1. PUSH-DOSE PRESSOR EDUCATION

2. 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:

3. 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:

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

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

6. PHENYLEPHRINE Pure alpha agonist
Increases blood pressure by increased peripheral vascular resistance
Increased afterload - “pipe squeezing”
Increased stroke volume
No inotropic effects
Onset seconds
Steckl, P. (2013). Push dose pressors – A novel method of drug administration. Retrieved November 14, 1014 from:
Medscape

7. 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:

8. 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

9. 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 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:

10. 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:

11. 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

12. 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

13. 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

14. 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

15. 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 mcg/min
You would give the patient 0.5 – 2 mL of push dose epinphrine every 2-5 minutes

16. 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

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

18. 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

19. 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

20. References
Browning, B. (2014). Push-dose pressors. Retrieved November 7, 2014 from: Bryant, R. (2012). July 2012 trick of the trade. Pharm: Prehospital and retrieval medicine. Retrieved November 7, 2014 from: 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: Medscape (2014). Medscape (version 3.2.2) [Mobile application software]. Retrieved from: Selde, W. (2014). Push dose epinephrine as a temporizing measure for drugs causing hypotension. JEMS. Retrieved November 7, 2014 from: Steckl, P. (2013). Push dose pressors – A novel method of drug administration. Retrieved November 14, 1014 from: