Push Dose Epi & Dirty Epi
Some of my all-time favorites are obviously the ultrasound machine, Bi-Pap, the Glidescope, etc. But another favorite of mine is a tool that works within seconds and is a great temporizing measure in patients with dangerously low perfusion when you need an immediate increase in blood pressure, STAT. Enter: Push-dose pressors - Nathalie Briones MD
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Push Dose Pressors: Your Quick & Dirty Guide
Epinephrine has both alpha as well as beta 1/2 effects, meaning that it will both vasoconstrict while also increasing heart rate, due to its intrinsic inotropic/chronotropic effects. It is most useful in patients who are hypotensive when an increase in heart rate is desired. Such is the case in your hypotensive patient when you want to help the heart give a little extra squeeze while concomitantly clamping down on the peripheral vasculature (which can be beneficial in many situations). Epinephrine’s onset of action is also about 1 minute with re-dosing to effect every 2-5 minutes (typical dose: 5-20 mcg per push), however the effects are slightly shorter than phenylephrine, with a duration…
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Push Dose Epinephrine
Empty 1 cc from a 10 cc flush. Draw up 1 cc from code cart epinephrine (1 amp, 100mcg/ml) and add it to the saline syringe. Shake. Label syringe. Now each 1 ml contains 10 mcg of epinephrine.
Articles of Interest
The Dirty Epi Drip: IV Epinephrine When You Need It
Be safe. Never push IV epinephrine 1:1,000 or 1:10,000 to a patient with a pulse. Use the “Dirty Epi Drip” trick as a temporizing measure until a pharmacy-made drip is available.
Pediatric Push Dose Epinephrine: Getting the Epi Dose Right During Pediatric Resuscitation
The easiest way to accomplish this individualized dosing is to put the standard code dose (0.01mg/kg) of epinephrine into a 10cc syringe, and then dilute with normal saline to make a total of 10cc of fluid. This will mean each cc in the 10cc syringe has 1 mcg/kg of epinephrine for the specific patient it is prepared for.
Push-Dose Epi Peds
Push-dose epinephrine, or low-dose bolus epinephrine, can be given safely in adults and children. In children, consider for severe anaphylaxis or asthma resistant to IM administration, or for peri-intubation.
Steps for drawing up epinephrine for push dose epinephrine and epinephrine infusion
Inject 1 mg of epinephrine 1:10,000 (one amp of crash cart epi) into a 1L bag of normal saline. Draw up 10mL from the 1L bag in a 10mL syringe (The concentration of epinephrine in the syringe is now 1 mcg/mL). Push Dose: 10 mL every 2-5 minutes (10 mcg). note that the onset = 1 minute and duration = 5-10 minutes. Dose of epinephrine given via infusion: 1mL/min (1 mcg/min) and titrate to a maximum of 20mL/min.
The Dirty Adrenaline (Epi) drip
This is a descriptive case series study that retrospectively examines patients who received peripheral dilute adrenaline infusions in remote clinics between January 2017 and October 2023. Data were collected from the Central Australian Retrieval Service’s database, focusing on patients receiving adrenaline infusions before patients were retrieved by an aeromedical service. As an observational study, there is no control group, as it is designed to describe the characteristics, outcomes, and potential adverse effects associated with the use of dirty adrenaline in this specific pre-hospital setting. We must always be cautious with observational studies as they can be prone to bias, but they can tell us about current practice and may be useful to pick up any major hazards, which in this case is really important.
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Paramedic Kardex
Take Epinephrine 1 mg (0.1 mg/mL) preparation and waste 9 mL of the Epinephrine. Take the same syringe and withdraw 9 mL of Normal Saline from the IV bag, shake well. Mixture now provides 10 mL of Epinephrine at a 10 mcg/mL concentration. Confirm procedure with partner.
