1. Push-dose epinephrine
EMS Agency training to be reviewed by all accredited paramedics prior to
June 1st, 2019
Thanks to Justin Bramlette for his work on this training

2. Epinephrine has broad effects on α, β1 and β2 receptors, so it is a potent agent to increase:
Chronotropy (heart rate) and inotropy (myocardium contraction strength)
Vasoconstriction
Bronchodilation
Push-Dose (PD) epinephrine has been used as a quick and easy temporizing vasopressor for years in critical care settings
PD epinephrine is a rapid method to administer a vasopressor
Delivers a dose that is similar to an Epi drip
Background

3. PD epi is considered by some clinicians to be superior to dopamine as a vasopressor
PD epi has been adopted by over 50% of the EMS Agencies across CA
PD Epi doses are small with an extremely dilute concentration
Less risk of tissue damage or necrosis (compared to other vasopressors) if infiltration accidentally occurs in a peripheral IV
Epinephrine has a very short half-life: <5 min
Small doses of PD Epi are unlikely to cause dangerous adverse events
Background

4. 5 Rights of Medication Admin:
Warnings!
Use caution to ensure PD epi is diluted correctly, and doses are administered as directed
PD epi is quite safe as prescribed in these protocols. HOWEVER, errors in the concentration or dose could produce dangerous overdose!
5 Rights of Medication Admin:
Right Patient
Right Drug
Right Dose
Right Time
Right Route
Further literature recommended for general review of push dose pressors:
2018 – The Use of Bolus-Dose Vasopressor in the Emergency Department – Weigand, S, et al
2017 – Bolus Dose of Epinephrine for Refractory Post-arrest Hypotension – Gottlieb, M

5. When do we use it?
Generalized Indications for requesting orders for any vasopressor (dopamine or PD epi):
Hypotension refractory to IV fluids
Most forms of hypotension and shock should have fluids attempted before pressors
Consider requesting orders for pressors prior to completing fluid bolus if
Pulmonary edema is present
Critical hypotension, impending cardiovascular collapse
Consider if Mean Arterial Pressure (MAP) is <45 mmHg
Consider for bradycardia refractory to other causes
Consider reversible causes of bradycardia
MAP

6. When do we use it? How is it used?
Shock (Medical) (Protocol 619) – Septic Shock, Cardiogenic Shock, Undifferentiated Shock
ROSC with persistent hypotension (Protocol 641)
Bradycardia (Protocol 644)
Neurogenic shock refractory to fluids (Protocol 660)
How is it used?
Dosing:
10mcg/mL (1 mL) IV/IO every 1-3 min
Repeat as needed to maintain SBP >90mmhg
1 syringe of correctly mixed PD Epi will contain 10 doses!
Base Hospital Order only
If both Dopamine and PD Epi are available make choice between the two in consultation with Base Hospital (until dopamine is phased out)

7. Protocol #619 - Shock
Hypovolemic Shock - dehydration, GI bleeding, vomiting and diarrhea, etc
Treatment should focus on fluid replacement
Septic Shock - fever, or other symptoms of infection, ALOC, tachypnea
First-line treatment – aggressive fluid replacement (consult base as needed)
Pressors - critical hypotension or shock refractory to fluids
Cardiogenic Shock - cardiac dysfunction, pulmonary edema
Pressors may be considered early
Undifferentiated Shock - uncertain etiology after prehospital assessment
First-line treatment should focus on IV fluids
Pressors - refractory to fluids

8. Protocol #641 Cardiac Arrest (atraumatic)
ROSC with Persistent Hypotension
Transient hypotension is common in first minutes after ROSC
Fluid bolus is a reasonable first-line treatment
Consider vasopressors for persistent hypotension
Consider early contact for severe hypotension
Consider early contact if vital signs appear to be deteriorating

9. Protocol #644 Bradycardia
Atropine - First-line treatment for most unstable bradycardias
Pressors – refractory to atropine
Consider early base-contact for orders in unstable high- degree heart blocks
High-degree heart blocks may not respond well to Atropine
2nd Degree II AVB or Mobitz II
3rd Degree AVB or Complete Heart Block

10. Protocol #660 Trauma Neurogenic shock
Distributive shock resulting from disruption of the autonomic pathways within the spinal cord
Occurs after damage to the spinal cord or traumatic brain injury
Trauma associated with abnormal motor/sensory exams
Low blood pressure, occasionally with a slowed heart rate
First-line treatment should focus on IV fluids
Pressors - persistent or severe hypotension refractory to fluids
MOST hypotension after trauma is caused by hemorrhage which should be treated with permissive hypotension and fluids

11. Push-Dose Epi Mixing instructions
Materials needed
Remove vial of Cardiac Epi 1:10,000 (0.1 mg/mL) from box
Attach needle to 10mL saline flush

12. Push-Dose Epi dilution
Discharge 1 mL of saline from 10 mL flush giving you 9 mL of saline
Draw back 1 mL of air into 10 mL saline flush
9 mL
1 mL of air

13. Push-Dose Epi dilution
Insert needle into vial of Cardiac Epi 1:10,000 (0.1 mg/mL)
Inject the 1 mL of air from the saline flush into vial of Cardiac Epi 1:10,000
Draw back 1 mL of Cardiac Epi into the saline flush to get 10 mL of Push-Dose Epi (10 mcg/mL)

14. Push-Dose Epi dilution
Remove needle from PD Epi and mix well.
LABEL PD Epi with cloth tape (or other label) marked as Epi 10 mcg/mL.
PD Epi 10 mcg/1mL is ready for administration IV or IO, syringe contains 10 doses
Epi
10 mcg/mL
Notes Regarding Epi Concentrations:
PD Epi – most dilute, appropriate as vasopressor
10 mcg/mL = 0.01 mg/mL = 1:100,000
Cardiac Epi – typically used during cardiac arrest
1:10,000 = 0.1 mg/mL = 100 mcg/mL
IM Epi – NEVER to be used IV/IO in this concentration
1:1,000 = 1 mg/mL

15. Push-Dose Epi dilution
Alternative mixing instructions
Video from Inland Counties EMS Agency
These mixing instructions may be used if equipment is available
Thank you for reviewing these protocols changes
PD Epi protocols may be utilized starting June 1st, 2019
Dopamine will be phased out of stock on equipment over several months
Updated protocols will be available from link on EMS Agency homepage starting June 1st, 2019
Sloemsa.org
EMS app update is pending
Contact with questions