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Push Dose Pressors for EMS: Epinephrine and Norepinephrine

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Sometimes a small dose of epinephrine or norepinephrine can keep a patient from becoming hypotensive during intubation, or may help bridge the patient to a continuous infusion. Dr. Pickett talks about simple methods for mixing and administering push doses of these pressors and how to administer the infusion.

Hey everyone it is the austin travis county ems system office of the chief medical officer official podcast i’m your host dr j.r pickett today we’re going to be doing a short episode on push dose pressers now what prompted this recently is i’ve had several questions about administering push-dose pressures when to choose what and also we have had a little national

Shortage of these babies these uh one milligram and temel or one to ten thousand epinephrine pre-filled syringes apparently we can’t get any of them right now and that’s a problem because we use them a lot especially for cardiac arrests well here we’re talking about push-dose pressures today for a few different indications the chief indications that i will do a

Push-dose presser is i have somebody with a tenuous blood pressure maybe low blood pressure maybe they’re a bit bradycardic and i’m going to be doing an rsi so i’m going to be giving them medications that could drop their systemic vascular resistance i’m going to push the versed and the rock uranium if their blood pressure is already borderline i might kind of

Push them into that hypotensive range which may not be good for them especially if we’re dealing with somebody like with a head injury or something like that so a little push-dose presser will help to counter that dip that you see when you give somebody a bunch of sedative and muscle relaxant type of medications the other situation is i have a patient who is

Hypotensive and i’m going to need to start a presser on them but that’s going to take some time to mix that up i mean especially if we’re in the hospital we may mix that to the bedside or we may have that mixed by pharmacy and sent up or by the in-department pharmacist and so that’s going to take a few minutes and if you have somebody who’s really bradycardic

Hypotensive you need to get something on board right now then a push-dose presser is a good way to go now i have heard some folks say well you know push those pressures are just easy we should use those instead of drips to maintain blood pressure and shock in the pre-hospital setting i don’t agree with that approach i don’t think that’s a good idea and the

Reason i don’t like that idea is because we’re pushing that and like you bring their blood pressure up and then it goes down and then you rebuild somebody goes up and then it goes down your bullets and it goes up and you know it’s you’re constantly like chasing it and i don’t think that is necessarily physiologically right because that’s not really as human

Beings what we do uh so i if i’m gonna do a push-dose presser for shock then that is simply a bridge i want to get that drip started as soon as i possibly can so first i want to talk about push-dose epinephrine how we’ve historically done it and also another method for doing this that you can use and you can start using tomorrow so have we done this normally

Well we’ve usually taken these pre-filled syringes i’m going to unbox this because like apparently it’s a thing like people love watching unboxing on youtube and so i do the medication cross check with my partner just verify that i’ve actually got the right drug and i don’t have something else and i take these out and i’ve verified the the date and so i take

These and just pop those off and put it together and now i have one milligram in 10 at 10 ml uh or 0.1 milligram per ml or 100 micrograms per ml i don’t want to push this for push those pressure that that that’s high concentration and badness could happen so what i want to do instead is i’m going to take this i’m going to pop that cap off and i’m going to get

Rid of 9 cc’s of this here so i’m just going to squirt that out and i’ll just do that in my coffee cup here boom okay i’ve got one ml left i’ve got one ml which has 0.1 milligrams of epinephrine concentration hasn’t changed yet we’re about to do that so what i’m then going to do is take this i’m going to take whatever fluid i happen to have handy so usually

Like a little bag of normal saline big bag of lactated ringers a bag of d5 you know whatever it is use if you have those uh if you have those uh little vials of uh saline that’s fine too uh but whatever i wanna some kind of fluid that i can then dilute this with so i’ll take this and i will take my needle here like so i will apply the needle and then i will

Take my bag of fluid again i’ve medication cross checked it make sure this isn’t like d10 or like lidocaine or something like that and i will pop that in here like so now notice i didn’t push any into the bag here i’m just getting some fluid out of here so and i will draw it up as such and now i’ve got 10 cc’s again so what’s my concentration in that syringe

Right there 0.1 milligrams in 10 ml uh so it is .01 milligrams or 10 micrograms per ml 10 mics per ml epinephrine the reason i like doing this way in this syringe rather than like you know getting other syringes and mixing all together is guess what it’s still labeled it still says epinephrine so if i take this i put in my pocket then i know what i have here

To push so now when i push this mixture i’m going to push 2 ml at a time that will give me 20 micrograms or 0.02 milligrams of epinephrine that’s enough to kind of bump that pressure for just a few minutes bump that heart rate for just a few minutes to get through to either let them stabilize after i give them the paralytics and so forth or uh it gets me a

Chance to mix up whatever infusion of a presser that i’m going to use whether that’s norepinephrine or dopamine or to be whatever your epinephrine whatever it is that you want to use so that’s one way that you can do you take that pre-filled syringe get rid of nine cc’s uh and then drop nine cc’s of something inert like saline and then that will be your uh

Your push-dose presser concentration now when i do this again i like these to be labeled um syringes that are sitting around with push-dose pressers they have a long history of being administered incorrectly and uh being mistaken for something else so you always want to have a label on it so that’s why i like doing this maybe make a little note on there take a

Sharpie and say okay it’s you know push dose press push does epinephrine something along those lines so i can either draw it out of a bag or if i have a bag that has a drip set attached to it then i can come on down here and i’ve got one ml there and i can just hook it up to that drip set like so i’ve got it open on this end i got to pinch the patient side

So i’m not drawing up from the patient’s side and then i can just draw it from that line into here so you don’t necessarily have to have the needle especially if you’re concerned about sharps injuries if you have a drip set with lure lock on it and if the patient’s already got some fluid hanging like a saline or ringers or whatever then you can use it for

That so again same process so now when i give this it’s going to be 2 mls 20 micrograms of epinephrine now let me do this another way let’s say we don’t have any more of these because it’s something we’re about to run into here and i have something that’s actually going to like make all of this a lot simpler especially if i’m going to start an epinephrine

Infusion when do i like epinephrine infusion couple reasons one anaphylaxis epinephrine is the drug and i like the intramuscular epinephrine but that to me is a bridge to get them to the epinephrine infusion the problem with using the intramuscular epinephrine in anaphylaxis is if that person’s in shock they may not be perfusing that well so you can’t really

Predict how much of that drug how quickly is going to get into their system when you hang an infusion you know it’s going where it needs to be it’s going there right away and that’s why i like it so if you’ve got somebody with good anaphylaxis going on then yeah go ahead give them the im epinephrine but then start an epinephrine infusion so i want to make a

An epinephrine infusion so i’m going to take a 250 ml bag of in this case saline 0.9 sodium chloride and i’m going to grab two of these little guys this is epinephrine this is one milligram and one ml so the same thing you’re going to draw up for your for your intramuscular dose right so i’ll grab two of those and we’ll do the medication crosscheck i’ll take

A look at the date i’ll take a look at the vial make sure i got the right patient etc and double check with my partner they’re going to lay eyes on that vial and make sure that i’ve got the right thing and so i’m going to draw that up and here so i’ve got some already drawn up i’ve got 2 mls of epinephrine 1 to one thousand or one milligram one ml so there’s

Two milligrams of epinephrine in here well now i take my my trusty 250 ml of fluid and i’m going to inject that right in there so again through the medication poor boom injecting that two milligrams in here and now so mix that up okay we’re not like shaking it vigorously we don’t make a whole bunch of bubbles we don’t make like foam in there um we’re just

You know inverting it making sure that it gets mixed around my concentration in this bag now is eight micrograms per ml so eight mics per ml now remember that what was the dose for push-dose epinephrine oh yeah 20 micrograms so if i draw up now from this bag two and a half mls got two and a half ml’s right there that’s 20 micrograms of epinephrine so that’s

My push dose i mix it up hang this up give them a little push dose and start running the infusion and so that gives them that loading dose brings that pressure up and then we can maintain that with the continuous infusion of epinephrine what dose am i going to continue this on so we want to go 2 to 20 micrograms per minute so if i have this 250 ml bag i’ve got

This on a 60 drop per ml set so a micro drip set if you will then it is 15 to 150 drops per minute for that 2 to 20 micrograms per minute so one drop every four seconds up to 150 drops per minute so it’s like uh two and a half drops per second uh so you can just titrate that up and down as you need to now that’s approximate okay like these aren’t that that

Precise instrument but that’ll that’ll get you where you need to be so again it’s 2 to 20 mics per minute 15 to 150 drops per minute is your dose when running the infusion two and a half cc’s gets you your bump to bring their pressure up to give them that loading dose fantastic okay now what about norepinephrine there is some data showing that norepinephrine

Is a superior presser for most of the shock that you’re going to run into that you’ll treat with pressers obviously we’re not going to treat hemorrhagic shock with oppressor but others spinal shock neurogenic shock a cardiogenic shock septic shock those things we will treat with norepinephrine preferentially so here’s how we do this i get out my nor epi i’ve

Got four mls four milligrams norepinephrine right here i’ll pop that and draw that up and now i have four mls right here of norepinephrine again i’m going to take that 4 mls and i’m going to put it in a 250 cc bag 250 ml bag of saline i’m just going to pop this in here like so boom four ml’s in there and i’m gonna shake it up shake it up shake it up shake

It up shake it okay now again not shaking shaking okay we’re just inverting it what’s my concentration here now okay it is 16 micrograms per ml in here so what is my push dose for norepinephrine usually it’s around 20 to 30 micrograms so if i draw up oh i drop 2 mls of this now if you want to get like exactly 20 micrograms it’s going to be like one and a

Quarter mls so who cares like i don’t want to be that precise about it honestly um so this will be close enough 2 mls will get you 32 micrograms of this and that 2ml that’s that’s your push dose right there so you give them that 2ml bump and then you can start the drip uh if you are just doing it because you’re gonna rsi somebody and they’re just kind of

You know tenuous blood pressure but they’re not to the point where you want to start them on a presser just yet then okay mix this up drop your 2 mls push that as your push dose presser before you push the paralytics and the and the sedatives and then if you need it you’ve got it it’s already made because this is a concentration that we’re going to use for

Running an infusion so what’s our dose for an infusion for norepinephrine is 2 to 12 micrograms per minute so with at this concentration right here it’s between 8 and 45 drops per minute so a little bit tighter range than what we have with the epinephrine but that will get you where you need to be again that’s on a 60 drop micro drip set 2 to 12 micrograms

Per minute 8 to 45 drops per minute 250 ml bag 4 milligrams of norepinephrine on a 60 drop set perfect i love it so once i’ve got my drip mixed up here i always want to label this drip i want to make sure that doesn’t get mistaken for just something else random because again that’s an error that has occurred in many places in the past so i’m gonna write on

Here you know either you have a sharpie marker if you’ve got drug labels that’s fantastic then i can put on here epinephrine or epi 2 milligrams if you want to put the end concentration that’s okay but at least we have something on here that tells us what’s in this bag that it’s not just the saline that it is labeled with now another method for doing this

If you don’t happen to have that sharpie on you is if you have some tape and say we’ve just mixed up a norepinephrine infusion here is to take that empty vial and tape it to the bag so then oh okay i added this in here the added advantage of that being that somebody else can kind of back check your work and they can see that oh yeah it’s norepinephrine it’s

Not expired it’s four milligrams and so they can do their own drug calculations if they want to do that i think that a lot of times ems starts infusions in the field and we get to the hospital and they discontinue the infusions right away which can be harmful to patients and we’ve actually had that result in deaths but it also it’s just a matter of well i

Didn’t mix this and therefore i don’t trust them and i don’t want to want to use it if we’re using standardized concentrations so we always know that this is exactly how much much is in here then it is less likely that that’s going to occur once you arrive in the emergency department now the hospital is always going to want to have somebody on drugs like if

You’re running something in the field and they want to start that drug in the hospital they’re eventually going to want to transition to something that has been mixed up by a pharmacist they’re at the hospital and so it’s been verified but until that takes place then the field drip will have to do so that is what i have for you today about push-dose pressers

If you like it give us a share appreciate it y’all have a good one bye

Transcribed from video
Push Dose Pressors for EMS: Epinephrine and Norepinephrine By ATCEMSOMD