Pulse Dosing For Hypotension

In this video we demonstrate how to use pulse doses of diluted epinephrine to support the blood pressure of a hypotensive patient. The patient was intoxicated with alcohol and had taken a handful of medications which included dicyclomine, melatonin, lisinopril and trazodone. He was hypotensive on arrival in the emergency department and his first recorded blood pressure was 59 systolic. His blood pressure remained low despite several liters of fluid. Rather than place an arterial, a central line and start the continuous infusion of a pressor, we decided to give the patient pulse doses of epinephrine diluted to 10 micrograms/mL. The patient's condition responded very nicely to the combination of fluids and small intermittent doses of diluted epinephrine. Phenylephrine can also be used for this purpose.

[lmellick]

Thanks for the question. We do not have phenylephrine in the ER PYXIS system and have to order it from pharmacy...which takes too much time in the setting of these patients.

[marieked]

I was in septic shock and it took 7L of fluids and pressors to get my BP up. I was awake and coherent and talking the whole time. Never felt faint. Weirdest thing ever as I have postural orthostatic tachycardia syndrome and will "grey" out then black out at those low BPs. I'm thankful to be alive.

[lmellick]

Good question. The air was put in to allow bubbles to cause mixing of the solution. The air was expelled from the syringe prior to treating the patient.

[lmellick]

Thanks. We agree. We love our work...most of the time. :-)

[jasonparnes]

Hi Dr Mellick! From the clocks on the wall, it looks like the first push dose epi went in at 08:27 h with good response in BP. The last segment where it's "time for more epinephrine" was at 10:20 h. Were you guys giving push dose epi for those two hours? Why not use an epi or norepi drip, if so?
Thanks!
Jason

[rabankroll]

I came to YouTube to watch a video of yours and just uploaded a new one 3 seconds ago

[donovancorcoran]

Thoughts on this method for making and administering 1:100k epi:

Use 1mL of 1:1000 (1 anaphylaxis ampule) and add to a 100mL bag of your choice of crystalloid.

Flow the IV continuously at 0.5mL/min (titrated to effect).

Maybe not in hospital when you could just as easily hang an infusion of Levophed, but a good option for EMS who might carry no other pressor but epi.

(If an EMS agency were to ever only carry epi in code ampules- 10mL of 1:10, 000- they could do the same by first wasting 10mL of fluid from the bag. Wasting 1mL when using 1:1000 epi probably isn’t necessary as the difference in concentration of 1mg in 100mL vs 1mg in 101mL is negligible)

[VogueLovesU]

Ahh, didn't see the tubing. Thanks for these videos!

[lovelynurse]

I can see your point about creating habits. I have certain habits I have come up with over the years, some good and some bad. Mainly we have used the needles with the shields for our injections, fingersticks, and IVs. You recap the same way I do. Where I work, we would get reprimanded if we had an uncapped needle to carry into a room. It was not my intention to come off as being mean. I apologize. Have a good night!

[VogueLovesU]

Curious as to if the line was flushed after the first dose... wouldn't a good portion of that mL still be trapped in the line?

[lmellick]

That might have been necessary on some patients, but several small boluses of epinephrine was all he ever needed and that is a lot less work. This technique is often an intermediate step to give you some time before you start a drip.

[srujanmims]

Why don’t you start a noradrenaline infusion rather than giving pulse adr?

[PaulizAgg]

I had a case of acei toxicity and gave 4 mg narcan ivp with good results in blood pressure. Something worth trying for yourself next time you are faced with this scenario.

[vrm]

Hi Dr. Mellick. Why exactly does the epinephrine solution need to have some air in the system? My initial concern is that air bubbles in blood vessels would cause complications. Does the IV apparatus cancel this out? Thank you.

[adam]

Was that a fifty shades reference at 4:20? "We aim to please"

[anthonybenelisha]

my understanding was that air in an IV wasnt a very big deal. something about the blood absorbing small volumes of air without a problem? Im an emt and a paramedic was talking to me about this.

[lmellick]

IV running full open. No need for flush.

[Viver]

Push dose is better to see if they can stabilize pt rather than starting a drip and sending the pt to ICU just because of hypotensive overdose. If then, the hypotension persist then a drip will be started and pt will be sent to ICU. It is a process, not just jumping to big guns. Process people, process.

[jaybaker]

If you don't mind I'd like to create a simulation case for my residents from this case.

[lovelynurse]

It was a clean needle, if he stuck himself, he would not be exposed to any blood bourne pathogens. I have recapped many clean needles, but I lay the cap on a hard clean surface and scoop the cap up with the needle. I do not recap dirty needles. Never have. In 17 years I have had 2 clean sticks, and that is it. He did fine.