I agree for the most part (nearly all) for medical arrest, but traumatic arrest is different...more similar to arrest secondary to potentially corrected acute problems, like tamponade, tension pneumo, even PE in some cases...but with traumatic arrest [in a very small population = basically stab wound (maybe single GSWs) to the ventricle that results in clotting tamponade] the underlying heart (and health in general) is usually much better.

So, I started wondering about intracardiac epi for those cases of repaired injuries when the heart appears to be trying to live again...that's when we just start pouring blood into the right subclavian and epi also...wondering if these cases we should just be going to straight intracardiac epi as soon as we feel the heart full

I realize this is a super rare event, but I have come across it a couple of times in residency and heard about intracardiac epi online recently...just thinking, really

so, has anyone done it? seen it?

HH

 

[suckstobeme]

I've done it a few times but never had anyone come back from it. I have gotten fibrillations that I used intra-cardiac paddles on, but again never got back a beating heart with a pulse.

My trauma surgeons back in the day told me look for a yellow/white/red streak coming down the anterior surface of the heart in an ant/posterior direction. Thats the LAD. Go lateral to that and you'll be in the LV.

 

[proman]

What's the goal of giving IC epi?

 

[docB]

What's the goal of giving IC epi?

So Marcellus doesn't kill you for ODing his wife.

 

[proman]

So Marcellus doesn't kill you for ODing his wife.

Of course. I meant besides that.

 

[docB]

Of course. I meant besides that.

Ok. I'll take the smart ass hat off.

You raise a good point. Why inject epi IC. You're presumably giving the epi for several reasons. One would be to get the peripheral vasoconstriction. The time advantage for that of IC over IV should be negligable. The argument that it gets to the myocytes faster for the inotropic and chronotropic effects also seems far fetched. I would imagine that it really doesn't help that much. I think that opinion is buttressed by the data that epi doesn't help that much in general. You add in the possible complications of vertricular laceration, coronary artery laceration, adding yet another sharp to the BBP exposure disaster that is the typical thoracotomy and I don't think it adds up.

I suppose if you've done a thoracotomy and have no IV access it might be more reasonable.

 

[proman]

Ok. I'll take the smart ass hat off.

You raise a good point. Why inject epi IC. You're presumably giving the epi for several reasons. One would be to get the peripheral vasoconstriction. The time advantage for that of IC over IV should be negligable. The argument that it gets to the myocytes faster for the inotropic and chronotropic effects also seems far fetched. I would imagine that it really doesn't help that much. I think that opinion is buttressed by the data that epi doesn't help that much in general. You add in the possible complications of vertricular laceration, coronary artery laceration, adding yet another sharp to the BBP exposure disaster that is the typical thoracotomy and I don't think it adds up.

I suppose if you've done a thoracotomy and have no IV access it might be more reasonable.

In cardiac ORs we like to joke that the world's best IV is a cannula in the aorta. It seems that IC epi doesn't really accomplish anything useful. Like you said, we give epi during codes to get the most profound vasoconstriction possible in an attempt to increase coronary and cerebral perfusion pressures (not inotropy).