PUSH-DOSE PRESSOR EDUCATION

History of push-dose pressors Originated in operating room Most typically as phenylephrine given to women undergoing C-section after spinal anesthesia to reverse hypotension Vast amount of literature in anesthesiology regarding excellent patient outcomes with prophylactic administration Browning, B. (2014). Push-dose pressors. Retrieved November 7, 2014 from: http://www.emdocs.net/push-dose-pressors/

History of push-dose pressors Difficult to extrapolate the data to the emergency department/EMS No studies have yet been completed showing benefit to emergency department patients Becoming more commonplace in emergency departments; beginning to enter the arena of flight medicine (administered during RSI protocol) Browning, B. (2014). Push-dose pressors. Retrieved November 7, 2014 from: http://www.emdocs.net/push-dose-pressors/

PUSH-DOSE PRESSORS Medications commonly used for push-dose administration: EPINEPHRINE PHENYLEPHRINE EPHEDRINE (not frequently used)

EPINEPHRINE Strong alpha adrenergic Increased cardiac output Increased HR Decreased PVR Systemic vasoconstriction Strong beta-1; moderate beta-2 Onset 30-60 seconds Medscape

PHENYLEPHRINE Pure alpha agonist Increases blood pressure by increased peripheral vascular resistance Increased afterload - “pipe squeezing” Increased stroke volume No inotropic effects Onset 30-60 seconds Steckl, P. (2013). Push dose pressors – A novel method of drug administration. Retrieved November 14, 1014 from: http://www.emerginet.com/risk-communique.php?id=33 Medscape

Indications for push-dose Epinephrine Short term optimizing of hemodynamics Prior to RSI of hypotensive patient Reversal of transient hypotension due to Induction agents for RSI Post sedation hypotension Bridge to central line placement with and initiation of vasopressor support Anaphylaxis Bridge to adequate fluid resuscitation Severe sepsis with profound hypotension until their “tank” is filled Selde, W. (2014). Push dose epinephrine as a temporizing measure for drugs causing hypotension. JEMS. Retrieved November 7, 2014 from: http://www.jems.com/print/33126

Indications for push-dose Phenylephrine (neostick) Cardioversion of a tachycardic patient (a-fib, psvt) who is hypotensive. Patient who is hypotensive but requires medication for HR control (calcium channel blocker) Sepsis patients who are hypotensive and have profound tachycardia. Patient needs a push dose pressor prior to placing CVL but have a high HR (150s) Any other patient with a hypotension and a tachyarrhythmia who requires intubation or sedation

RSI & Hypotension Hypotension associated with RSI has shown significant increase in morbidity and mortality rates One retrospective cohort study demonstrated 33% mortality rate vs. 21% for normotensive patients after RSI Longer hospitalization with post-intubation hypotension (17 vs. 11.4 days); including longer stay in intensive care (9.7 vs. 5.9 days) as well This study also demonstrated that 25% of patients who were normotensive prior to RSI developed post-intubation hypotension. Heffner, A. C., Jones, A. E., Kline, J. A, & Swords, D. (2012). The frequency and significane of postintubation hypotension during emergency airway management. Journal of Critical Care. Retrieved November 15, 2014 from: http://www.ncbi.mlm.nih.gov/pubmed/22033053

Contraindications for push-dose pressors Hypotension related to acute blood loss Patients without an immediately reversible cause of hypotension Not an alternative to definitive vasopressor support or central line placement Extreme tachycardia (Epinephrine) Bryant, R. (2012). July 2012 trick of the trade. Pharm: Prehospital and retrieval medicine. Retrieved November 7, 2014 from: http://prehospitalmed.com/2012/08/03/july-2012-trick-of-the-trade-winner

Push dose Epinephrine prior to intubation Case Examples 60 year old female patient Sepsis Altered LOC Requires intubation Vitals – HR 125, BP 70/42, RR 26, SPO2 88% Push dose Epinephrine prior to intubation

Push dose Phenylephrine prior to cardioversion Case Examples 70 year old female HR 150 – atrial fibrillation Hypotensive 80/44 with chest pressure Needs cardioversion but is awake and you would like to sedate Push dose Phenylephrine prior to cardioversion

Push dose Epinephrine after intubation Case Examples 25 year old male Anaphylaxis from bee sting Respiratory distress needing intubation Pre-intubation vitals 100/70, HR 122 Post-intubation BP drops to 80/50 Push dose Epinephrine after intubation

MAKING PUSH-DOSE EPI ITEMS YOU NEED HOW TO MIX 1 VIAL OF CARDIAC EPI (1:10,000) 1 10 ML NSS FLUSH 1 NEEDLE HOW TO MIX WASTE 1 ML OF FLUSH ATTACH NEEDLE DRAW UP 1 ML OF 1:10,000 EPI ROLL VIGOROUSLY

PUSH-DOSE EPI You now have a concentration of 1:100,000 Epinephrine in 10 mL OR 10 mcg/mL The range of dosing for an EPI drip is 5-20 mcg/min You would give the patient 0.5 – 2 mL of push dose epinphrine every 2-5 minutes

MAKING PUSH-DOSE NEO ITEMS YOU NEED HOW TO MIX 10 mg/ml Phenyephrine vial 100 mL bag of normal saline 10 mL syringe 1 needle HOW TO MIX DRAW 1 ML FROM THE PHENYLEPHRINE VIAL INJECT INTO 100 ML NSS BAG AND MIX WELL WITHDRAW 10 ML OF THE MIX INTO THE SYRINGE

PUSH DOSE NEO Concentration you have equals 100 mcg/mL (10,000 mcg/100 mL) Neo drip typically 80-100 mcg/min 0.5-2 mL every 2-5 minutes Same amount administered as with Epi (0.5-2 mL)

PITFALLS PEARLS DO NOT push the cardiac Epinephrine dose Epinephrine may not be good option for extreme tachycardia Not indicated for patients hypotensive d/t acute blood loss Quick, simple procedure; Epinephrine is readily available Will not need central access in case of extravasation (same dose in lido w/Epinephrine for suturing Can use across the lifespan

LIFE FLIGHT USE At this point education is being disseminated Will have laminated cards made up to keep in a “kit” EPINEPHRINE only at this point Medical command order

References Browning, B. (2014). Push-dose pressors. Retrieved November 7, 2014 from: http://www.emdocs.net/push-dose-pressors/ Bryant, R. (2012). July 2012 trick of the trade. Pharm: Prehospital and retrieval medicine. Retrieved November 7, 2014 from: http://prehospitalmed.com/2012/08/03/july-2012-trick-of-the-trade-winner Heffner, A. C., Jones, A. E., Kline, J. A, & Swords, D. (2012). The frequency and significane of postintubation hypotension during emergency airway management. Journal of Critical Care. Retrieved November 15, 2014 from: http://www.ncbi.mlm.nih.gov/pubmed/22033053 Medscape (2014). Medscape (version 3.2.2) [Mobile application software]. Retrieved from: https://play.google.com/store?hl=en Selde, W. (2014). Push dose epinephrine as a temporizing measure for drugs causing hypotension. JEMS. Retrieved November 7, 2014 from: http://www.jems.com/print/33126 Steckl, P. (2013). Push dose pressors – A novel method of drug administration. Retrieved November 14, 1014 from: http://www.emerginet.com/risk-communique.php?id=33