Goals on Initiation
Reverse shock and increase tissue perfusion:
For the prehospital provider, most of these are not an option. However, having one pressor that you're familiar with that can be implemented safely and rapidly is probably more beneficial to the patient than not using a pressor at all, or worse, using it incorrectly.
Currently, norepinephrine is recommended as first line in the vast majority of shock states. However, this is only commercially available in a vial as a concentrated solution, requiring drip preparation.
Most EMS Providers in our area are either more familiar with dopamine or have it as their only option per Protocol. This is likely due to it being a commercially available pre-mixed drip. In short term, may be fine, but is more arrhythmogenic than norepinephrine.
Alternatively, "Dirty" Epi is an option:
Or, compel your service administrators to buy the right equipment (IV Pumps) and the right vasopressor (Norepi).
Maximum doses vary greatly between institutions. It is likely that your hospital or agency has set a maximum dose for each vasopressor. Maximum doses can be exceeded if needed to maintain hemodynamics.
Tips for peripheral administration:
When properly mixing Push Dose Epinephrine, repeated entries into any one container should be limited to maintain integrity/sterility of the original container.
Ways to limit puncturing the carpuject, as described by Dr. Baum in the podcast:
Instead of puncturing the carpuject, it may be more more sterile to remove needleless cap from the Epi and insert it into the tip of the 10 cc syringe.
Purchase a Luer Lock-to-Luer Lock connector so you don't have to expose a needle.
Be cautious when stopping drips when delivering patient to the hospital. This is especially important with agents like vasopressors as they have short half-lives. Patients needing these for support may decline. Best practice is to transition to hospital product before discontinuing.
Reporting of infusion rates during hand off:
Special thanks to Dr. Regan Baum for providing us with these notes and images. A few additions were made by Curbside to Bedside.