Do you have this tool in your therapeutic tool box? If not, it’s time. A detailed discussion of a potentially game changer of a technique.
Well good day everybody this is krista the ancient scholar i hope you guys are doing well today hey i’d like to talk about a somewhat of a novel therapeutic method that is becoming more popular in certain systems and i want to push for the popularity of this method full disclosure i have no financial interests in any of this information about i’m about to disseminate
This really comes down to a practical tool that every ems provider every vance level ems provider really should have in their toolbox and let’s just start this off with a quick scenario – a gedanken a thought experiment to help demonstrate the utility of this particular technique ok so let’s say that you’ve been called to the scene of a long-term care facility a
Nursing home something on lines of that you arrived to find a 78 year old male patient the patient has altered mental status he is profoundly hypotensive and appears to be moribund he’s knocking on death’s door essentially you get on scene you begin a providing positive pressure ventilation he’s profoundly hypotensive you’re considering an intubation perhaps you
Even have protocols or clinical practice guidelines that allow you to innovate you’re considering that you have this really hypotensive patient and you need to stabilize this patient’s vital signs and you need to do it rather quickly so traditionally what have we taught ems providers well traditionally we’ve taught ems providers to first think about fluid bolus
Right so we all administer fluid fluid challenge depending on additional history 250 500 milliliters in a patient like this who may have some underlying cardiovascular pathophysiology for all we know okay that’s gonna take a little while all right right put some fluids into this patient okay so we’ve got fluid bolus going on patient may or may not be improving
But we have this act crashing patient who is who is really critical and we really need to augment that patient’s hemodynamics with some sort of pharmaceutical agent now classically in ems at least this is classically comes down to a medication called dopamine right or at least that’s what we all talk about and that’s what we all verbalize and they’ll spit out
Dopamine dopamine dopamine dopamine right everybody pretty much knows the dose of dopamine that’s 2 to 20 micrograms per kilogram per minute and in a patient like this we know that we’re probably going to have to go for a presser dose and i know presser dose because we probably want to increase i know trophy and and cost some alpha effects alpha one effects to
Cause vasoconstriction increase blood pressure increased cardiac output yada yada yada so we’re probably looking at starting somewhere around 10 micrograms per kilogram per minute okay here’s the question i want to pose to you that question is how rapidly can you pull your dopamine out of your med box get your dopamine set up calculate and actually calculate a
Proper flow rate and get that dopamine flowing into your patient in a reasonable amount of time i would suggest that this is or i would i would suppose that in many places this is going to be a significant amount of time for most providers okay that’s just the reality that we face and that’s something that we need to do expect even in a controlled didactic setting
Where where i work a lot as as an as an ems instructor i spend you know do we teach an entire course you know 6 68 70 hours of pharmacology about half of which is in the lab drilling our students on mixing drips ok at the end of this course after we’ve had the mix strips and hangar it still takes its everal minutes to get this going and that’s just the reality
That we face out in the field where first of all you’re not doing this a lot right you’re not hanging dopamine a lot okay that that’s the first the first point the second point is you’re not practicing this a lot okay there are probably outlying systems where you probably may drill this but i’m talking the bread and butter ems provider you’re just not running into
This a lot right you’re not doing this a lot so now you have this critical patient that you run into occasionally write this this septic nursing home patient may be to have a pneumonia septic wound or or you could think of any any number of problems see chf or copd patient that we’re prepared to innovate that’s profoundly hypotensive and we need to augment their
Blood pressure we need to get their blood pressure augmented quickly right we’ve got a fluid bolus going or perhaps fluids aren’t indicated or fluids have already been given whatever the case may be right we need to rapidly increase that blood pressure and i am posing an honest assessment of our capabilities as paramedics and ems providers and i’m saying that we
Probably are not going to be very quick at doing that right getting the dopamine getting a drip calculated getting it up ging and infusing on time at a proper dose and in a stress tested environment it’s not going to happen the other thing is dopamine has some really interesting properties right at modest modest doses dopamine’s not even a direct acting agent
Right dopamine doesn’t have a lot of direct effects on alpha alpha 1 and beta 1 receptors right so you’re giving it you know 10 micrograms per kilogram per minute and at those doses it may it causes some endogenous epinephrine norepinephrine to be released and then you know hopefully that works well what if i have this a septic patient or or or a patient that’s
Been in a shock state for an extended period of time that they may be catecholamine depleted right and and so now i’m giving an indirect acting agent to a catecholamine depleted patient probably not going to have great results with that medication so now i’m m-more delay because i’m giving a medication like don’t mean that doesn’t have really profound direct effects
Until you get titrate this up to really a much higher doses and then you know work for many minutes into the game here right and we’ve got a moribund crashing patient we kind of think about that right so what’s the other option that we classically think of well epinephrine right okay mix an epinephrine drip do it get it up and get it going see how fast it takes again
I i’m gonna ask you to be as honest as you possibly can put the ego aside and think about this how quickly can you get an epinephrine drip up right how many of you just pull out of the top of your head oh i need to mix one milligram into two 250 milliliters and then run that at two to ten micrograms per minute and calculate an appropriate dose and appropriate flow
Rate and titrate that up and get it going right are you mixing up in efrain drips all the time are you pressure testing are you doing pressure tested training with these kinds of things probably not again significant delay so what to do right what to do how can we rapidly stabilize these patients with with an ein oppressive agent like epinephrine and do it with a
Technique utilizing a technique that is that is rapid that doesn’t require significant amount of cognitive processing ie dosage calculations and something that’s effective well what is effective well anesthesia requisite let’s talk about an anesthesiologist and that’s artists you know they’ve been doing something similar to this for firm for decades right and that
Is they will give small bonuses of vasopressors to stabilize blood pressure prior to and during and and perhaps after procedures specifically when it comes to airway manipulation airway management oftentimes the blood pressure tends to decrease when we perform airway procedures because we’re giving medications that can cause vasodilation myocardial suppression
Etc so this is a relatively commonly encountered issue in the anesthesia environment and now that this concept is kind of filtering down and the concept i really want to talk about okay hopefully hopefully you guys are on board right the first part is video is getting you on board with okay doing it the way that we may have learned it leads to significant delays
At least medication errors it’s hard to do or not practicing it a lot we’re not practicing in our pressure tested conditions yada-yada-yada hopefully you guys are on board so what is an alternative well the alternative is something called push dose pressors now we can use many different kinds of agents right we could use levophed or norepinephrine we could use
Neos in efrain orphanet laureen fan em whatever that whatever however it’s ananse neos in efrain right it’s a pure alpha agent for vae so concealed for one vasoconstrictive properties norepinephrine levophed is another one that has fairly profound alpha effects but you know the way i look at it is i’m not and out in the field it is it’s not necessarily my job to
Be highly highly nuanced in these really critical emergency situations that require rapid action and so what i would propose is going with an agent that has a large amount of utility an agent that can can do lots of different things for us it can increase i know it has i know tropic effects it can increase contractility increase the heart rate perhaps it can cause
Bronchodilation it can have alpha-1 effects and it can cause vascular constriction increase the blood pressure right and what’s a good agent well epinephrine really is one of the best agents right it’s a direct acting agent it’s very given a parenteral e iv ios for rapid acting it has very potent alpha 1 beta 1 beta 2 effects right so you can do lots of things with
It it has the greatest amount of utility i think for what we’re trying to do as ems providers okay so how does this whole push dose everything work well here’s an easy method there there are many ways we can do it here’s one method okay so what do we do well you take your epinephrine here right so here i’ve got up a nephron of cardiac epinephrine one milligram in
10 milliliters that’s that one to 10,000 concentration and we’re actually phasing out the old labeling the 1 to 10,000 we’re just going with 1 milligram and 10 milliliters and that’s to simplify things that is to decrease the the incidence of medication errors right so cardiac epinephrine one milligram and 10 milliliters all right so one milligram is a thousand
Micrograms right so i got a thousand micrograms in a 10 milliliter syringe and what does that give me well that gives me 0.1 or 0.1 milligrams or 100 micrograms per milliliter so forever bill of this i have a hundred micrograms okay so this is what you want to do take a ten milliliter syringe okay fill that 10 milliliter syringe with nine milliliters of saline
Normal saline okay put one milliliter a hundred micrograms into that ten milliliter syringe right okay so that’ll be one milliliter and now i have ten milliliters right so i put one milliliter of epinephrine one two ten thousand okay or a hundred micrograms okay in nine milliliters of saline saline and now mix it up i’ve got ten milliliters right ten milliliters
Of or a hundred micrograms of epinephrine here okay that’s ten micrograms per milliliter easy math right and i label that right epinephrine adrenaline i’ve got ten micrograms per milliliter okay label my syringe all right and then what do i do every two to five minutes i give this iv push i give 0.5 to 2 milliliters every 2 to 5 minutes that’s 5 to 20 micrograms
Of epinephrine every 2 to 5 minutes if you want to even simplify it more give one milliliter every two minutes if you need you to stabilize that blood pressure right to get that heart rate up but stabilize that blood pressure to help stabilize that patient right so one milliliter every two minutes right that’s that’s 10 micrograms every two minutes right so i’m
Giving one milliliter i do push every two minutes and that’s what’s called push dose on pressors it’s push dose epinephrine right and and i don’t have to do an epinephrine drip i don’t have to do a dopamine drip i don’t have to do a norepinephrine or a noose in effort and rip right i don’t have to do any of that in the immediate stabilization period of my patient
Now talking about here we’re talking about i’m out in the field i’ve just come into contact with a critical moribund crashing patient i need to augment and stabilize that patient’s hemodynamic status so they can survive the next several minutes of the resuscitation and ultimately survive transport to a more secure environment where drips and things like that can
Can get done right so i can do this this is a great bridge to infusion tool doesn’t require complex dosage calculations and really all it requires is nine milliliters of saline in a and a $10 syringe mix in one milliliter of epinephrine one to ten thousand or 1 milligram 10 milliliters you have 10 micrograms per milliliter and you can give one milliliter every
Two minutes or two to five minutes get that patient’s blood pressure stabilized get them intubated loaded it up transported right and you can augment them during the transport particularly if you have a short transport time right you’re just giving push bolus or push doses of epinephrine keeping that patient stabilized and getting them to definitive care or buying
Yourself time right buying somebody time to slowly methodically get the drip up get get it mixed and get things calculated infusing without worry of dosage calculation problems med errors and like that right you can take some of that pressure off whoever else is mixing that or maybe yourself if you’re the one mixing that infusion okay guys so i think i’ve rambled
On enough about this particular tool um it’s a really good tool if your service is not using this i would strongly suggest that you approach your medical direction whoever that may be and explain this concept to them and this is not just chris baer this is a concept that many people are using um there are very respected providers who are using this there’s some
Data out on this probably the most popular reference that i could point you in the direction of is is dr. scott winegard who runs the e/m crit the m crit podcast and is it very very well respected in the emergency and critical care world and you can actually check his podcast out m crest and this specific concept of push shows pressors is is uh is talked about
Is discussed in quite some detail in a couple of different podcasts and some posts and some threads as well so that would be a good reference and that’s actually if you want to approach your medical direction that’s another physician right this is something that’s coming from a physician so there’s some familiarity there and and hopefully you can have some good
Discussion and dialogue with your medical direction hopefully you can articulate this in a way that makes sense right it really does it’s a practical easy to employ tool um that that works quite frankly so there you go hopefully you guys found this video helpful and you know hopefully if you weren’t aware of this this might become a great tool for you to use as an
Ems provider in the future okay guys as always thanks for hanging in there
Transcribed from video
Push Dose Epinephrine By TheAncientScholar
