Vasopressor Doses of Epinephrine PUSHDOSE EPINEPHRINE and EPINEPHRINE

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Vasopressor Doses of Epinephrine PUSH-DOSE EPINEPHRINE and EPINEPHRINE DRIPS AUGUST 1 ST, 2019 •

Vasopressor Doses of Epinephrine PUSH-DOSE EPINEPHRINE and EPINEPHRINE DRIPS AUGUST 1 ST, 2019 • PROTOCOL #619 – SHOCK • PROTOCOL #641 – CARDIAC ARREST (NON-TRAUMATIC) • PROTOCOL #644 – BRADYCARDIA • SEE UPDATES TO #640 AND #660 IN OTHER PRESENTATIONS

Vasopressor Effects of Epinephrine is a potent inopressor: α receptors – increase peripheral vasoconstriction

Vasopressor Effects of Epinephrine is a potent inopressor: α receptors – increase peripheral vasoconstriction Rapidly increases blood pressure by increasing systemic vascular resistance β 1 receptors – increase chronotropy (heart rate) and inotropy (myocardium contraction strength) Increases cardiac output Increases heart rate in bradycardias refractory to atropine β 2 receptors - bronchodilation

Vasopressor Types Push-Dose (PD) epinephrine – started June 1 st Epinephrine Drips – starting

Vasopressor Types Push-Dose (PD) epinephrine – started June 1 st Epinephrine Drips – starting August 1 st Dopamine – removing August 1 st 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

Indications for Use of Pressor Doses of Epinephrine An epinephrine drip OR PD epi

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

Vasopressor Selection Push-Dose (PD) epinephrine Quick and easy method to administer doses of vasopressors

Vasopressor Selection Push-Dose (PD) epinephrine Quick and easy method to administer doses of vasopressors to critical patients 1 m. L of PD epi (10 mcg/m. L), 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/m. L 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

Epinephrine Drip Mixing instructions Assemble pre-load of epinephrine 1 mg/10 m. L (cardiac epi)

Epinephrine Drip Mixing instructions Assemble pre-load of epinephrine 1 mg/10 m. L (cardiac epi) Inject 1 mg of epinephrine into FULL bag of Normal Saline (1 Liter) Epinephrine 1 mcg/m. L Date Time Inject through port LABEL BAG with sticker or cloth tape “Epinephrine 1 mcg/m. L” Date and time Bag contains 1 mcg/m. L (0. 001 mg/m. L) Assemble labelled 1 L bag with macro drip tubing 10 gtts or 15 gtts Do not administer other medications through the epinephrine drip line Injection Port

Notes - Epinephrine Concentrations 2016 guidelines from the Institute of Safe Medication Practice Epinephrine

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 1 mg/m. L = 1: 1, 000 1 mg/10 m. L (0. 1 mg/m. L) = 1: 10, 000 • IM Epi – 1 mg/m. L NEVER to be used IV/IO, for IM injections in anaphylaxis Cardiac Epi – 1 mg/10 m. L = 0. 1 mg/m. L = 100 mcg/m. L • Given IV/IO bolus, typically during cardiac arrest PD Epi – 10 mcg/m. L = 0. 01 mg/m. L • Bolus dose vasopressor • 9 m. L of NS with 0. 1 mg of epinephrine (1 m. L of cardiac epi) Epi Drip – 1 mcg/m. L = 1 mg/L • Vasopressor for infusion • 1 mg of epinephrine in 1000 m. L of NS • •

Epi Dilutions PD Epi 10 mcg/m. L Date Time • Ensure any diluted solutions

Epi Dilutions PD Epi 10 mcg/m. L Date Time • 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

Dosing Guidelines Dose (mcg/min) Drops/min 10 drop tubing (Gtts) 2 20 4 40 6

Dosing Guidelines Dose (mcg/min) Drops/min 10 drop tubing (Gtts) 2 20 4 40 6 60 8 80 10 100 15 drop tubing (Gtts) 2 30 4 60 6 90 8 120 10 150 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 mm. Hg, 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 m. L IV/IO every 1 -3 min • Repeat as needed. No max Pediatric dose: • 1 m. L IV/IO (0. 1 m. L/kg if <10 kg) every 1 -3 min • Repeat as need. No max

Protocol #619 - Shock Undifferentiated Shock First-line treatment should focus on IV fluids Vasopressors

Protocol #619 - Shock Undifferentiated Shock First-line treatment should focus on IV fluids Vasopressors refractory to fluids Hypovolemic Shock Estimated only 34% of patients are given proper fluid challenge prior to administration of vasopressors* 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. Pharm. D, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

Protocol #619 - Shock Physician Consult Vasopressor doses of epinephrine may be indicated for

Protocol #619 - Shock Physician Consult 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. Pharm. D, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

Protocol #641 Cardiac Arrest (atraumatic) ROSC with Persistent Hypotension Transient hypotension is common in

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 m. L/kg Epi drip – 1 mcg/kg

Protocol #644 Bradycardia Atropine - First-line treatment for most unstable bradycardias Consider other reversible

Protocol #644 Bradycardia Atropine - First-line treatment for most unstable bradycardias Consider other reversible causes (i. e. Ca. Cl for hyperkalemia) Vasopressors – refractory to atropine Consider early base-contact for orders in unstable highdegree 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

Optional references for Push-Dose Epi Detailed information and instructions for PD epi SLO EMSA

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? Email dbrim@co. slo. ca. us