ORIGINAL CONTRIBUTION
Paramedic Use of Intracardiac Medications in Prehospital Sudden Cardiac Death Brent D. Amey, MD* Eric E. Harrison, MDt Edward J. Straub, MD• Myra McLeod, RN Tampa, Florida
The intracardiac administration of medications in cardiac arrest is advocated when an intravenous route cannot be established. Although warnings of complications of this mode of therapy are reiterated throughout the literature, their careful documentation is lacking. Paramedics were trained to administer intracardiac medications, under strict criteria, in patients with prehospital sudden cardiac death. Longterm survivors who received intracardiac medications from paramedics were compared to a control group resuscitated by paramedics with intravenous medications alone. By far, the patients who received intracardiac medications were more nearly refractory to resuscitation because of the criteria for intracardiac medication use. Potential complications of the intracardiac route were identified and sought. However, complications were no more common in this group of patients than in the control group. Paramedics can successfully administer intracardiac medications when indicated. Amey BD, Harrison EE, Straub EJ, McLeod M: Paramedic use of intracardiac medications in prehospital sudden cardiac death. JACEP 7:130-134, April, 1978.
cardiac arrest, prehospital, intracardiac drugs; paramedic personnel, intracardiac drugs.
INTRODUCTION
Sudden cardiac d e a t h r e m a i n s one of the nation's principal h e a l t h problems, c l a i m i n g 300,000 to 400,000 lives yearly. 1 The evolution of emergency medical systems, in addition to b r i n g i n g basic and advanced life support to the population, offers a unique opportunity to s t u d y characteristics of p a t i e n t s with sudden cardiac d e a t h 2-7 and methods of r e s u s c i t a t i o n . The i n t r a c a r d i a c route of d e l i v e r i n g medications in cardiac a r r e s t was popular over 25 y e a r s ago s-9 but r e c e n t l y has fallen into disfavor. TM Even w h e n other a t t e m p t s at resuscitation have failed, the i n t r a c a r d i a c route is avoided for fear of possible complications. However, there has been little d o c u m e n t a t i o n of these complicatioris other t h a n isolated case reports and anecdotal information. H,12 This study assesses the usefulness of the i n t r a c a r d i a c route as well as the incidence of complications of the i n t r a c a r d i a c route in d e l i v e r i n g medications to p a t i e n t s suffering from p r e h o s p i t a l sudden cardiac death. Our study is unique in t h a t it is the first 1) to assess the effectiveness of the i n t r a c a r d i a c route; 2) to assess the incidence of complications, and 3) to d e m o n s t r a t e t h a t p a r a m e d i c s can employ From the Emergency Department, St. Joseph's Hospital;* The Cardiology Center, Tampa General Hospital,t and the West Coast Cardiology Center,$ Tampa, Florida. Presented at the FifthAnnual ACEP/EDNAScientific Assemblyin San Francisco, November, 1977. Address for reprints: Eric E. Harrison, MD, The Cardiology Center, Tampa General Hospital, Tampa, Florida 33606. 7"4 (Apr) 1978
JACEP
130/15
f~ ~
J
P~
r
F i g . 1. W i t h the p a r a s t e r n a l approach, an 18 gauge 31/2 inch needle on a prefilled syringe is inserted in the 4th and 5th intercostal space, 2 fingerbreadths lateral to the sternum. Although we have not observed this, laceration of the left anterior descendi n g c o r o n a r y artery or i n t e r n a l m a m m a r y artery presents a potential hazard. these techniques successfully.
METHODS The rescue division of the T a m p a Fire D e p a r t m e n t has been providing paramedic service to Tampa, Florida's p o p u l a t i o n s i n c e J u l y , 1972. The mobile coronary care u n i t response time is generally three to five minutes. 2 The p a r a m e d i c s staffing the mobile coronary care u n i t received advanced training and continuing education u n d e r the auspices of the Hillsborough County Medical Association. They perform basic a n d advanced c a r d i o p u l m o n a r y resuscitation - - i n c l u d i n g defibrillation, telemetry, intubation (tracheal and esophageal) - - establish i n t r a v e n o u s routes and administer medication (intravenous and intracardiac) as directed by a physician via radio contact. They i n t e r p r e t electrocardiograms (EKGs) on the scene which are confirmed by a coronary care nurse at a hospital base station. P a t i e n t s are transported to area medical facilities for further care. I n d i c a t i o n s for i n t r a c a r d i a c e p i n e p h r i n e were asystole, countershock, refractory v e n t r i c u l a r fibrillation, or a slow idioventricular r h y t h m without a pulse. Intracardiac sodium bicarbonate was a d m i n i s t e r e d in cases of refractory v e n t r i c u l a r fibrillation
16/131
when an i n t r a v e n o u s route could not be immediately established. Intracardiac calcium was a d m i n i s t e r e d infrequently. Two different t e c h n i q u e s were employed for a d m i n i s t r a t i o n of intracardiac medications. From July, 1972 u n t i l early 1976, the p a r a s t e r n a l approach was used exclusively. In this t e c h n i q u e a n # 1 8 g a u g e 31/2 i n c h needle on a prefilled syringe was inserted in the 4th or 5th intercostal space two f i n g e r b r e a d t h s l a t e r a l to the s t e r n u m (Figure 1). Blood was asp i r a t e d into the s y r i n g e to i n s u r e e n t r y into the right ventricle a n d the m e d i c a t i o n was injected. Recently, the subxiphoid route has been employed in the majority of cases. This t e c h n i q u e involves i n s e r t i n g an 18 gauge 31/2 inch needle at the j u n c t i o n of the xiphoid and left costal rib margin, the needle aimed at a 45 ° angle to the plane of the body and directed to the right shoulder (Figure 2). Blood was aspirated into the syringe to insure entry into the r i g h t ventricle and the medication was injected. The subxiphoid t e c h n i q u e h a s now r e p l a c e d the p a r a s t e r n a l approach due to the decrease of p o t e n t i a l complications such as l a c e r a t i n g or p u n c t u r i n g the left a n t e r i o r d e s c e n d i n g c o r o n a r y artery. E i t h e r t e c h n i q u e is r e a d i l y learned by the paramedic and can be accomplished w i t h o u t stopping car-
d i o p u l m o n a r y r e s u s u c i t a t i o n (CPR) longer t h a n is allowed. 13 T w e n t y - n i n e survivors who received intracardiac medications were compared to 67 survivors who were resuscitated without intracardiac medications. The definition of a survivor is a p a t i e n t who experienced an o u t - o f - h o s p i t a l c a r d i a c a r r e s t , received t r e a t m e n t at the scene and cont i n u e d t r e a t m e n t at a hospital with e v e n t u a l discharge. Information concerning patients in this study was obtained from rescue r u n reports and review of hospital charts. Complete sets of data were not available on all patients. Acute t r a n s m u r a l infarction was defined as the development of new Q waves 0.04 seconds or greater in duration in serial postresuscitation EKGs. EKGs with left bundle b r a n c h block were excluded from compilation. All o t h e r E K G s , i n c l u d i n g those with t r a n s m u r a l i n f a r c t i o n of u n d e t e r m i n e d age, were c l a s s i f i e d as not showing acute t r a n s m u r a l infarction. In addition, echocardiograms were obtained on as m a n y of these patients as possible i n the immediate recovery period in the coronary care unit of the m a j o r t e a c h i n g h o s p i t a l . Echocardiograms were also obtained on short term survivors. Pericardial effusions were defined by accepted criteria24
RESULTS Intracardiac Medication Group
m..._ J
F i g . 2. W i t h the s u b x i p h o i d approach, an 18 g a u g e needle is inserted at the junction o f the xiphoid and left costal rib margin, directed at a 30 ° to 45 ° angle to the frontal plane of the body and aimed in the sector between the right shoulder and sternal notch.
JACEP
Of the 29 survivors who received intracardiac medication, epinephrine was a d m i n i s t e r e d 33 times, sodium bicarbonate 13 times and calcium once (Table 1). In addition, these patients required 93 injections of other medications i n t r a v e n o u s l y d u r i n g resuscitation (mean 4.4 injections per patient). When combined, the patients received a m e a n of 4.8 injections per patient regardless of the route. These 29 survivors were d e f i b r i l l a t e d 89 times (mean three t i m e s per patient) to establish a stable rhythm. In this group there were eight patients in whom an i n t r a v e n o u s route could not be established prior to stabilization of the pat i e n t despite repeated attempts. These patients received a total of 19 cardiac m e d i c a t i o n s (2.4 injections per patient). The average age was 59 years with 26 males a n d three females. Review of the EKGs of these survivors revealed 28 interpretable tracings, as one p a t i e n t had a left bundle branch block pattern. Thirty-six percent (10/28) of the 28 p a t i e n t s had a documented acute myocardial infarc-
7:4 (Apr) 1978
DISCUSSION Table 1 INTRACARDIAC MEDICATION PATIENTS: MEDICATION, DEFIBRILLATION, RHYTHM n=29
Previous Observations
Injections of intracardiac medications Epinephrine Sodium bicarbonate Calcium chloride
No. 47 33 13 1
Injections of intravenous medications
93
Number of defibrillations
89
Intravenous line could not be established
8
Rhythm reasons for intracardiac epinephrine Asystole Countershock refractory ventricular fibrillation Idioventricular rhythm without a pulse Unknown from records
tion, w i t h 25% (7/28) a n t e r i o r in location and 11% (3/28) inferior. Survivors who were r e s u s c i t a t e d with i n t r a c a r d i a c medications spent an average of 19.5 days in the hospital (range 7 to 32), and an average of 7.4 days (range 2 to 24) in a coronary care unit a n d had an average of 2.2 days (range 0 to 8) o f v e n t i l a t o r y assistance. Significant v e n t r i c u l a r irritability was p r e s e n t in 36% o f i n t r a c a r d i a c m e d i c a t i o n s u r v i v o r s of whom 45% (13/29) h a d clinically significant premature ventricular contractions (PVCs) and 28% (8/29) h a d ventricular t a c h y c a r d i a or v e n t r i c u l a r fibrillation. No survivors h a d documented arterial emboli. Thirty-four percent (10/29) of the p a t i e n t s developed aspiration pneumonia. No p a t i e n t had a suspected p e r i c a r d i a l effusion, cerebral v a s c u l a r accident, or subacute bacterial endocarditis. Three p a t i e n t s developed pneumothoraces. One patient who was r e s u s c i t a t e d on two different occasions d e v e l o p e d a pneumothorax on both occasions. One patient developed a pneumopericardium. However, only one p a t i e n t required tube thoracotomy.
29
6 17 3 3
Review of the E K G s of survivors who d i d n o t r e c e i v e i n t r a c a r d i a c m e d i c a t i o n s r e v e a l e d t h a t 30% (17/ 57) h a d p r o v e n m y o c a r d i a l infarctions, 18% (10/57) a n t e r i o r a n d 12% (7/57) inferior. Survivors resuscitated without i n t r a c a r d i a c medication spent an ave r a g e of 17.7 d a y s in t h e h o s p i t a l (range 6 to 79). A n a v e r a g e of 6.1 days (range 0 to 19) were spent in the coronary care u n i t with an average of 1.8 d a y s (range 0 to 29) of vent i l a t o r y a s s i s t a n c e required. Significant v e n t r i c u l a r i r r i t a b i l i t y (34%) w a s also p r e s e n t in t h e group r e s u s c i t a t e d w i t h o u t i n t r a c a r diac medications 29% (19/65) experienced clinically significant PVCs a n d 38% (25/65) h a d v e n t r i c u l a r t a c h y c a r d i a or v e n t r i c u l a r f i b r i l l a tion. Only 17% (11/65) of this group had aspiration pneumonia. There were no d o c u m e n t e d cases of subacute b a c t e r i a l endocarditis, a r t e r i a l e m b o l i s m , c e r e b r a l v a s c u l a r accident, or suspected p e r i c a r d i a l effusion. One p a t i e n t did, however, have a h e m o p n e u m o t h o r a x as well as multiple rib fractures and required closed thoracotomy.
Control Group W h e n we c o m p a r e t h e 29 survivors who received intracardiac medications with 64 of the survivors resuscitated w i t h o u t t h e i n t r a c a r d i a c medications, we find t h a t the l a t t e r received an a v e r a g e of 2.4 intravenous injections per p a t i e n t and were d e f i b r i l l a t e d 98 t i m e s ( a v e r a g e 1.5 p e r p a t i e n t ) to e s t a b l i s h a s t a b l e r h y t h m . The a v e r a g e age of 64 of • these p a t i e n t s was also 59 y e a r s with 54 m a l e s a n d t e n females.
7:4 (Ap r) 1978
Echocardiographic Studies In addition, 26 survivors from both groups h a d echocardiograms to detect the presence of a p e r i c a r d i a l effusion. E i g h t p a t i e n t s had received i n t r a c a r d i a c m e d i c a t i o n s while t h e r e m a i n i n g 18 h a d been resuscitated by the i n t r a v e n o u s route. Of the 25 p a t i e n t s , t h r e e were found to have m i n i m a l p e r i c a r d i a l effusions deemed clinically insignificant. One of these had i n t r a c a r d i a c medications.
JACEP
The i n t r a c a r d i a c a d m i n i s t r a t i o n of m e d i c a t i o n s has been a d v o c a t e d for r e s u s c i t a t i o n o f p a t i e n t s w i t h cardiac a r r e s t for m a n y years. Jude, 15 a p i o n e e r in c a r d i a c r e s u s c i t a t i o n , r e c o m m e n d e d i n t r a c a r d i a c epinephrine or Isuprel hydrochloride as direct c a r d i a c s t i m u l a n t s a n d q u i n i dine g l u c o n a t e a n d p r o c a i n e a m i d e as m y o c a r d i a l depressants to be given by the intracardiac route. However, he w a r n e d a g a i n s t the use o f i n t r a c a r diac a n t a c i d s because c o n c e n t r a t e d bicarbonate solution inadvertently injected i n t r a m y o c a r d i a l l y will cause extensive necrosis. However, others 16 involved in the resuscitation of children a n d i n f a n t s often use the int r a c a r d i a c route i n i t i a l l y in delivery of e p i n e p h r i n e and, if p e r f u s i o n is poor w i t h closed chest massage, reco m m e n d i n t r a c a r d i a c i n j e c t i o n of sodium bicarbonate. Riker 17 also reco m m e n d s i n t r a c a r d i a c sodium bicarbonate w h e n necessary and intracardiac e p i n e p h r i n e and Isuprel. He also m e n t i o n s t h a t the needle s t i m u l u s m a y i n i t i a t e a h e a r t beat. G r e e n b l a t t e t alllS a s s e r t t h a t r e p e a t e d doses of m y o c a r d i a l s t i m u l a n t drugs m a y be g i v e n i n t r a c a r d i a c if no response is o b t a i n e d by central venous line bolus injection. Cohen and Turco 19 r e c o m m e n d e d the i n t r a c a r d i a c r o u t e w h e n no a d e q u a t e int r a v e n o u s line exists or when establ i s h i n g one c o u l d c a u s e d e l a y . S t e p h e n s o n 2° also r e c o m m e n d s the i n t r a c a r d i a c route when s t a r t i n g an i n t r a v e n o u s line would cause delay. On the o t h e r hand, G o l d b e r g 21 r e c o m m e n d s t h a t d r u g s not be del i v e r e d i n t r a c a r d i a t l y u n l e s s absolutely necessary. Disadvantages e n u m e r a t e d are the dangers of injection into the m y o c a r d i u m r e s u l t i n g in i n t r a c t a b l e v e n t r i c u l a r f i b r i l l a tion, coronary a r t e r y laceration, cardiac tamponade, and pneumothorax. ~z Vijay a n d Schoomaker 22 give t h e s a m e w a r n i n g . J u d e ~2 in h i s experience has not seen the most feared complication: coronary a r t e r y laceration. American Heart Association (AHA) g u i d e l i n e s for a d v a n c e d life support (1975) r e c o m m e n d intracard i a c u s e of e p i n e p h r i n e by w e l l t r a i n e d personnel if there is not sufficient t i m e to s t a r t an intravenous line. S c h e c t e r z° in J A M A h a r s h l y condemns the technique s t a t i n g t h a t this a p p r o a c h has been obsolete for 20 years.
13~17
Present Observations B e c a u s e of t h e s e c a v e a t s , t h e c r i t e r i a for t h e i n t r a c a r d i a c use of medications in our study were very strict. This a p p r o a c h was r e s e r v e d for w h e n i n t r a v e n o u s r o u t e s could not be e s t a b l i s h e d or r e s u s c i t a t i o n was n o t g o i n g well. T h e r h y t h m s t r e a t e d by i n t r a c a r d i a c e p i n e p h r i n e were i d i o v e n t r i c u l a r r h y t h m w i t h o u t a pulse, v e n t r i c u l a r f i b r i l l a t i o n refractory to defibrillation, and asysrole. These r h y t h m s a r e g e n e r a l l y seen in p a t i e n t s w i t h u n w i t n e s s e d a r r e s t s who received no CPR prior to a r r i v a l of the advanced life support - - g e n e r a l l y a less stable population in whom good results of resuscitation would not be expected. The long-term s u r v i v o r s of t h i s g r o u p of p a t i e n t s were compared to a control group of p a t i e n t s who were less refractory and who responded more rapidly w i t h a s t a b l e r h y t h m to r e s u s c i t a t i v e efforts. Thus, p a t i e n t s who r e c e i v e d drugs by the i n t r a c a r d i a c route because t h e i r conditions were refractory to resuscitation received on the average twice as m a n y drugs as the control group and r e q u i r e d twice as m a n y defibrillations prior to the est a b l i s h m e n t of a stable r h y t h m . Expected complications from the intracardiac route are pneumothorax, h e m o t h o r a x , l a c e r a t i o n of the
left a n t e r i o r descending coronary artery with resulting anterior wall myocardial infarction and hemop e r i c a r d i u m , h e m o p e r i c a r d i u m seco n d a r y to l e a k a g e f r o m c h a m b e r p u n c t u r e , air, f a t or c a r t i l a g e systemic embolization, subacute bacter i a l e n d o c a r d i t i s s e c o n d a r y to cont a m i n a t i o n , and more frequent vent r i c u l a r a r r h y t h m i a s secondary to int r a m y o c a r d i a l i n j e c t i o n (Advanced Cardiac Life Support. A m e r i c a n H e a r t Association, 1975).12,21, 22 The frequency of these complications was e x a m i n e d in t h e i n t r a c a r diac medicine group versus the control group (Table 2). To be complete, we would like to have had autopsy d a t a on nonsurvivors, b u t t h i s was not logistically possible. Pneumothoraces were more common in the i n t r a c a r d i a c medicine group. However, none of the control group had subclavian lines established out of the hospital. Because of the h a z a r d of pneumothoraces when e s t a b l i s h i n g a s u b c l a v i a n line, one m i g h t expect this complication to be more frequent if t h i s route had been used in the controls. 23 Of the pneumothoraces in the i n t r a c a r d i a c medication group, only one r e q u i r e d chest tube insertion. This p a t i e n t h a d several a t t e m p t s at i n t r a c a r d i a c injection using both techniques and the p n e u m o t h o r a x m a y have been pres-
ent prior to the i n t r a c a r d i a c injection a t t e m p t s since the h e a r t was not easily l o c a t e d u s i n g t h e p r o p e r tecb. nique. We c a n n o t exclude rib fract u r e r a t h e r t h a n the t r a n s t h o r a c i c puncture as a cause of these complications since all s u r v i v o r s received v i g o r o u s CPR. O n e i n t r a c a r d i a c medication p a t i e n t h a d a s m a l l pneum o p e r i c a r d i u m t h a t did not require treatment. Because of the possiblity of laceration of the left a n t e r i o r descend. ing coronary a r t e r y by intracardiac needle via the p a r a s t e r n a l approach, the incidence of acute m y o c a r d i a l infarction was assessed in both groups along with the incidence of anterior wall m y o c a r d i a l infarction. Twenty. five percent (7/28) of the intracardiac m e d i c a t i o n group had a n t e r i o r wall m y o c a r d i a l infarction. T h i r t y percent (17/57) o f t h e c o n t r o l g r o u p b a d acute t r a n s m u r a l m y o c a r d i a l infarctions, and 18% (10/57) h a d anterior w a l l m y o c a r d i a l i n f a r c t i o n s . In a group r e s u s c i t a t e d w i t h o u t intracardiac medication (n=80) r e p o r t e d by L i b e r t h s o n e t al, 24 39% h a d acute m y o c a r d i a l infarctions. T w e n t y percent had a n t e r i o r w a l l m y o c a r d i a l infarctions. If left bundle b r a n c h block p a t i e n t s were t h r o w n out of t h e data, as we did, 42% h a d acute myocardial i n f a r c t i o n s a n d 22% h a d a n t e r i o r wall m y o c a r d i a l infarctions (n=73). 24
Table 2 RATE OF COMPLICATIONS OF CARDIAC ARREST
Average days Hospitalized In coronary care unit On respirator Ventricular tachycardia/ ventricular fibrillation PVCs Total ventricular arrhythmias Subacute bacterial endocarditis Arterial embolism Pericardial effusion suspected Cerebral vascular accident Aspiration pneumonia Pneu mothoraces Myocardial infarctions Acute transmural Anterior wall Inferior wall Average age
Intracardiac Medications n=29
Control n=67 17.7 6.1 1.83
19.5 7.4 2.2 8/29 13/29 21/58 0/17 0/29 0/17 1/17 10/29 4/17
28% 45% 36% 0 0 0 6% 34% 24%
25/65 19/65 44/130 0/31 O/65 0/31 0/31 11/65 1/31
10/28 7/28 3/28
36% 25% 11%
17/57 10/57 7/57
59 (9 mo-90 yr)
38°/0 29% 34% 0 0 0 0 17% 3%
(X2 = .62)* (X2 = 1.53)*
(X2 = 30% (X2 = 18% 12% 59.1 (17 yr-79 yr)
.09)* .27)*
* Nonsignificant.
18/133
JACEP
7:4 (Ap r) 1978
Baum et al 2~ found 17% (24/140) of out of hospital v e n t r i c u l a r fibrillation patients with acute t r a n s m u r a l i n f a r c t i o n . T h u s , the i n c i d e n c e of acute myocardial infarctions in out of hospital resuscitated p a t i e n t s ranges from 17% to 39%, with anterior wall myocardial infarctions occurring most frequently. In autopsy studies this incidence r a n g e s from 10% to 47% of s u d d e n c a r d i a c d e a t h s . 24 Within these limits, patients receiving intracardiac medications do not differ g r e a t l y from other resuscitative populations. The echocardiographic examinations of both long-term and shortterm survivors in the i m m e d i a t e postresuscitative period assessed the possible occurrence of hemopericardium by looking for the presence of p e r i c a r d i a l effusions. Of e i g h t patients receiving intracardiac medications, only one had a pericardial effusion, which was small and could be e x p l a i n e d a w a y on t h e b a s i s of t r a n s u d a t i o n of fluid secondary to a n ischemic c a r d i o m y o p a t h y . Two patients in the control group had minor pericardial effusions, one secondary to congestive h e a r t failure and the other secondary to a steering wheel injury. Small unsuspected pericardial effusions are not u n c o m m o n in patients with congestive heart failure. 2~ Systemic embolic episodes were searched for in survivors, since systemic emboli m i g h t be produced by i n a d v e r t e n t injection of air or foreign material into the left ventricle if this chamber was accidentally entered. No embolic episodes were detected. C o n t a m i n a t i o n is always possible w h e n u s i n g r e l a t i v e l y asterile t e c h n i q u e s i n the field. However, there were no cases of demonstrated or suspected subacute bacterial endocarditis. Cessation or i n t e r r u p t i o n of CPR has been cited in the AHA gui~lelines as a possible d r a w b a c k of the intracardiac route of drug administration. In no case was CPR i n t e r r u p t e d for longer periods t h a n recommended in the AHA guidelines. A l t e r n a t i v e s to this route, such as e s t a b l i s h i n g a s u b c l a v i a n l i n e or a j u g u l a r line, may also present this hazard. Refractory v e n t r i c u l a r arrhythmias have b e e n cited 22 as possible complications i n patients who have i n a d v e r t e n t l y received intramyocardial i n j e c t i o n s . A r r h y t h m i a s were examined in all patients d u r i n g their hospital course. T w e n t y - e i g h t percent (8/29) of the intracardiac medication group had r e c u r r e n t ventricu-
7"4 (Apr) 1978
lar tachycardia or v e n t r i c u l a r fibrillation and 38% (25/65) of the control group had recurrent ventricular t a c h y c a r d i a or v e n t r i c u l a r fibrillation sometime d u r i n g their hospital course. PVCs in hospitalized patients occurred in 45% (13/29) of the intracardiac m e d i c a t i o n p a t i e n t s a n d 29% (19/65) of control patients. Thus, a l t h o u g h PVCs were slightly more c o m m o n in p a t i e n t s r e c e i v i n g i n tracardiac medications, recurrent v e n t r i c u l a r tachycardia and fibrillat i o n was s l i g h t l y more common i n the control group.
Clinical Implications Our data does not demonstrate a significant increase in complications of i n t r a c a r d i a c a d m i n i s t r a t i o n of medications in out-of-hospital sudden c a r d i a c d e a t h . We c o n c l u d e t h a t paramedics can be t r a i n e d to safely administer medications intracardially when indicated and, in m a n y instances, this is the only route conv e n i e n t l y available. We would like to acknowledge the cooperation and enthusiasm of the Tampa Fire Rescue, the technical assistance of Mrs. Susie Sharp and Ms. Elizabeth McKinnon, and the secretarial assistance of Mrs. Gloria J. Haddock. We would also like to thank Dennis F. Pupello, MD, for his encouragement in the paramedic use of this technique, George Ebra, PhD, for statistical analysis, and Mr. James Thornton for medical illustrations.
REFERENCES 1. Corday E: Symposium on identification and management of the candidate for sudden cardiac death-introduction. A m J Cardiol 39:813-815, 1977. 2. Amey BD, Harrison EE, Straub EJ: Sudden cardiac death: a restrospective and prospective study. J A C E P 5:429-433, 1976. 3. Straub EJ, Pupello DF, Harrison EE: Onset of Prinzmetal's angina two years following sudden death syndrome survival. J A C E P 6:405-407, 1977. 4. Harrison EE, Straub EJ, Amey BD: Pre-hospital sudden cardiac death. Read before the 57th annual scientific session, American College of Physicians, Philadelphia, Pennsylvania, April, 1976. 5. Harrison EE, Straub EJ, Amey BD: Sudden cardiac death. B r Heart J 38:997, 1976. 6. Briggs RS, Brown PM, Crabb ME, et ah The Brighton resuscitation ambulances: a continuing experiment in prehospital care by ambulance staff. B r Heart J 2:1161-1165, 1976. 7. Harrison EE, Straub EJ, Amey BD: Sudden cardiac death: a restrospective
JACEP
and prospective case study. Compilation of abstracts of contributed papers, 103rd APHA annual meeting, Chicago, Illinois, November, 1975. 8. Gerbode F: The cardiac emergency. A n n S u r g 135:431-432, 1952. 9. Kay JH: The treatment of cardiac arrest. S u r g Gynecol Obst 93:682-690, 1951. 10. Schechter DC: Transthoracic epinephrine injection in heart resuscitation is dangerous. J A M A 234:1184, 1975. 11. Kay JH: The treatment of cardiac arrest. S u r g Gynecol Obst 93:682-690, 1951. 12. Jude JR, Neumaster T, Kfoury E: Vasopressor-cardiotonic drugs in cardiac resuscitation. Acta Anaesth Scand Suppl 29:147-163, 1968. 13. Standards for cardiopulmonary re: suscitation and emergency cardiac care. J A M A 227:833-868, 1974. 14. Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239-247, 1974. 15. Jude JR, Elam JO: Fundamentals of cardiopulmonary resuscitation. F.A. Davis Company, Philadelphia, Pennsylvania, 1975. 16. Anthony CL, Crawford EW, Morgan BC: Management of cardiac and respiratory arrest in children. C l i n P e d i a t r 8:647-654, 1969. 17. Riker WL: Cardiac arrest in infants and children. Pediatr Clin N A m 16:661669. 18. Greenblatt DJ, Gross PL, Bolognini V: Phamacotherapy of cardiopulmonary arrest. A m J Hosp P h a r m 33:579-583, 1976. 19. Cohen MR, Turco J: Parenteral drugs used in cardiopulmonary resuscitation. Bull Parenter Drug Assoc 29:39-45, 1975. 20. Stephenson HE: Cardiac arrest and resuscitation. 4th Edition. CV Mosby Company, 1974. 21. Goldberg AH: Cardiopulmonary arrest. New E n g l J Med 290:381-385, 1974. 22. Vijay NK, Schoomaker FW: Cardiopulmonary arrest and resuscitation. A m Faro Physician p 85-90, August, 1975. 23~ Knopp R, Dailey RH: Central venous cannulation and pressure monitoring. J A C E P 6:358-366, 1977. 24. Liberthson RR, Nagel EL, Hirschman JC, et ah Pathophysiologic observations in pre-hospital ventricular fibrillation and sudden cardiac death. Circulation 49:790-798, 1974. 25. Baum RS, Alvarez H, Cobb LA: Survival after resuscitation from out-ofhospital ventricular fibrillation. Circulation 50:1231-1235, 1974. 26. Riba AL, Morgamoth J: Unsuspected substantial pericardial effusions detected by echocardiography. J A M A 236:26232625, 1976.
134/19
Paramedic Use of Intracardiac Medications in Prehospital Sudden Cardiac Death Brent D. Amey, MD* Eric E. Harrison, MDt Edward J. Straub, MD• Myra McLeod, RN Tampa, Florida
The intracardiac administration of medications in cardiac arrest is advocated when an intravenous route cannot be established. Although warnings of complications of this mode of therapy are reiterated throughout the literature, their careful documentation is lacking. Paramedics were trained to administer intracardiac medications, under strict criteria, in patients with prehospital sudden cardiac death. Longterm survivors who received intracardiac medications from paramedics were compared to a control group resuscitated by paramedics with intravenous medications alone. By far, the patients who received intracardiac medications were more nearly refractory to resuscitation because of the criteria for intracardiac medication use. Potential complications of the intracardiac route were identified and sought. However, complications were no more common in this group of patients than in the control group. Paramedics can successfully administer intracardiac medications when indicated. Amey BD, Harrison EE, Straub EJ, McLeod M: Paramedic use of intracardiac medications in prehospital sudden cardiac death. JACEP 7:130-134, April, 1978.
cardiac arrest, prehospital, intracardiac drugs; paramedic personnel, intracardiac drugs.
INTRODUCTION
Sudden cardiac d e a t h r e m a i n s one of the nation's principal h e a l t h problems, c l a i m i n g 300,000 to 400,000 lives yearly. 1 The evolution of emergency medical systems, in addition to b r i n g i n g basic and advanced life support to the population, offers a unique opportunity to s t u d y characteristics of p a t i e n t s with sudden cardiac d e a t h 2-7 and methods of r e s u s c i t a t i o n . The i n t r a c a r d i a c route of d e l i v e r i n g medications in cardiac a r r e s t was popular over 25 y e a r s ago s-9 but r e c e n t l y has fallen into disfavor. TM Even w h e n other a t t e m p t s at resuscitation have failed, the i n t r a c a r d i a c route is avoided for fear of possible complications. However, there has been little d o c u m e n t a t i o n of these complicatioris other t h a n isolated case reports and anecdotal information. H,12 This study assesses the usefulness of the i n t r a c a r d i a c route as well as the incidence of complications of the i n t r a c a r d i a c route in d e l i v e r i n g medications to p a t i e n t s suffering from p r e h o s p i t a l sudden cardiac death. Our study is unique in t h a t it is the first 1) to assess the effectiveness of the i n t r a c a r d i a c route; 2) to assess the incidence of complications, and 3) to d e m o n s t r a t e t h a t p a r a m e d i c s can employ From the Emergency Department, St. Joseph's Hospital;* The Cardiology Center, Tampa General Hospital,t and the West Coast Cardiology Center,$ Tampa, Florida. Presented at the FifthAnnual ACEP/EDNAScientific Assemblyin San Francisco, November, 1977. Address for reprints: Eric E. Harrison, MD, The Cardiology Center, Tampa General Hospital, Tampa, Florida 33606. 7"4 (Apr) 1978
JACEP
130/15
f~ ~
J
P~
r
F i g . 1. W i t h the p a r a s t e r n a l approach, an 18 gauge 31/2 inch needle on a prefilled syringe is inserted in the 4th and 5th intercostal space, 2 fingerbreadths lateral to the sternum. Although we have not observed this, laceration of the left anterior descendi n g c o r o n a r y artery or i n t e r n a l m a m m a r y artery presents a potential hazard. these techniques successfully.
METHODS The rescue division of the T a m p a Fire D e p a r t m e n t has been providing paramedic service to Tampa, Florida's p o p u l a t i o n s i n c e J u l y , 1972. The mobile coronary care u n i t response time is generally three to five minutes. 2 The p a r a m e d i c s staffing the mobile coronary care u n i t received advanced training and continuing education u n d e r the auspices of the Hillsborough County Medical Association. They perform basic a n d advanced c a r d i o p u l m o n a r y resuscitation - - i n c l u d i n g defibrillation, telemetry, intubation (tracheal and esophageal) - - establish i n t r a v e n o u s routes and administer medication (intravenous and intracardiac) as directed by a physician via radio contact. They i n t e r p r e t electrocardiograms (EKGs) on the scene which are confirmed by a coronary care nurse at a hospital base station. P a t i e n t s are transported to area medical facilities for further care. I n d i c a t i o n s for i n t r a c a r d i a c e p i n e p h r i n e were asystole, countershock, refractory v e n t r i c u l a r fibrillation, or a slow idioventricular r h y t h m without a pulse. Intracardiac sodium bicarbonate was a d m i n i s t e r e d in cases of refractory v e n t r i c u l a r fibrillation
16/131
when an i n t r a v e n o u s route could not be immediately established. Intracardiac calcium was a d m i n i s t e r e d infrequently. Two different t e c h n i q u e s were employed for a d m i n i s t r a t i o n of intracardiac medications. From July, 1972 u n t i l early 1976, the p a r a s t e r n a l approach was used exclusively. In this t e c h n i q u e a n # 1 8 g a u g e 31/2 i n c h needle on a prefilled syringe was inserted in the 4th or 5th intercostal space two f i n g e r b r e a d t h s l a t e r a l to the s t e r n u m (Figure 1). Blood was asp i r a t e d into the s y r i n g e to i n s u r e e n t r y into the right ventricle a n d the m e d i c a t i o n was injected. Recently, the subxiphoid route has been employed in the majority of cases. This t e c h n i q u e involves i n s e r t i n g an 18 gauge 31/2 inch needle at the j u n c t i o n of the xiphoid and left costal rib margin, the needle aimed at a 45 ° angle to the plane of the body and directed to the right shoulder (Figure 2). Blood was aspirated into the syringe to insure entry into the r i g h t ventricle and the medication was injected. The subxiphoid t e c h n i q u e h a s now r e p l a c e d the p a r a s t e r n a l approach due to the decrease of p o t e n t i a l complications such as l a c e r a t i n g or p u n c t u r i n g the left a n t e r i o r d e s c e n d i n g c o r o n a r y artery. E i t h e r t e c h n i q u e is r e a d i l y learned by the paramedic and can be accomplished w i t h o u t stopping car-
d i o p u l m o n a r y r e s u s u c i t a t i o n (CPR) longer t h a n is allowed. 13 T w e n t y - n i n e survivors who received intracardiac medications were compared to 67 survivors who were resuscitated without intracardiac medications. The definition of a survivor is a p a t i e n t who experienced an o u t - o f - h o s p i t a l c a r d i a c a r r e s t , received t r e a t m e n t at the scene and cont i n u e d t r e a t m e n t at a hospital with e v e n t u a l discharge. Information concerning patients in this study was obtained from rescue r u n reports and review of hospital charts. Complete sets of data were not available on all patients. Acute t r a n s m u r a l infarction was defined as the development of new Q waves 0.04 seconds or greater in duration in serial postresuscitation EKGs. EKGs with left bundle b r a n c h block were excluded from compilation. All o t h e r E K G s , i n c l u d i n g those with t r a n s m u r a l i n f a r c t i o n of u n d e t e r m i n e d age, were c l a s s i f i e d as not showing acute t r a n s m u r a l infarction. In addition, echocardiograms were obtained on as m a n y of these patients as possible i n the immediate recovery period in the coronary care unit of the m a j o r t e a c h i n g h o s p i t a l . Echocardiograms were also obtained on short term survivors. Pericardial effusions were defined by accepted criteria24
RESULTS Intracardiac Medication Group
m..._ J
F i g . 2. W i t h the s u b x i p h o i d approach, an 18 g a u g e needle is inserted at the junction o f the xiphoid and left costal rib margin, directed at a 30 ° to 45 ° angle to the frontal plane of the body and aimed in the sector between the right shoulder and sternal notch.
JACEP
Of the 29 survivors who received intracardiac medication, epinephrine was a d m i n i s t e r e d 33 times, sodium bicarbonate 13 times and calcium once (Table 1). In addition, these patients required 93 injections of other medications i n t r a v e n o u s l y d u r i n g resuscitation (mean 4.4 injections per patient). When combined, the patients received a m e a n of 4.8 injections per patient regardless of the route. These 29 survivors were d e f i b r i l l a t e d 89 times (mean three t i m e s per patient) to establish a stable rhythm. In this group there were eight patients in whom an i n t r a v e n o u s route could not be established prior to stabilization of the pat i e n t despite repeated attempts. These patients received a total of 19 cardiac m e d i c a t i o n s (2.4 injections per patient). The average age was 59 years with 26 males a n d three females. Review of the EKGs of these survivors revealed 28 interpretable tracings, as one p a t i e n t had a left bundle branch block pattern. Thirty-six percent (10/28) of the 28 p a t i e n t s had a documented acute myocardial infarc-
7:4 (Apr) 1978
DISCUSSION Table 1 INTRACARDIAC MEDICATION PATIENTS: MEDICATION, DEFIBRILLATION, RHYTHM n=29
Previous Observations
Injections of intracardiac medications Epinephrine Sodium bicarbonate Calcium chloride
No. 47 33 13 1
Injections of intravenous medications
93
Number of defibrillations
89
Intravenous line could not be established
8
Rhythm reasons for intracardiac epinephrine Asystole Countershock refractory ventricular fibrillation Idioventricular rhythm without a pulse Unknown from records
tion, w i t h 25% (7/28) a n t e r i o r in location and 11% (3/28) inferior. Survivors who were r e s u s c i t a t e d with i n t r a c a r d i a c medications spent an average of 19.5 days in the hospital (range 7 to 32), and an average of 7.4 days (range 2 to 24) in a coronary care unit a n d had an average of 2.2 days (range 0 to 8) o f v e n t i l a t o r y assistance. Significant v e n t r i c u l a r irritability was p r e s e n t in 36% o f i n t r a c a r d i a c m e d i c a t i o n s u r v i v o r s of whom 45% (13/29) h a d clinically significant premature ventricular contractions (PVCs) and 28% (8/29) h a d ventricular t a c h y c a r d i a or v e n t r i c u l a r fibrillation. No survivors h a d documented arterial emboli. Thirty-four percent (10/29) of the p a t i e n t s developed aspiration pneumonia. No p a t i e n t had a suspected p e r i c a r d i a l effusion, cerebral v a s c u l a r accident, or subacute bacterial endocarditis. Three p a t i e n t s developed pneumothoraces. One patient who was r e s u s c i t a t e d on two different occasions d e v e l o p e d a pneumothorax on both occasions. One patient developed a pneumopericardium. However, only one p a t i e n t required tube thoracotomy.
29
6 17 3 3
Review of the E K G s of survivors who d i d n o t r e c e i v e i n t r a c a r d i a c m e d i c a t i o n s r e v e a l e d t h a t 30% (17/ 57) h a d p r o v e n m y o c a r d i a l infarctions, 18% (10/57) a n t e r i o r a n d 12% (7/57) inferior. Survivors resuscitated without i n t r a c a r d i a c medication spent an ave r a g e of 17.7 d a y s in t h e h o s p i t a l (range 6 to 79). A n a v e r a g e of 6.1 days (range 0 to 19) were spent in the coronary care u n i t with an average of 1.8 d a y s (range 0 to 29) of vent i l a t o r y a s s i s t a n c e required. Significant v e n t r i c u l a r i r r i t a b i l i t y (34%) w a s also p r e s e n t in t h e group r e s u s c i t a t e d w i t h o u t i n t r a c a r diac medications 29% (19/65) experienced clinically significant PVCs a n d 38% (25/65) h a d v e n t r i c u l a r t a c h y c a r d i a or v e n t r i c u l a r f i b r i l l a tion. Only 17% (11/65) of this group had aspiration pneumonia. There were no d o c u m e n t e d cases of subacute b a c t e r i a l endocarditis, a r t e r i a l e m b o l i s m , c e r e b r a l v a s c u l a r accident, or suspected p e r i c a r d i a l effusion. One p a t i e n t did, however, have a h e m o p n e u m o t h o r a x as well as multiple rib fractures and required closed thoracotomy.
Control Group W h e n we c o m p a r e t h e 29 survivors who received intracardiac medications with 64 of the survivors resuscitated w i t h o u t t h e i n t r a c a r d i a c medications, we find t h a t the l a t t e r received an a v e r a g e of 2.4 intravenous injections per p a t i e n t and were d e f i b r i l l a t e d 98 t i m e s ( a v e r a g e 1.5 p e r p a t i e n t ) to e s t a b l i s h a s t a b l e r h y t h m . The a v e r a g e age of 64 of • these p a t i e n t s was also 59 y e a r s with 54 m a l e s a n d t e n females.
7:4 (Ap r) 1978
Echocardiographic Studies In addition, 26 survivors from both groups h a d echocardiograms to detect the presence of a p e r i c a r d i a l effusion. E i g h t p a t i e n t s had received i n t r a c a r d i a c m e d i c a t i o n s while t h e r e m a i n i n g 18 h a d been resuscitated by the i n t r a v e n o u s route. Of the 25 p a t i e n t s , t h r e e were found to have m i n i m a l p e r i c a r d i a l effusions deemed clinically insignificant. One of these had i n t r a c a r d i a c medications.
JACEP
The i n t r a c a r d i a c a d m i n i s t r a t i o n of m e d i c a t i o n s has been a d v o c a t e d for r e s u s c i t a t i o n o f p a t i e n t s w i t h cardiac a r r e s t for m a n y years. Jude, 15 a p i o n e e r in c a r d i a c r e s u s c i t a t i o n , r e c o m m e n d e d i n t r a c a r d i a c epinephrine or Isuprel hydrochloride as direct c a r d i a c s t i m u l a n t s a n d q u i n i dine g l u c o n a t e a n d p r o c a i n e a m i d e as m y o c a r d i a l depressants to be given by the intracardiac route. However, he w a r n e d a g a i n s t the use o f i n t r a c a r diac a n t a c i d s because c o n c e n t r a t e d bicarbonate solution inadvertently injected i n t r a m y o c a r d i a l l y will cause extensive necrosis. However, others 16 involved in the resuscitation of children a n d i n f a n t s often use the int r a c a r d i a c route i n i t i a l l y in delivery of e p i n e p h r i n e and, if p e r f u s i o n is poor w i t h closed chest massage, reco m m e n d i n t r a c a r d i a c i n j e c t i o n of sodium bicarbonate. Riker 17 also reco m m e n d s i n t r a c a r d i a c sodium bicarbonate w h e n necessary and intracardiac e p i n e p h r i n e and Isuprel. He also m e n t i o n s t h a t the needle s t i m u l u s m a y i n i t i a t e a h e a r t beat. G r e e n b l a t t e t alllS a s s e r t t h a t r e p e a t e d doses of m y o c a r d i a l s t i m u l a n t drugs m a y be g i v e n i n t r a c a r d i a c if no response is o b t a i n e d by central venous line bolus injection. Cohen and Turco 19 r e c o m m e n d e d the i n t r a c a r d i a c r o u t e w h e n no a d e q u a t e int r a v e n o u s line exists or when establ i s h i n g one c o u l d c a u s e d e l a y . S t e p h e n s o n 2° also r e c o m m e n d s the i n t r a c a r d i a c route when s t a r t i n g an i n t r a v e n o u s line would cause delay. On the o t h e r hand, G o l d b e r g 21 r e c o m m e n d s t h a t d r u g s not be del i v e r e d i n t r a c a r d i a t l y u n l e s s absolutely necessary. Disadvantages e n u m e r a t e d are the dangers of injection into the m y o c a r d i u m r e s u l t i n g in i n t r a c t a b l e v e n t r i c u l a r f i b r i l l a tion, coronary a r t e r y laceration, cardiac tamponade, and pneumothorax. ~z Vijay a n d Schoomaker 22 give t h e s a m e w a r n i n g . J u d e ~2 in h i s experience has not seen the most feared complication: coronary a r t e r y laceration. American Heart Association (AHA) g u i d e l i n e s for a d v a n c e d life support (1975) r e c o m m e n d intracard i a c u s e of e p i n e p h r i n e by w e l l t r a i n e d personnel if there is not sufficient t i m e to s t a r t an intravenous line. S c h e c t e r z° in J A M A h a r s h l y condemns the technique s t a t i n g t h a t this a p p r o a c h has been obsolete for 20 years.
13~17
Present Observations B e c a u s e of t h e s e c a v e a t s , t h e c r i t e r i a for t h e i n t r a c a r d i a c use of medications in our study were very strict. This a p p r o a c h was r e s e r v e d for w h e n i n t r a v e n o u s r o u t e s could not be e s t a b l i s h e d or r e s u s c i t a t i o n was n o t g o i n g well. T h e r h y t h m s t r e a t e d by i n t r a c a r d i a c e p i n e p h r i n e were i d i o v e n t r i c u l a r r h y t h m w i t h o u t a pulse, v e n t r i c u l a r f i b r i l l a t i o n refractory to defibrillation, and asysrole. These r h y t h m s a r e g e n e r a l l y seen in p a t i e n t s w i t h u n w i t n e s s e d a r r e s t s who received no CPR prior to a r r i v a l of the advanced life support - - g e n e r a l l y a less stable population in whom good results of resuscitation would not be expected. The long-term s u r v i v o r s of t h i s g r o u p of p a t i e n t s were compared to a control group of p a t i e n t s who were less refractory and who responded more rapidly w i t h a s t a b l e r h y t h m to r e s u s c i t a t i v e efforts. Thus, p a t i e n t s who r e c e i v e d drugs by the i n t r a c a r d i a c route because t h e i r conditions were refractory to resuscitation received on the average twice as m a n y drugs as the control group and r e q u i r e d twice as m a n y defibrillations prior to the est a b l i s h m e n t of a stable r h y t h m . Expected complications from the intracardiac route are pneumothorax, h e m o t h o r a x , l a c e r a t i o n of the
left a n t e r i o r descending coronary artery with resulting anterior wall myocardial infarction and hemop e r i c a r d i u m , h e m o p e r i c a r d i u m seco n d a r y to l e a k a g e f r o m c h a m b e r p u n c t u r e , air, f a t or c a r t i l a g e systemic embolization, subacute bacter i a l e n d o c a r d i t i s s e c o n d a r y to cont a m i n a t i o n , and more frequent vent r i c u l a r a r r h y t h m i a s secondary to int r a m y o c a r d i a l i n j e c t i o n (Advanced Cardiac Life Support. A m e r i c a n H e a r t Association, 1975).12,21, 22 The frequency of these complications was e x a m i n e d in t h e i n t r a c a r diac medicine group versus the control group (Table 2). To be complete, we would like to have had autopsy d a t a on nonsurvivors, b u t t h i s was not logistically possible. Pneumothoraces were more common in the i n t r a c a r d i a c medicine group. However, none of the control group had subclavian lines established out of the hospital. Because of the h a z a r d of pneumothoraces when e s t a b l i s h i n g a s u b c l a v i a n line, one m i g h t expect this complication to be more frequent if t h i s route had been used in the controls. 23 Of the pneumothoraces in the i n t r a c a r d i a c medication group, only one r e q u i r e d chest tube insertion. This p a t i e n t h a d several a t t e m p t s at i n t r a c a r d i a c injection using both techniques and the p n e u m o t h o r a x m a y have been pres-
ent prior to the i n t r a c a r d i a c injection a t t e m p t s since the h e a r t was not easily l o c a t e d u s i n g t h e p r o p e r tecb. nique. We c a n n o t exclude rib fract u r e r a t h e r t h a n the t r a n s t h o r a c i c puncture as a cause of these complications since all s u r v i v o r s received v i g o r o u s CPR. O n e i n t r a c a r d i a c medication p a t i e n t h a d a s m a l l pneum o p e r i c a r d i u m t h a t did not require treatment. Because of the possiblity of laceration of the left a n t e r i o r descend. ing coronary a r t e r y by intracardiac needle via the p a r a s t e r n a l approach, the incidence of acute m y o c a r d i a l infarction was assessed in both groups along with the incidence of anterior wall m y o c a r d i a l infarction. Twenty. five percent (7/28) of the intracardiac m e d i c a t i o n group had a n t e r i o r wall m y o c a r d i a l infarction. T h i r t y percent (17/57) o f t h e c o n t r o l g r o u p b a d acute t r a n s m u r a l m y o c a r d i a l infarctions, and 18% (10/57) h a d anterior w a l l m y o c a r d i a l i n f a r c t i o n s . In a group r e s u s c i t a t e d w i t h o u t intracardiac medication (n=80) r e p o r t e d by L i b e r t h s o n e t al, 24 39% h a d acute m y o c a r d i a l infarctions. T w e n t y percent had a n t e r i o r w a l l m y o c a r d i a l infarctions. If left bundle b r a n c h block p a t i e n t s were t h r o w n out of t h e data, as we did, 42% h a d acute myocardial i n f a r c t i o n s a n d 22% h a d a n t e r i o r wall m y o c a r d i a l infarctions (n=73). 24
Table 2 RATE OF COMPLICATIONS OF CARDIAC ARREST
Average days Hospitalized In coronary care unit On respirator Ventricular tachycardia/ ventricular fibrillation PVCs Total ventricular arrhythmias Subacute bacterial endocarditis Arterial embolism Pericardial effusion suspected Cerebral vascular accident Aspiration pneumonia Pneu mothoraces Myocardial infarctions Acute transmural Anterior wall Inferior wall Average age
Intracardiac Medications n=29
Control n=67 17.7 6.1 1.83
19.5 7.4 2.2 8/29 13/29 21/58 0/17 0/29 0/17 1/17 10/29 4/17
28% 45% 36% 0 0 0 6% 34% 24%
25/65 19/65 44/130 0/31 O/65 0/31 0/31 11/65 1/31
10/28 7/28 3/28
36% 25% 11%
17/57 10/57 7/57
59 (9 mo-90 yr)
38°/0 29% 34% 0 0 0 0 17% 3%
(X2 = .62)* (X2 = 1.53)*
(X2 = 30% (X2 = 18% 12% 59.1 (17 yr-79 yr)
.09)* .27)*
* Nonsignificant.
18/133
JACEP
7:4 (Ap r) 1978
Baum et al 2~ found 17% (24/140) of out of hospital v e n t r i c u l a r fibrillation patients with acute t r a n s m u r a l i n f a r c t i o n . T h u s , the i n c i d e n c e of acute myocardial infarctions in out of hospital resuscitated p a t i e n t s ranges from 17% to 39%, with anterior wall myocardial infarctions occurring most frequently. In autopsy studies this incidence r a n g e s from 10% to 47% of s u d d e n c a r d i a c d e a t h s . 24 Within these limits, patients receiving intracardiac medications do not differ g r e a t l y from other resuscitative populations. The echocardiographic examinations of both long-term and shortterm survivors in the i m m e d i a t e postresuscitative period assessed the possible occurrence of hemopericardium by looking for the presence of p e r i c a r d i a l effusions. Of e i g h t patients receiving intracardiac medications, only one had a pericardial effusion, which was small and could be e x p l a i n e d a w a y on t h e b a s i s of t r a n s u d a t i o n of fluid secondary to a n ischemic c a r d i o m y o p a t h y . Two patients in the control group had minor pericardial effusions, one secondary to congestive h e a r t failure and the other secondary to a steering wheel injury. Small unsuspected pericardial effusions are not u n c o m m o n in patients with congestive heart failure. 2~ Systemic embolic episodes were searched for in survivors, since systemic emboli m i g h t be produced by i n a d v e r t e n t injection of air or foreign material into the left ventricle if this chamber was accidentally entered. No embolic episodes were detected. C o n t a m i n a t i o n is always possible w h e n u s i n g r e l a t i v e l y asterile t e c h n i q u e s i n the field. However, there were no cases of demonstrated or suspected subacute bacterial endocarditis. Cessation or i n t e r r u p t i o n of CPR has been cited in the AHA gui~lelines as a possible d r a w b a c k of the intracardiac route of drug administration. In no case was CPR i n t e r r u p t e d for longer periods t h a n recommended in the AHA guidelines. A l t e r n a t i v e s to this route, such as e s t a b l i s h i n g a s u b c l a v i a n l i n e or a j u g u l a r line, may also present this hazard. Refractory v e n t r i c u l a r arrhythmias have b e e n cited 22 as possible complications i n patients who have i n a d v e r t e n t l y received intramyocardial i n j e c t i o n s . A r r h y t h m i a s were examined in all patients d u r i n g their hospital course. T w e n t y - e i g h t percent (8/29) of the intracardiac medication group had r e c u r r e n t ventricu-
7"4 (Apr) 1978
lar tachycardia or v e n t r i c u l a r fibrillation and 38% (25/65) of the control group had recurrent ventricular t a c h y c a r d i a or v e n t r i c u l a r fibrillation sometime d u r i n g their hospital course. PVCs in hospitalized patients occurred in 45% (13/29) of the intracardiac m e d i c a t i o n p a t i e n t s a n d 29% (19/65) of control patients. Thus, a l t h o u g h PVCs were slightly more c o m m o n in p a t i e n t s r e c e i v i n g i n tracardiac medications, recurrent v e n t r i c u l a r tachycardia and fibrillat i o n was s l i g h t l y more common i n the control group.
Clinical Implications Our data does not demonstrate a significant increase in complications of i n t r a c a r d i a c a d m i n i s t r a t i o n of medications in out-of-hospital sudden c a r d i a c d e a t h . We c o n c l u d e t h a t paramedics can be t r a i n e d to safely administer medications intracardially when indicated and, in m a n y instances, this is the only route conv e n i e n t l y available. We would like to acknowledge the cooperation and enthusiasm of the Tampa Fire Rescue, the technical assistance of Mrs. Susie Sharp and Ms. Elizabeth McKinnon, and the secretarial assistance of Mrs. Gloria J. Haddock. We would also like to thank Dennis F. Pupello, MD, for his encouragement in the paramedic use of this technique, George Ebra, PhD, for statistical analysis, and Mr. James Thornton for medical illustrations.
REFERENCES 1. Corday E: Symposium on identification and management of the candidate for sudden cardiac death-introduction. A m J Cardiol 39:813-815, 1977. 2. Amey BD, Harrison EE, Straub EJ: Sudden cardiac death: a restrospective and prospective study. J A C E P 5:429-433, 1976. 3. Straub EJ, Pupello DF, Harrison EE: Onset of Prinzmetal's angina two years following sudden death syndrome survival. J A C E P 6:405-407, 1977. 4. Harrison EE, Straub EJ, Amey BD: Pre-hospital sudden cardiac death. Read before the 57th annual scientific session, American College of Physicians, Philadelphia, Pennsylvania, April, 1976. 5. Harrison EE, Straub EJ, Amey BD: Sudden cardiac death. B r Heart J 38:997, 1976. 6. Briggs RS, Brown PM, Crabb ME, et ah The Brighton resuscitation ambulances: a continuing experiment in prehospital care by ambulance staff. B r Heart J 2:1161-1165, 1976. 7. Harrison EE, Straub EJ, Amey BD: Sudden cardiac death: a restrospective
JACEP
and prospective case study. Compilation of abstracts of contributed papers, 103rd APHA annual meeting, Chicago, Illinois, November, 1975. 8. Gerbode F: The cardiac emergency. A n n S u r g 135:431-432, 1952. 9. Kay JH: The treatment of cardiac arrest. S u r g Gynecol Obst 93:682-690, 1951. 10. Schechter DC: Transthoracic epinephrine injection in heart resuscitation is dangerous. J A M A 234:1184, 1975. 11. Kay JH: The treatment of cardiac arrest. S u r g Gynecol Obst 93:682-690, 1951. 12. Jude JR, Neumaster T, Kfoury E: Vasopressor-cardiotonic drugs in cardiac resuscitation. Acta Anaesth Scand Suppl 29:147-163, 1968. 13. Standards for cardiopulmonary re: suscitation and emergency cardiac care. J A M A 227:833-868, 1974. 14. Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239-247, 1974. 15. Jude JR, Elam JO: Fundamentals of cardiopulmonary resuscitation. F.A. Davis Company, Philadelphia, Pennsylvania, 1975. 16. Anthony CL, Crawford EW, Morgan BC: Management of cardiac and respiratory arrest in children. C l i n P e d i a t r 8:647-654, 1969. 17. Riker WL: Cardiac arrest in infants and children. Pediatr Clin N A m 16:661669. 18. Greenblatt DJ, Gross PL, Bolognini V: Phamacotherapy of cardiopulmonary arrest. A m J Hosp P h a r m 33:579-583, 1976. 19. Cohen MR, Turco J: Parenteral drugs used in cardiopulmonary resuscitation. Bull Parenter Drug Assoc 29:39-45, 1975. 20. Stephenson HE: Cardiac arrest and resuscitation. 4th Edition. CV Mosby Company, 1974. 21. Goldberg AH: Cardiopulmonary arrest. New E n g l J Med 290:381-385, 1974. 22. Vijay NK, Schoomaker FW: Cardiopulmonary arrest and resuscitation. A m Faro Physician p 85-90, August, 1975. 23~ Knopp R, Dailey RH: Central venous cannulation and pressure monitoring. J A C E P 6:358-366, 1977. 24. Liberthson RR, Nagel EL, Hirschman JC, et ah Pathophysiologic observations in pre-hospital ventricular fibrillation and sudden cardiac death. Circulation 49:790-798, 1974. 25. Baum RS, Alvarez H, Cobb LA: Survival after resuscitation from out-ofhospital ventricular fibrillation. Circulation 50:1231-1235, 1974. 26. Riba AL, Morgamoth J: Unsuspected substantial pericardial effusions detected by echocardiography. J A M A 236:26232625, 1976.
134/19
