Introduction

In emergency medical services (EMS), the ability to rapidly respond to acute hypotension can be lifesaving. Push dose epinephrine (also known as bolus dose epinephrine) is a critical intervention for temporary management of hypotension in critical care settings, such as during septic shock, anesthesia-induced hypotension, or post-cardiac arrest care. This article will provide an overview of push dose epinephrine, including how to prepare it and the appropriate dosing for EMS providers.

What is Push Dose Epinephrine?

Push dose epinephrine involves the administration of small, controlled doses of epinephrine intravenously to quickly elevate blood pressure. This method is particularly useful in situations where traditional methods, such as fluid boluses or continuous vasopressor infusions, are not immediately available or effective.

Indications for Use

Push dose epinephrine is typically indicated in the following situations:

  • Severe hypotension unresponsive to initial fluid resuscitation.
  • Hypotension during sedation or anesthesia.
  • Post-cardiac arrest hypotension.
  • Shock states, including septic shock and anaphylactic shock.

Preparation of Push Dose Epinephrine

Materials Needed:

  • Epinephrine 1 mg/10 mL (1:10,000) prefilled syringe
  • 10 mL syringe
  • 9 mL of normal saline
  • 18-gauge needle or blunt tip needle
  • Alcohol swab
  • Labels for syringe

Step-by-Step Instructions:

  1. Gather Supplies: Ensure you have all the necessary materials before beginning the preparation. This includes a 1 mg/10 mL (1:10,000) prefilled syringe of epinephrine, a 10 mL syringe, normal saline, and labeling supplies.
  2. Aseptic Technique: Use an alcohol swab to clean the tops of the epinephrine prefilled syringe and the saline vial to maintain sterility.
  3. Draw Saline: Using the 10 mL syringe, draw up 9 mL of normal saline. This will dilute the concentrated epinephrine to a more manageable concentration.
  4. Add Epinephrine: Carefully draw up 1 mL of epinephrine (1 mg/10 mL, or 1:10,000) using the syringe. Add this to the 9 mL of saline in the syringe, making a total volume of 10 mL.
  5. Mix and Label: Gently mix the contents of the syringe to ensure even distribution of the epinephrine. Label the syringe clearly, noting the concentration (10 mcg/mL) and the date and time of preparation.

Dosing and Administration

Standard Concentration: The resulting concentration after dilution is 10 mcg/mL.

Adult Dosing:

  • Administer 1 mL (10 mcg) every 1-5 minutes as needed to maintain a systolic blood pressure above 90 mmHg or mean arterial pressure (MAP) above 65 mmHg.
  • Monitor blood pressure closely between doses to avoid excessive hypertension.

Pediatric Dosing:

  • The pediatric dose is typically 0.1-1 mcg/kg, administered every 1-5 minutes as needed.
  • Adjust the dosing based on the child’s response and clinical condition.

Safety Considerations

  • Monitoring: Continuous monitoring of blood pressure and heart rate is essential when administering push dose epinephrine. This will help prevent adverse effects such as hypertension or tachycardia.
  • Documentation: Record the dose, time, and patient response to each administration. This information is vital for ongoing patient management and for communication during patient handoff.
  • Adverse Effects: Be aware of potential side effects, including arrhythmias, chest pain, and excessive hypertension. If adverse effects occur, reassess the patient and consider alternative treatments.

Conclusion

Push dose epinephrine is a valuable tool in the EMS provider’s arsenal, offering a rapid and effective means to manage acute hypotension in critical situations. By understanding the proper preparation and dosing, EMS providers can ensure the safe and effective use of this life-saving medication. Always follow your local protocols and guidelines, and consult with medical direction as needed.

For further training and protocols, consult your medical director or local EMS guidelines.

References

  1. American Heart Association. Advanced Cardiovascular Life Support (ACLS) Provider Manual.
  2. Marino, P. L. (2014). The ICU Book. Lippincott Williams & Wilkins.
  3. Emergency Medical Services Protocols for Epinephrine Administration. Local EMS Guidelines.

By staying informed and prepared, EMS providers can make a significant difference in the outcomes of their patients through the skilled use of push dose epinephrine.