# Dopamine math made easy, and other random stuff



## 46Young (Jun 11, 2009)

Mix 200 mg Dopa in a 250 bag, resulting in 800 mcg/cc. If running at 10 mcg/kg/min, the drip rate will be EXACTLY the pt's weight in kg multiplied by 0.75. Adjust accordingly for 400/250(1600 mcg/cc), and/or 5, 10, or 20 mcg/kg/min. Do the math, it will work out perfectly every time. Ever wonder why the LP12 three lead default is II, III, AvF? Some monitors don't have 12 lead capability. If you have a cardiac pt, and need to begin NTG therapy(time is muscle), you can change the monitor to diagnostic mode and rule out an inferior STEMI at least, so you can go ahead with nitro. Approx 30% of inferior wall MI's will have Rt vent involvement. Maybe you're the only ALS provider, and don't have the time to mess with a 12 lead in lieu of other therapies. Note that when you pace a pt, you should have both the pads and three lead hooked up. If a limb lead comes off, the pacing mode will change from demand to non demand. When monitoring a critical pt, the AED mode can be swiched on. If you're busy with an IV, tube, or drawing up meds, the monitor will alert you if V-Tach or V-Fib is detected. It will quickly grab your attention. Don't forget to switch off of AED mode afterward. Dialing up the QRS volume would be a good idea, also. When you are managing an SVT, your ears will pick up an irregular beat long before your eyes will. Some of these features may be exclusive to the LP 12. When preparing an IV drip, please make sure that you add the med to the solution and mix it before you spike the bag. I've witnessed some spike the bag, then add the med. You're getting only saline or D5 or whatever for the first minute or so. These are just some random thoughts and tips that I wanted to share. I encouage others to add their own to this thread.


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## rmellish (Jun 12, 2009)

46Young said:


> Maybe you're the only ALS provider, and don't have the time to mess with a 12 lead in lieu of other therapies.



They aren't that hard to set up. Have your basic do it. Just don't ask them to interpret it...


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## mikie (Jun 12, 2009)

rmellish said:


> They aren't that hard to set up. Have your basic do it. Just don't ask them to interpret it...



And as long as they are proficient in lead placement!


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## 46Young (Jun 13, 2009)

You're missing the point. You can rule out inferior ischemia, initiate IV/ntg, and do a 12 while transporting. Not having to deal with shaving the Cx, a diaphoretic pt, or female clothing preventing access to the needed areas will shorten the contact to ED/Cath lab time by several minutes. Our engine LP 12's don't have 12 lead capability, but can be placed in diagnostic mode to circumvent this shortcoming. If the EMT is competent in lead placement, that's great. Some agencies will have you working with different partners quite often. You never know what you're getting. Also, if you run the inferior leads in diagnostic, you can begin reperfusion therapy while the 12 is being set up, not waiting a few minutes for set up, print, and analysis. Anything you can do to shorten Tx/Txp time while providing all appropriate interventions, should be done. In reality, we typically have so much quality help, that this wont be an issue.


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## mikie (Jun 13, 2009)

46Young said:


> You're missing the point.



With all due respect, I'm not sure I understand the point of this thread...could you elaborate??  Are you saying we spend too much time on unnecessary procedures?


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## 46Young (Jun 13, 2009)

Not unnecessary, just a quicker way of doing things, in the interest of delivery to definitive care in a more rapid manner. Everything will get done, it's just a manner of doing it as quickly as possible. Defer a 12 lead momentarily if an inferior interpretation is performed, sure. Delay O2, or prophylactic IV prior to txp or drug therapy, absolutely not. For most pts, time is probably not of the essence. For some, they need definitive care at a hosp ASAP, and it's up to us to get them there expeditiously, while doing what needs to be done along the way. Too many times I've seen the crew sit onscene doing everything, and then leave the scene. Some pts need to be treated on the spot, and some can be moved to the bus after diagnostics with advanced interventions being done enroute to the hosp. In some instances, if the hospital is one or two blocks away, delivery to the ED may be more beneficial to the pt that sitting onscene to get everything in. I'm just interested in doing what's in the best interest of the pt. The OP was intended for people to weigh in with their own observations, clinical pearls, and methods. I didn't specify BLS because there already is an excellent thread devoted to EMT tricks of the trade. BLS is important, and I will occasionally learn a better way of doing things from a Basic.


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## HotelCo (Jun 13, 2009)

mikie said:


> And as long as they are proficient in lead placement!



It's not that hard.


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## rmellish (Jun 13, 2009)

HotelCo said:


> It's not that hard.



It's one of the skills which our emt-b preceptees have to have checked off prior to clearing.


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## mikie (Jun 13, 2009)

HotelCo said:


> It's not that hard.



Agreed.  But if someone is basing their placement off of "I saw them do it before" as opposed to their proper anatomical spots, big Oops! can happen.

MisLeading: The Clinical implications of misplaced ECG leads
 ^compliments to the origional poster of this article a few months ago*
*


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## Markhk (Jun 14, 2009)

You don't need to turn on the AED mode on the LP12 to monitor for VF/VT. 

There is an option for VF/VT detection on the monitor that will sound 5-8 seconds after it detects VF/VT. The icon with the magnifying class looking at the EKG indicates this feature is on. This is an option that can be disabled under the Alarms menu. 

The feature doesn't work during TCP though. Also forces the monitor into Paddles or Leads II only. 

A similar feature exists on the MRx...which you can't shut off. It just sounds the continuous "red" level alarm and blinks "VFIB/VTACH" upon detection. And then the monitor starts vomiting paper....


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## Flight-LP (Jun 14, 2009)

Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. Even an appropriately acquired 12 lead doe not rule out anything, enzymes are the only definitive when it comes to making the "yes or no" statement.

I say just do it right the first time.......................


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## Flight-LP (Jun 14, 2009)

But to add a positive to the thread, Dopamine is actually even easier than previously described......................

Take the pts. weight in pounds, drop the last number and subtract 2. That will be your 5mcg/min drip rate.................

Or you could take the extra 20-30 seconds and actually do the math that was impregnated into all of our heads!


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## MSDeltaFlt (Jun 14, 2009)

Flight-LP said:


> But to add a positive to the thread, Dopamine is actually even easier than previously described......................
> 
> Take the pts. weight in pounds, drop the last number and subtract 2. That will be your 5mcg/min drip rate.................
> 
> *Or you could take the extra 20-30 seconds and actually do the math that was impregnated into all of our heads*!


 
Amen, brother.  I always wear a cheap $20 calculator watch from Wally World.  That's my brain.  It's the best thing since melted butter.  I'll use up the full 30 seconds figuring out the drip rates if my gloved finger accidentally hits the wrong button... and it has.:blush:


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## Ridryder911 (Jun 14, 2009)

How many, re-checks and verifies IV drips? I do. Too many times, I have flown for IFT in to find many of the drips at the wrong rate. So before changing over, I re-calculate.. amazing the errors one will find. 

R/r 911


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## VentMedic (Jun 14, 2009)

Flight-LP said:


> Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. Even an appropriately acquired 12 lead doe not rule out anything, enzymes are the only definitive when it comes to making the "yes or no" statement.
> 
> *I say just do it right the first time.......................[/*quote]
> 
> ...


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## remote_medic (Jun 14, 2009)

VentMedic said:


> Flight-LP said:
> 
> 
> > Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. Even an appropriately acquired 12 lead doe not rule out anything, enzymes are the only definitive when it comes to making the "yes or no" statement.
> ...


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## daedalus (Jun 14, 2009)

I was taught 

kg x mcg x .037 = gtts/min

for dopamine. anyone else using this?


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## remote_medic (Jun 14, 2009)

No short cuts allowed around here


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## daedalus (Jun 14, 2009)

remote_medic said:


> No short cuts allowed around here


Eh, I suppose my patients pressure can zero out while I preform dimensional analysis. Hehehehe.


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## ResTech (Jun 14, 2009)

I studied and have the basic formula ingrained in my head:

mcgs/min x weight (kg) x drip set (60)
         Total concentration (1600mcg)

400mg in 250cc = 1600mcg/mL



> Take the pts. weight in pounds, drop the last number and subtract 2. That will be your 5mcg/min drip rate



I never knew this!


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## Flight-LP (Jun 14, 2009)

VentMedic said:


> Flight-LP said:
> 
> 
> > Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. Even an appropriately acquired 12 lead doe not rule out anything, enzymes are the only definitive when it comes to making the "yes or no" statement.
> ...


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## VentMedic (Jun 14, 2009)

> Originally Posted by *Flight-LP*
> 
> 
> _Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. _


 
Reading some of the shortcuts to EKGs done by EMS and complacency by not prepping to do the test properly one should question if these companies do any QA on quality.

This should not become a peeing match that EMS is better than the hospital staff because you have found errors. EMS should actually have less errors than hospital staff because they are dealing with only one patient and not 10 at the same time. We know in the hospital that errors happen with medication and try our best to prevent them. However, there are some in EMS who perceive themselves to be perfect and sometimes this is also reflected by the shortcuts they take in procedures and education.

On the flip side, we do have problems with some CCTs that fail to note the concentration of the med on the pump and assume it is "just like what they use in the field" and start screwing with the settings. This is another reason why hospitals now have their own inhouse CCT staff. It also goes for those that try to "match" ventilator settings and measured pressures without understanding the differences between a portable "ATV" and an ICU ventilator.




remote_medic said:


> Wow...someone is having a rough day. Like momma used to say - If you don't have something nice to say don't say anything at all


 
If you can not handle criticism or having your work critiqued when it comes to quality patient care...find another occupation that is not in health care.


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## 46Young (Jun 15, 2009)

Markhk said:


> You don't need to turn on the AED mode on the LP12 to monitor for VF/VT.
> 
> There is an option for VF/VT detection on the monitor that will sound 5-8 seconds after it detects VF/VT. The icon with the magnifying class looking at the EKG indicates this feature is on. This is an option that can be disabled under the Alarms menu.
> 
> ...



Thanks for the tip.


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## 46Young (Jun 15, 2009)

Flight-LP said:


> Sorry, but the only item you are promoting is complacency. Taking the time to properly prep the chest and acquiring an appropriate 12 lead does not take that long and is a basic premise to acquisition of appropriate and reliable 12 lead EKG. Even an appropriately acquired 12 lead doe not rule out anything, enzymes are the only definitive when it comes to making the "yes or no" statement.
> 
> I say just do it right the first time.......................



Last time I checked, We don't have the time or equipment to do serial cardiac enzyme screening in the field. Inferior ischemia would be the most important finding when evaluating a 12 for ischemic changes in regard to ntg/morphine therapy. If I had no help, and it would shorten the Tx/Txp time, the full 12 can be deferred for a few minutes. As I mentioned earlier, our engine LP12's don't have 12 lead capability.


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## 46Young (Jun 15, 2009)

remote_medic said:


> No short cuts allowed around here



Things I've mentioned earlier, such as a quicker way of doing dopamine math(I've done the math the proper way many times over to ensure accuracy of the kg X .75 method), and the inferior interpretation before the full 12(if I'm doing all ALS by myself), aren't omtting anything. Things still get done, no negligence or malpractice has transpired. I advocate practicing effective time management, doing things as efficiently as possible. Shortcuts ought not = omissions.


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## 46Young (Jun 15, 2009)

Hey everyone, how about we cut the nonsense and post tips, knowledge and such that can be helpful? It seems like some get their jollies by pointing out other's inadequacies. There are plenty of other threads available where you can tell others how dumb they are, and how they aren't fit for the field without 10 bazillion years of education. Not everyone has attended a stellar medic program. It's likely that some weren't absorbing everything due to fatigue, and missed a thing or two. We also forget things as the years go by. I was hoping this thread would prove helpful for some. Again, the dopamine thing could be helpful at 0300 hours, when you're half awake. Ive heard frequently that one should run dopa wide open, figure out the drip rate, and adjust. Now THAT'S an improper shortcut. My math is accurate, and is quicker than the long way.


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## VentMedic (Jun 15, 2009)

Shortcuts should not be used to make up for inadequate education, no sleep or poor quality patient care. 

In fact, I do not recommend shortcuts to people who do not have proper education or have not mastered quality patient care. I can also see shortcuts becoming very dangerous when some are too tired to think things through properly.


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## Flight-LP (Jun 15, 2009)

46Young said:


> Hey everyone, how about we cut the nonsense and post tips, knowledge and such that can be helpful? It seems like some get their jollies by pointing out other's inadequacies. There are plenty of other threads available where you can tell others how dumb they are, and how they aren't fit for the field without 10 bazillion years of education. Not everyone has attended a stellar medic program. It's likely that some weren't absorbing everything due to fatigue, and missed a thing or two. We also forget things as the years go by. I was hoping this thread would prove helpful for some. Again, the dopamine thing could be helpful at 0300 hours, when you're half awake. Ive heard frequently that one should run dopa wide open, figure out the drip rate, and adjust. Now THAT'S an improper shortcut. My math is accurate, and is quicker than the long way.



As someone who infuses pressors regularly, I can tell you that I don't care what time of the day or night it is, I'm checking and rechecking the math. As Dopamine is usually the only pressor agent used by EMS (as it is the only one that can be continuously infused via a peripheral line, the rest strongy recommend or require central access), it is overutilized when not indicated, mismanaged, and them adverse effects can be critical. There are many methods of quickening the calculation, but if you don't know what it is exactly you are calculating, or even more importantly WHY you are calculating it, then you shouldn't be giving it. 

I'm sure everyone enjoys hearing about others' "simplicities" in EMS, but many are nothing more than bad habits. As Vent pointed out, unless you are truly proficient in your practice of medicine, then you need to stick to the approved methodology.


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## Ridryder911 (Jun 15, 2009)

Flight-LP said:


> As someone who infuses pressors regularly, I can tell you that I don't care what time of the day or night it is, I'm checking and rechecking the math. As Dopamine is usually the only pressor agent used by EMS (as it is the only one that can be continuously infused via a peripheral line, the rest strongy recommend or require central access), it is overutilized when not indicated, mismanaged, and them adverse effects can be critical. There are many methods of quickening the calculation, but if you don't know what it is exactly you are calculating, or even more importantly WHY you are calculating it, then you shouldn't be giving it.
> 
> I'm sure everyone enjoys hearing about others' "simplicities" in EMS, but many are nothing more than bad habits. As Vent pointed out, unless you are truly proficient in your practice of medicine, then you need to stick to the approved methodology.



Amen! As one that understands to achieve the pressor level for Dopamine is actually at a high "toxic" range; that it is dose dependent upon what the medication will do and perform. Some physicians are even naive on this. 

Many Paramedics still fail to recognize that it is NOT a "titrate to effect" medication, or understand the ranges of renal, mesenteric and alpha vasoconstrictive. All again upon the weight and dosage needed. 

R/r 911


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## daedalus (Jun 15, 2009)

I thought new research was showing that the renal dose of dopamine is a myth, and even at small does the kidney may lose perfusion.


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## Shishkabob (Jul 16, 2009)

Flight-LP said:


> But to add a positive to the thread, Dopamine is actually even easier than previously described......................
> 
> Take the pts. weight in pounds, drop the last number and subtract 2. That will be your 5mcg/min drip rate.................



We were taught >209 you subtract 2, <209 you subtract 3. I tried doing it on a practice quiz they gave and it didn't add up... neither of the 2.





> You have a patient that weighs 150 pounds. He has been resuscitated and now has a BP of 60/40. You are going to establish a dopamine drip IV piggyback. You are using a 60gtt/mL set and wish to deliver 5 mcg/kg/min. You mix 200 mg of dopamine into 250 mL of normal saline. What is your flow rate?
> 
> Your answer:
> 26 gtts/min
> ...




150 = 15

15-2 = 13gtts ???
15-3 = 12gtts ???

46youngs math adds up to 26gtts, and doing it the long way adds up to 26gtts.  


I don't know how I got the really short way to work before, but it's not working for me now.


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## ResTech (Jul 16, 2009)

All of the places I've seen and protocols I've read have the standard Dopamine mix of 400mg in 250mL which gives ya a 1600mcg concentration. 

Everyone carries a cell phone which most have a built in calculator and if not buy a cheap calculator to keep in your pocket or onboard ur unit. 

dose x weight(kg) x drip factor (60gtts)
        Concentration (1600mcg)

To me that is simple... and simpler yet... carry a pocket guide with a Dopamine chart in it. 

One of the hardest things I have found with some patient's IV's is actually setting the drip rate... to sit there and count the drops when the IV may be positional... running fast one minute, then slower the next... its sometimes hard to get an accurate drip rate without a pump. 

I practice setting the drip rates in the ED when the physician orders x amount of fluid over an hour or whatever time. The RN is always like "do your thing" 'cause she is so used to using a pump.


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## Flight-LP (Jul 16, 2009)

Linuss said:


> We were taught >209 you subtract 2, <209 you subtract 3. I tried doing it on a practice quiz they gave and it didn't add up... neither of the 2.
> 
> 
> 
> ...



It does work. What is half of 26???? 

It is correct, look at the concentration in the question. It states 200mg instead of the standard 400mg. 

13 gtts per minute will deliver 5mcg/kg/min.


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## Flight-LP (Jul 16, 2009)

Or as ResTech pointed out, you can do it the good old fashion way.

5mcg x 70kg (approx.) x 60gtts / 1600 mcg = 13.125 gtts / minute.

My shortcut posted works directly with the standard 1600mcg concentration. You have to double it for the 800mcg concentration.


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## Shishkabob (Jul 16, 2009)

Nevermind.  midnight + me + math = not good.  Need to work on that...


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## AnthonyM83 (Jul 16, 2009)

So I guess no one uses the "Fischer-Price" Los Angeles way?

Mix 400mg Dopamine into a 500ml NS bag. 
Start at 30 mcgtts/min. 
Titrate to BP of 90-100mmHg and signs of adequate perfusion.
Max of 120 mcggts/min.


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## Flight-LP (Jul 16, 2009)

AnthonyM83 said:


> So I guess no one uses the "Fischer-Price" Los Angeles way?
> 
> Mix 400mg Dopamine into a 500ml NS bag.
> Start at 30 mcgtts/min.
> ...




**shaking head and sighing**

No, not wise. But expected from LA......................


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## triemal04 (Jul 16, 2009)

One of the easiest formulas for dopamine out there and one of the least known for some reason.

(weight in kg x dose (ie XXmcg/kg/min))/25.  Will give you gtts/min with a 60 set or ml/hr if you are using a pump.  Only works for a 1600mcg/ml concentration but can easily be adjusted for others.

For the above pt:  (68kg x 5)/25  340/25=13.5 (without using a calculator anyway), so 13gtt/min.


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## 46Young (Jul 16, 2009)

Linuss said:


> We were taught >209 you subtract 2, <209 you subtract 3. I tried doing it on a practice quiz they gave and it didn't add up... neither of the 2.
> 
> 
> 
> ...



Thanks for pointing out that my math works. I originally posted the shortcut to help people do things a little more efficiently, god forbid, but I got beef from a few people looking down their nose at me for not doing certain things the long drawn out way. If you can do the math the proper way, there's absolutely no reason not to use a shortcut. It's supposed to make things quicker, easier, more simple.

150 lb pt: 150/2 = 75, 75-7.5 = 67.5, 67.5 x 5 = 337.5, 337.5/800 = 0.421875, 0.421875 x 60 = 25.3125 gtt/min.

150 lb pt = 67.5 kg, 67.5 x 0.75=50.625, 50.625/2 = 25.3125 gtts/min. 50.625 is divided by two because my "pt's wt in kg x 0.75 = drip rate is for 10mcg/kg/min. I divided by two to adjust for 5 mcg/kg/min. This is for 200mg/250cc's.


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## 46Young (Jul 16, 2009)

Thanks to all the others for their shortcuts. Don't limit it to dopamine math. Feel free to post "more efficient" ways of doing things in other areas. Do I want to carry a heavy box in my arms for a distance, or would I rather put the box on a dolly? Would you rather run five miles to the store then carry groceries home, or would you prefer to take the car? Do I want to do things the long way, when a more efficient method is available, provided the end result is the same?


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