Do intravenous sedatives act instantly as depicted by Hollywood?

February 18, 2005

Dear Cecil:

In the movies or on television, when a doctor or a nurse needs to subdue a raving, hysterical patient, they inject a strong sedative, to which the patient succumbs mere seconds later. How accurate is this depiction? Does the drug travel from the arm to the brain that quickly?

We have two questions here, Stephen — the one you asked, and the even more interesting one you'd have asked if you'd thought of it, namely whether there's any factual basis to the unforgettable scene in Quentin Tarantino's 1994 film Pulp Fiction, in which a dying drug-overdose victim instantly revives when two jamokes stab a giant hypodermic of adrenaline into her heart. Short rap on near-instantaneous sedation: wacky. On heart shots: wacky, but not completely off the wall.

Response time to a sedative injection varies widely depending on drug, dose, patient size, drug tolerance, route of administration, and so on. Any anesthesiologist will tell you that while some people drop off pretty fast, others take a long time to knock out. Blood cells take maybe 30 seconds to make a complete circuit of the body; under optimal conditions — let's say you can inject via a previously inserted subclavian IV line — some people might fade in two to five seconds with a fast-acting drug such as methohexital.

However, optimal conditions seldom prevail in Hollywood depictions. The party is usually flailing; the medic doesn't bother hunting for a vein but rather jabs wherever it's convenient. Intramuscular injections take effect relatively slowly — three to fifteen minutes or longer is typical. Directors don't have that kind of time, so the subject goes limp immediately. Dramatic? Yes. Realistic? No.

Now to Pulp Fiction. To refresh your memory, hit man Vincent (John Travolta) has the job of squiring his boss's wife, Mia (Uma Thurman), around town. While he's in the bathroom, she discovers his stash of what she thinks is cocaine and promptly snorts some. Bad idea — it's actually high-octane heroin. Vincent returns to find her comatose and frantically drives her to the home of his dealer Lance (Eric Stoltz), who hands Vincent a railroad-spike-sized syringe. The following classic dialogue ensues over the supine Mia:

Lance: OK, you're giving her an injection of adrenaline straight to her heart. But she's got breastplates. You've gotta pierce through that. So what you gotta do is, you gotta bring the needle down in a stabbing motion. [Makes multiple stabbing motions]

Vincent: I gotta stab her three times?

Lance: No, you don't gotta fucking stab her three times! You gotta stab her once, but it's gotta be hard enough to get through her breastplate into her heart, all right? And then once you do that, you press down on the plunger.

Vincent: OK, then what happens?

Lance: I'm curious about that myself.

Vincent does as instructed. Mia immediately sits bolt upright, eyes wide open and apparently fully recovered.

OK, this isn't a 100 percent accurate depiction of what would actually occur. But here's the thing: doctors honest to God do on (rare) occasion jab a big hypodermic of epinephrine, AKA adrenaline, directly into the heart of someone who's gone into cardiac arrest, a technique called intracardiac injection (ICI). If the patient is lucky she revives quickly — epinephrine is the fight-or-flight hormone that blasts through your system in moments of extremity. So there's a grain of truth to the scene.

But only a grain. Among the problematic details:

  1. The heart isn't beneath the "breastplate" (presumably Lance means the breastbone, or sternum — the heart is to the left of this), and in any case only a fool would try to force a needle through bone — you'd go between the ribs.
  2. A cardiac arrest victim getting ICI doesn't instantly jerk up like the alarm clock just went off — the heart might restart right away, but it would take a while to regain consciousness.
  3. Mia's problem probably isn't cardiac arrest anyway — the immediate consequence of heroin overdose is severe respiratory depression. As long as her heart keeps beating, ICI is pointless. If Mia needs an injection of something, a plain old intravenous shot will work just fine, since her blood is still circulating.
  4. Epinephrine wouldn't sober up someone who was ODing. To neutralize heroin you'd administer a drug such as Narcan (naloxone), which blocks the opiate receptors in the brain and can bring a junkie back to earth in a matter of minutes.

ICI is a technique of last resort. My ER doctor friend John says that in 16 or so years of service he never did it and never saw it done. Risks include lacerating the coronary artery and getting air and fluid into places they hadn't oughta be. On the other hand, it does make for memorable moviemaking, and assuming Quentin Tarantino films aren't the primary instructional tool for ER physicians, what's the harm in that?

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