medical question - taking epinephrine

Okay, I am aware that epinephrine is adrenaline. It is often used during heart attacks to help restart the heart. If TV shows are to be believed (and in this instance I think so), a common method of administering it is pouring it down the breathing tube directly into the lungs. Presumedly this allows the lungs to quickly absorb it into the bloodstream.

Another common method of administering it is using a big-ass needle, and injecting it directly into the heart. This is AFAIK, the preferred method for treating anaphalactic shock, a severe allergic reaction that causes the heart to stop beating regularly and go into arythmia or stop altogether (aka a heart attack). Correct?

Okay, recently I have seen two TV shows use the needle to inject adrenaline in some slightly different circumstances.

Case 1: In a science fiction show (Firefly), a guy on a space ship is suffering from a gunshot wound. His life support is off and he is surviving on the oxygen left in the atmosphere that is rapidly being used up. Suffering from hypoxia, he goes to the medlab, and after bandaging his bleeding wound, he digs out an adrenaline shot and injects himself in the heart. I assume this was done to help him somehow absorb more oxygen or better use the remaining oxygen so he can finish his repairs.

Case 2: (Alias)A man who has been captured and held against his will is sedated and groggy. A rescuer arrives, but is in a hurry to pull him out before the enemy can catch them both. She pulls out the ubiquitous epinephrine needle and injects him in the heart, making him suddenly more alert and responsive, so they can run away.

In both these instances, the explicit purpose does not include restarting the heart. Rather, they are just “performance enhancers”, so to speak. My questions… Are these valid uses of adrenaline? Would they even work? If so, how? Is it necessary in these cases to inject the heart, or would anywhere in the bloodstream work?

My curiousity abounds.

Case 1 seems like a poor idea. Oxygen consumption would immediately go up and probably put the person in worse shape than he was already in.

Case 2 is a common use… That is what they give to opiate overdose patients to bring them around.

Any epinephrine you obtain should come from the hands of a pharmacist. And the doc should give you the proper instructions on how to use it. I have an Epi-Pen in my hiking backpac because I hike a lot with my wife who will die if she gets stung by a bee. The epinephrine that she would get from the pen which is 10cc I think, would be enough to get us to a hospital.

Last year in Arizona we were hiking and came upon a gentleman who had just been bitten by a rattle snake. His leg was swelling in front of us and he was sweating more than anyone I have ever seen. Luckily we were just starting our hike so the car was right there. He mentioned that if he had an epi-pen he’d be ok for the hour ride to the hospital. So Mrs. Coda saved the day with her epi-pen. The guy turned out to be a PA (physicians assistant) and new what he was doing.

I guess the moral of the story is I’d be careful how one takes epinephrine. And a huge needle injected into the heart is not a normal thing I’d say. It’s a bit pulp-fiction-esque I’d say.

injecting epinephrine into the heart is a last resort for someone who is in cardiac standstill where there is no venous access (IV line) in place, or an endotracheal tube in place where you could dump it into the lungs.

Epinephrine is NOT what is used for opiate overdose, Scotth! Naloxone, an opiate antagonist is what is used for this purpose. It is not injected into the heart either.

Both scenarios mentioned in the OP are completely off-the-wall uses of epinephrine.

Do not rely on TV for your medical care!


but it looks so REAL!


Having twice had an epinephrine shot for allergic reactions, I can testify that they do not normally stab you in the heart for that, at least not while you’re concious. You get a shot in the arm or leg or, if you have one hooked up, IV. Frankly, if someone came at me with a big-ass needle and said they were going to insert it into my heart it might well generate a natural adrenalin rush of sufficient size to render the medical dose redundant.

What does it feel like? Well, like the most intense fear rush you’ve ever had multipled by at least a factor of 10. Your heat gives a big thunk, then starts an imitation of a mule kicking your sterum (from the inside). Meanwhile, you feel things constricting and tensing up all over your body and your skin and hair do this weird stand-up-and-crawl thing. Subjectively, it’s quite an experience.

Epinephrine in low doses can be used for asthma, but I seem to recall that it’s no longer the remedy of choice. Maybe if you’ve got someone in danger of death, but certainly not on a daily basis.

Now, about that TV crap… the Firefly thing struck me as off-the-wall, but it IS fiction. I thought he was usuing it to prevent himself going into shock (which is a use of it) but that was in no way clear. But by the time you need something like that, you’re most likely in no condition to self-doctor. Certainly not with an administration device that requires some aim (Epi-pens require considerably less precision to use. Hey, ever read the warning labels on those? Side effects include heart attack, stroke, and death…)

As Qagdop pointed out it’s not used for opiate overdose. There was that scene in Pulp Fiction, but remember those folks weren’t trained medical personnel. They were junkies in a panic. I could see junkies in a panic doing stuff like that, because there’s a high level of idiocy among them.

I think movie and TV people do this stuff for the “OOOO! GROSS!” impact and not because there’s an connection to real life (or death) with this stuff.

Irishman, I think a little explanation of exactly what epinephrine does would help.

Epinephrine (adrenalin) is a catecholemine produced by the adrenal glands, and its secretion is controlled by the sympathetic division of the autonomic nervous system. It acts mainly to increase the rate and strength of cardiac contraction, and to constrict peripheral blood vessels, in order to maintan adequate supply of blood to vital organs when the body is stressed. It also acts to dilate the small airways, stimulate the start of slower (but longer lasting) measures of maintaining adequate blood supply, and mobilise energy stores for instant use. There are other effects but these are the main ones.

As a paramedic, I am authorised to use adrenalin in managing:

  • cardiac arrest (intravenous)
  • severe asthma that has deteriorated beyond effective inhalational remedies (intramuscular)
  • severe allergic reactions (intramuscular)

Almost all adrenalin is given intravenously or by intramuscular injection. Putting it down an airway is not very effective because you need to use twice as much to get the same result as an IV dose, because it has to cross the respiratory membrane to get into the blood. And as for the direct injection into the heart…this is very much an emergency procedure limited to very specific circumstances.

Lastly, the two scenarios you describe show a completely inappropriate use of adrenalin. The first man actually needs oxygen and IV fluids to restore lost volume, and the second man is revived with naloxone (also known as Narcan). Adrenalin would not have helped in either of these cases at all.

Thanks. My immediate reaction was “No way, that’s so wrong!” But I wanted some confirmation.

Coda, I have no Epi-pens. I have never seen an Epi-pen. Well, CSI Miami had one on it, so maybe that counts, but that’s the closest I have been to an Epi-pen. I am not planning to take epinephrine. I was not advocating using epinephrine counter to medical instructions. I just wanted information to confirm or deny that my intuitive grasp of the situations was correct. (DON’T DO THAT!)

So the answers to my questions are They are not valid uses, they probably wouldn’t work as shown, and injecting the heart is unnecessary, it just needs to hit the bloodstream. Direct heart injection is only used for immediate heart restart. Anaphalactic shock just needs it in the bloodstream.


Call me crazy, but wouldn’t this make his heart beat faster, encouraging an even faster dispersal of the venom throughout his entire body, increasing the likelihood of his death?

Epi-pens are used in cases of bee stings, but only when the person is allergic to bee venom (or so I thought). In other words, a bee sting for a nonallergic person is painful but not life-threatening; a rattlesnake bite for anyone is potentially deadly, for reasons having nothing to do with anaphylactic shock. My understanding was that the standard first-aid admonition in event of a poisonous snake bite was to keep the victim as calm as possible, so as to slow the spread of the poison.

Am I wrong here?

Nope, you’re right.

Rattlesnake venom can have a variety of effects, including hemolysis, intravascular coagulation, and convulsions. Coral snake venom is a neurotoxin with anticholinergic effects. Either way, epinephrin would have a harmful effect on a snake envenomation patient.

DVous, This is a question, not an attempt at correction, I’m just confused about the procedure.

After all, dammit, I’m an engineer not a doctor. (I’ve been waiting years to say that)

I recently got my CPR certification. We were taught when to apply CPR and when not to. We had to differentiate between things that could stop your breathing vs. stopping your heart, like a blocked airway or something. My point is, we were told never to apply CPR unless there was no pulse, because otherwise you’re compressing a heart that’s already beating.

My question, and my point is, that means that in cardiac arrest, by definition, your heart is not pumping any blood, which of course is the big problem. So, why is it the recommended procedure for cardiac arrest to administer the drug intravenously? With no circulation, how will the drug get from your arm to your heart? I thought THAT was the reason for the Pulp-fiction, needle-in-the-chest thing, because it’s the only way to get the drug to the heart muscle itself when the blood is not pumping.

Again, I’m not trying to correct you, I just wanna learn.

//\etalhea|), this demonstrates the usefullness of CPR. Good CPR will move enough blood for the drug to be circulated systemically. All of the other methods (intramuscular, subcutaneous, or via an endotracheal tube) also rely on the blood circulating. Basically, you’re right in that injecting epinephrine and then doing nothing will be of no benefit to a cardiac arrest patient. That’s why CPR needs to be done also.

St. Urho
EMT-B (EMT-P student)

So then, I’m assuming that really is the reason for the Pulp-Fiction needle stabbing the heart thing then, if for some reason the attending doctor/paramedic or whatever determines that they can’t apply good CPR or get good enough circulation for some reason? At that point, they’d inject it directly into the heart muscle?

I would assume so, but intracardiac injections are outside of the scope of practice for prehospital providers here. Perhaps Qadgop can enlighten us further.

Thanks St Urho - your comments were spot on.

//\etalhea|), let me elaborate on the CPR issue.

Early defibrilliation takes precendence over everything else when starting CPR, so one paramedic will prepare the LifePak (or similar defib machine) while the other(s) commence CPR.

Once connected, the machine is allowed to run its protocol (usually 3 shocks, one minute of CPR, 3 more shocks), before any more elborate care is attempted.

At this point, airway management wil be upgraded from a simple oral airway to either a laryngeal mask airway or an endotracheal tube. Another minute of high quality CPR will follow.

If there is still no recovery, an IV access will be established in a large bore vein (usually the antecubital fossa in the elbow). A freely flowing normal saline drip is started, followed by 1 ml doses of adrenalin 1:1000. Each dose is separated by a couple of minutes of CPR.

The action of adrenalin in this scenario is not just to create some cardiac stimulation. It also acts on the veins to cause peripheral vasoconstriction, thus forcing blood back into the torso to boost venous return to the heart to boost output. This action helps to move the drug towards the heart, in concert with circulation provided by CPR.

Increased cardiac ouput, albeit by CPR, helps to improve coronary circulation to the heart muscle. The aim of the whole procedure is to get enough oxygen into the cells of the heart muscle to get it back into normal function.

St. Urho, as far as I understand the toxic effects of snake venom take a while to set in. At first the major concern is anaphylaxis (an allergic reaction) caused by the immune response to a foreign protein (the venom). Since anaphylaxis is going to kill the patient before the hemotoxic effects, anaphylaxis is treated first—epinephrine plus other drugs, along with airway management.

Secondly, epinephrine is not going to increase the rate of movement of the venom through the lymphatic system. The lymph is driven by the movement of the surrounding skeletal muscle, not the heart, so a change in heart rate should have not effect of its movement. The basic prehospital treatments for snakebite—keeping the patient still, applying a loose constricting band, and keeping the extremity low—are meant to slow the movement of the lymphatic fluid.

EMT-ST (EMT-C student)