1. Vasopressor Doses of Epinephrine
Push-dose Epinephrine
and
Epinephrine drips
August 1st, 2019
Protocol #619 – Shock
Protocol #641 – Cardiac Arrest (non-traumatic)
Protocol #644 – Bradycardia
See updates to #640 and #660 in other presentations

2. Vasopressor Effects of Epinephrine
Epinephrine is a potent inopressor:
α receptors – increase peripheral vasoconstriction
Rapidly increases blood pressure by increasing systemic vascular resistance
β1 receptors – increase chronotropy (heart rate) and inotropy (myocardium contraction strength)
Increases cardiac output
Increases heart rate in bradycardias refractory to atropine
β2 receptors - bronchodilation

3. Vasopressor Types Push-Dose (PD) epinephrine – started June 1st
Epinephrine Drips – starting August 1st
Dopamine – removing August 1st
Will be completely removed from protocols and stocking requirements
Will remain in the formulary
Paramedic may administer and monitor dopamine drips started by hospital staff

4. Indications for Use of Pressor Doses of Epinephrine
An epinephrine drip OR PD epi are appropriate for hypotensive shock that is NOT caused by hypovolemia:
Hypotension refractory to IV fluids
Potential hypovolemia should be corrected before administering vasopressors
Consider requesting orders to administer vasopressors early if:
Pulmonary edema is present
ROSC with deteriorating vital signs
Critical hypotension, impending cardiovascular collapse
Mean Arterial Pressure (MAP) is <45 mmHg
Consider for bradycardia refractory to other causes
Consider reversible causes of bradycardia

5. Vasopressor Selection
Push-Dose (PD) epinephrine
Quick and easy method to administer doses of vasopressors to critical patients
1 mL of PD epi (10 mcg/mL), pushed slowly and repeated as needed
Total dose is similar to that delivered with an epi drip, but is given in short boluses
Administering PD epi may be quicker, and easier in a critical situation then setting up a drip
May be particularly useful in patients rapidly deteriorating towards cardiac arrest
Some patients may only require temporary pressor support and have no need for an ongoing infusion of vasopressors
Epinephrine drips
Starting dose of 10 mcg/mL is similar to dose provided by PD epi
Continuous infusion may allow for finer titration of minimum necessary dose to maintain perfusion
Ideal for patients that need ongoing pressor support following administration of PD epinephrine, particularly during long transports
Base hospital preference may dictate orders for epi drip vs. PD epi

6. Epinephrine Drip Mixing instructions
Assemble pre-load of epinephrine 1 mg/10 mL (cardiac epi)
Inject 1 mg of epinephrine into FULL bag of Normal Saline (1 Liter)
Inject through port
LABEL BAG with sticker or cloth tape
“Epinephrine 1 mcg/mL”
Date and time
Bag contains 1 mcg/mL (0.001 mg/mL)
Assemble labelled 1L bag with macro drip tubing
10 gtts or 15 gtts
Do not administer other medications through the epinephrine drip line
Epinephrine
1 mcg/mL
Date Time
Injection Port

7. Notes - Epinephrine Concentrations
2016 guidelines from the Institute of Safe Medication Practice
Epinephrine should not be labelled with ratio expressions
Providers should be familiar with the normal expression of epinephrine concentrations
1mg/mL = 1:1,000
1 mg/10 mL (0.1 mg/mL) = 1:10,000
IM Epi – 1 mg/mL
NEVER to be used IV/IO, for IM injections in anaphylaxis
Cardiac Epi – 1 mg/10 mL = 0.1 mg/mL = 100 mcg/mL
Given IV/IO bolus, typically during cardiac arrest
PD Epi – 10 mcg/mL = 0.01 mg/mL
Bolus dose vasopressor
9 mL of NS with 0.1 mg of epinephrine (1 mL of cardiac epi)
Epi Drip – 1 mcg/mL = 1 mg/L
Vasopressor for infusion
1 mg of epinephrine in 1000 mL of NS

8. Epi Dilutions
Ensure any diluted solutions of Epinephrine are labelled clearly and correctly
Take care to make sure dilutions are done correctly
Accidental administration of epinephrine that is too concentrated can result in serious adverse effects including:
Dysrhythmias
Myocardial ischemia
CVA
PD Epi
10 mcg/mL
Date Time

9. Dosing Guidelines Epinephrine Drip: Pediatric dose:
Dose (mcg/min)
Drops/min
10 drop tubing (Gtts) 2 20 4 40 6 60 8 80 10
100
15 drop tubing (Gtts) 30 90
120
150
Epinephrine Drip:
Up to 10 mcg/min IV/IO infusion. Start infusion at 10 mcg/min
Titrate down to minimum rate to maintain SBP >90 mmHg, or other indicators of response (i.e. heart rate, mental status, skin signs, etc)
Pediatric dose:
1 mcg/kg (max of 10 mcg/min) IV/IO infusion
Start infusion at recommended dose
Titrate down to maintain age appropriate SBP or other indicators of response
Consider using Metronome (if available) to set drip rate
Push-Dose Epinephrine:
1 mL IV/IO every 1-3 min
Repeat as needed. No max
Pediatric dose:
1 mL IV/IO (0.1 mL/kg if <10 kg) every 1-3 min
Repeat as need. No max

10. Protocol #619 - Shock Undifferentiated Shock Hypovolemic Shock
First-line treatment should focus on IV fluids
Estimated only 34% of patients are given proper fluid challenge prior to administration of vasopressors*
Vasopressors refractory to fluids
Hypovolemic Shock
Treatment should focus on fluid replacement
Septic Shock
First-line treatment – aggressive fluid replacement (consult base as needed)
Vasopressors for critical hypotension or shock refractory to fluids
Cardiogenic Shock
Vasopressors may be considered early
* Holden, D. PharmD, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

11. Protocol #619 - Shock Physician Consult Pediatric considerations
Vasopressor doses of epinephrine may be indicated for pediatrics, and other conditions (severe anaphylaxis)
Request Physician Consult as needed
Pediatric considerations
Wide array of differential diagnoses for pediatric shock – most common is hypovolemia
Order requires Physician Consult
During communication failure treatment should focus on fluid boluses
* Holden, D. PharmD, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

12. 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
Pediatric Considerations
Indications are the same as adult (age appropriate signs of perfusion)
1 mcg/kg is appropriate starting dose (max of 10 mcg/min)
Dosing only needs to be adjusted if patient <10 kg
PD epi – 0.1 mL/kg
Epi drip – 1 mcg/kg

13. Protocol #644 Bradycardia
Atropine - First-line treatment for most unstable bradycardias
Consider other reversible causes (i.e. CaCl for hyperkalemia)
Vasopressors – 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

14. Optional references for Push-Dose Epi
Detailed information and instructions for PD epi
SLO EMSA Provider Training Page
PD Epi Dilution Demo from Inland Counties EMS Agency
End of Presentation
Please review:
Tranexamic Acid (TXA)
2019 General Updates
Pain Management and Fentanyl
Questions?