PUSHDOSE EPINEPHRINE EMS AGENCY TRAINING TO BE REVIEWED

PUSH-DOSE EPINEPHRINE EMS AGENCY TRAINING TO BE REVIEWED BY ALL ACCREDITED PARAMEDICS PRIOR TO JUNE 1 ST, 2019 THANKS TO JUSTIN BRAMLETTE FOR HIS WORK ON THIS TRAINING

• Epinephrine has broad effects on α, β 1 and β 2 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

BACKGROUND 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 Epinephrine has a very short half-life: <5 min Less risk of tissue damage or necrosis (compared to other vasopressors) if infiltration accidentally occurs in a peripheral IV Small doses of PD Epi are unlikely to cause dangerous adverse events

WARNINGS! PD epi is quite safe as prescribed in these protocols. HOWEVER, errors in the concentration or dose could produce dangerous overdose! Use caution to ensure PD epi is diluted correctly, and doses are administered as directed 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

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 mm. Hg • Consider for bradycardia refractory to other causes • Consider reversible causes of bradycardia MAP

WHEN DO WE USE IT? • 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: 10 mcg/m. L (1 m. L) IV/IO every 1 -3 min Repeat as needed to maintain SBP >90 mmhg 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)

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

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

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 • 2 nd Degree II AVB or Mobitz II • 3 rd Degree AVB or Complete Heart Block

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

PUSH-DOSE EPI MIXING INSTRUCTIONS Materials needed 1. Remove vial of Cardiac Epi 1: 10, 000 (0. 1 mg/m. L) from box 2. Attach needle to 10 m. L saline flush

PUSH-DOSE EPI DILUTION 3. Discharge 1 m. L of saline from 10 m. L flush giving you 9 m. L of saline 4. Draw back 1 m. L of air into 10 m. L saline flush 1 m. L of air 9 m. L

PUSH-DOSE EPI DILUTION 5. Insert needle into vial of Cardiac Epi 1: 10, 000 (0. 1 mg/m. L) 6. Inject the 1 m. L of air from the saline flush into vial of Cardiac Epi 1: 10, 000 7. Draw back 1 m. L of Cardiac Epi into the saline flush to get 10 m. L of Push-Dose Epi (10 mcg/m. L)

PUSH-DOSE EPI DILUTION 8. Remove needle from PD Epi and mix well. 9. LABEL PD Epi with cloth tape (or other label) marked as Epi 10 mcg/m. L. 10. PD Epi 10 mcg/1 m. L is ready for administration IV or IO, syringe contains 10 doses Epi 10 mcg/m. L Notes Regarding Epi Concentrations: • PD Epi – most dilute, appropriate as vasopressor • 10 mcg/m. L = 0. 01 mg/m. L = 1: 100, 000 • Cardiac Epi – typically used during cardiac arrest • 1: 10, 000 = 0. 1 mg/m. L = 100 mcg/m. L • IM Epi – NEVER to be used IV/IO in this concentration • 1: 1, 000 = 1 mg/m. L

PUSH-DOSE EPI DILUTION Alternative mixing instructions • https: //www. youtube. com/watch? v=Db. Hue. Iqmvn. A • 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 1 st, 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 1 st, 2019 • Sloemsa. org • EMS app update is pending • Contact dbrim@co. slo. ca. us with questions