There is something about using obsolete techniques in rural societies. This is mainly because of the lack of facilities and exposure to the latest technologies. Intracardiac adrenaline injection is used for patients who are inevitably seen in the emergency room (casualty); after a serious series of events leading to acute cardiac failure.

The discovery of this modality- though medieval in origin- goes beyond several decades: 1920s to be precise. The first ever paper published about the actual use of this technique was in JAMA (Journal of American Medical Association) in 1922. During those times, this method was considered lifesaving and thus was in demand. Although, this practice of injecting terminal patients with adrenaline straight into their auricle/ventricles came with the price of: A steep learning curve; and many unknown complications.

The needle is inserted in the 4th intercostal space and the drug administered. The technique of intracardiac injection is like pericardiocentesis. This therapy flourished till the 1960s, until it gained some alarming evidence against its use in the 1970s.

Intracardiac injections were mainly used for,

• Sudden onset cardiac arrest,
• Substance abuse (overdose),
• Fetal rhesus isoimmunization,
• Malignant hyperthermia
• Cardiac arrhythmias (asystole, pulseless electrical activity, pulseless ventricular tachycardia, or ventricular fibrillation).

And other secondary causes terminating into sudden ceasing of the heart.

The statistics present reveal the use of this emergency intervention mainly present in American journals and textbooks. Over this period, there have also been alleged cases and shreds of evidence stating against its use.

The various immediate complications followed by the procedure are, Coronary artery vessel wall damage, Hemorrhage, Tamponade, Heart Failure, Arrhythmias

Non-medical reasons: Time consumption, Clinical acumen, and expertise, Cessation of cardiopulmonary resuscitation

Evidence-based medicine:

These lists of complications did not have the predictive capability to be assertive enough to make this conventional technique obsolete. The studies followed on large scales by - Research fundamentalists and Pharmaceutical companies – proved very little evidence on the advantage of adrenaline injected directly into the ventricles and the use of any other peripheral intravenous route. Thus, at the time of sudden cardiac arrest, intravenous adrenaline works with equal efficacy along with no complications whatsoever.

Tertiary Health System

In a very few government hospitals in Maharashtra, this obsolete method is still used in emergency situations. The government medical college and hospital in Kolhapur city, has been giving intracardiac injection for very severe cases.

It has been used for all those cases that terminate into a sudden cardiac arrest and where traditional resuscitation methods fail to revive the patient.

‘Due to its already non-existential uses, the indications are not-limited to any specific cause of “cardiac arrest”’.

This outdated technique is seldom used in the tertiary health sector and because of inconsistent data of its infrequent use, it is still used as one of the final measures in the periphery of our country. The strategy used in this sector is (strictly adhering to the government setup):

• Expose the chest and palpate for the ‘sternal angle’. (This acts as a quick reference point as the sternal prominence coincides with the position of the second rib)
• After finding the second rib, going four finger spaces down, there is the fourth rib – Palpate and confirm the position.
• The space below the fourth rib is the fourth intercostal space and the injection should enter from here.
• The injection passes diagonally and downwards, with the tip pointing towards the acromio-clavicular joint in a 2-dimensional plane.
• Followed by a bolus dose of adrenaline. [1 mg (dose) and 1:10000 (concentration)]

(During this procedure, cardiopulmonary resuscitation is contraindicated mandatorily) [One of the drawbacks of this procedure; adding to its discontinuity]

The crux of this write up is that, how much ever archaic this technique is, there are hospitals and setups where it is still being used.

This is an outright example of a “Necessary evil” and along with the added “Time constraints”; this act has received a promising pretext to still find its way into the system and used as a last resort – Despite of its meagre ability to provide any added benefits in human resuscitation. However, because of the increasing deaths, complications and similar success with a lesser invasive technique (intravenous/intraosseous route), this sort of undeterred routine should come to a standstill and cease to exist. It has been using “Emergency revival” as a decoy for times immemorial and it only takes common sense to stop its practice, because of the omnipresent evidence against it.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.