# Factual reason behind using 1:10000 over 1:1000 Epi in Cardiac Arrest



## Ecgg

Hello!

I was looking for studies or any supported scientific data/studies that shows why 1:10000 solution IV/IO is preferred in Arrest setting over 1:1000?

I herd multiple accounts stating various things without any material to support it. Here is some of the things that I herd:

1-1:10000 has the Saline in it to help propel the medication further into the central circulation. Thus don't have to follow up with Syringe NS boluses. 
2-1:1000 Epi given IV can cause phlebitis, necrosis and all kinds of havoc if given IV. Thus avoid giving 1:1 1mg per 1ml epi IV.
3- To avoid medication errors. Prefilled syringes offer idiot proofing. 

Science/Data backing would be appreciated why 1:10000 is the preferred solution in arrest setting.


----------



## usalsfyre

Considering epi has never proven to be helpful in ensuring survival to discharge in the setting of arrest AND 1mg of epi is 1mg of epi is 1mg of epi no matter how much solution it's dissolved in AND even 1:10000 should be followed with a flush to ensure all of the medication makes it into circulation, I highly doubt there's any data like what you seek out there. I'm certainly not aware of any.

The only reasons I can think of for 1:10000 are a.) ease of use and b.) so it's easier to dilute down for use as a bolus dose pressor.

What are you seeking this info for?


----------



## medicsb

www.pubmed.com - search til you're blue in the face here.

What usalsfyre said.

However, diluted vs. undiluted amiodarone for cardiac arrest was studied in Europe somewhere, so you never know.


----------



## mycrofft

*Whether or not it works...*

The potential excitement and crowded conditions of codes makes for heightened chances for misdoseage. Better to have a lower concentration ready to go instead of titrating from more-concentrated solutions, leaving half-used syringes lying around, etc.

Also, in re. "excitement" above, not all codes take place in calm well-lit and constantly rehearsed places like hospitals or with experienced MD's etc around.

They probably did a study long ago, maybe on dogs, and it crept into practice because it seemed to work.


----------



## usalsfyre

Anyone remember 30mgs in 30ml vials?


----------



## Aidey

usalsfyre said:


> Anyone remember 30mgs in 30ml vials?



Oddly enough, yes. Never could figure out the point of that aside from an epi drip (which was so far out of my protocols at the time I doubt any of my co-workers knew it was possible).


----------



## 18G

I'm not aware of any evidence for either but just thinking of the effect 1:000 epi has on a conscious person when given IV it makes sense as to why that concentration is not given in an arrest. 

My guess would be the 1:000 in an arrest would be too potent and cause too much vasoconstriction to the point its harmful and may impede the improved cerebral and coronary perfusion pressures were shooting for. 

I'm not saying this to be true cause I've never seen any evidence but it does make sense and is my educated guess for what it's worth


----------



## usalsfyre

18G said:


> I'm not aware of any evidence for either but just thinking of the effect 1:000 epi has on a conscious person when given IV it makes sense as to why that concentration is not given in an arrest.
> 
> My guess would be the 1:000 in an arrest would be too potent and cause too much vasoconstriction to the point its harmful and may impede the improved cerebral and coronary perfusion pressures were shooting for.
> 
> I'm not saying this to be true cause I've never seen any evidence but it does make sense and is my educated guess for what it's worth



How does 1 mg of epi cause more vasoconstriction than 1 mg of epi?


----------



## 18G

The rate of absorption and potency makes the difference. 

How does 1mg of epi in 250mL cause a different effect than 1mg of 1:1000 epi as 1mL? 

It's all 1mg right? But a big difference in effect.

Try giving 1:1000 epi IVP to a conscious patient as compared to 1:10000 epi IVP of the same dose and tell me if the patient responds any differently. I think you would tell the difference really quick!


----------



## usalsfyre

1 mg of epi causes the affect no matter what it's diluted in, assuming the same rate of administration. Now obviously there's practical limits to that, I can't administer a 500ml bolus as fast as I can give 1ml. But I can push 1mg in 10mls just as fast as I can push 1mg in 1ml. The rate of absorption will be the same, your talking about a minor difference in volume.


----------



## usalsfyre

18G said:


> Try giving 1:1000 epi IVP to a conscious patient as compared to 1:10000 epi IVP of the same dose and tell me if the patient responds any differently. I think you would tell the difference really quick!


I've done it and never noticed a difference between the two, they all get jittery as hell.


----------



## 18G

It still comes down to potency. 

Heat is heat right. What if I touch you with something that is 70F versus something that is 250F for the same length of time? It's the same element touching you but with drastically different results. 

Epi is a high-profile medication solely due to the different potencies. If they were both the same and resulted in the same effects than why is there two different potencies???

Many patients have been harmed significantly when given 1:1000 IVP versus the lesser concentrated 1:10,000.

I have never, ever heard of patients being administered 1:1000 epi IVP. In fact I have always read and personally been strongly warned about ever giving 1:1000 epi IVP.


----------



## usalsfyre

Your confusing volume and dose. 1mg of epinephrine is no way shape or form more potent than 1mg of epinephrine. However, 1 miliLITER of 1:1000 epinephrine solution is drastically more potent than 1 ml of 1:10000 epinephrine solution.


----------



## usalsfyre

18G said:


> I have never, ever heard of patients being administered 1:1000 epi IVP. In fact I have always read and personally been strongly warned about ever giving 1:1000 epi IVP.



See my above note about 30mg in 30ml vials. One service I worked for did not carry any prefills.


----------



## 18G

I've seen services that carry vials of "high-dose" 1:1000 epi when it had to be given down an ET tube so your not putting all that fluid into the lungs with the pre-filled 1:10,000 syringes. But I have never heard of 1:1000 epi EVER being given IVP. 

Maybe I'm not hearing you correctly, but several high-profile and lethal cases have resulted from 1:1000 epi being given IVP instead of 1:10,000. And hospitals and EMS services are always cautioned about having the epi concentrations marked appropriately so there is no chance for the wrong concentration to be administered.


----------



## usalsfyre

18G said:


> But I have never heard of 1:1000 epi EVER being given IVP.


We were supposed to mix it with 9mls of saline to make....Epi 1:10000. Most of us just gave 1ml out of a syringe into a running IV line. In fact during the last prefill shortage our hospital pharmacy supplied us with bags containing a 10ml syringe, filter needle, a 1mg amp of 1:1000 epi and a strip vial of saline and told us to mix the drug.



18G said:


> Maybe I'm not hearing you correctly, but several high-profile and lethal cases have resulted from 1:1000 epi being given IVP instead of 1:10,000.


Again, your mixing up concentration and dose. If I determine I need to give 3mls of 1:10000 solution, but pull the wrong med and give 3mls of 1:1000 solution, yes I have MASSIVELY overdosed the patient (3mgs vs 300mcgs). But if I give 0.3mls of 1:1000 solution or 3mls of 1:10000 solution, I have given 300mcgs either way. The dose is EXACTLY the same, the volume needed to do so is less.



18G said:


> And hospitals and EMS services are always cautioned about having the epi concentrations marked appropriately so there is no chance for the wrong concentration to be administered.


Another wonderful pile of Joint Commission crap.

Epi is no different from any other drug. For instance I have carried Midazolam in 10mg in 1ml (1:100 solution) and 5 mgs in 5mls (1:1000) solution. If I give 0.5mls of the 10 in 1 and 5mls of the 5 in 5 have I not given the EXACT SAME DOSE?

The reason for 1:1000 on EMS units is subcutaneous and intramuscular injection.


----------



## the_negro_puppy

usalsfyre said:


> We were supposed to mix it with 9mls of saline to make....Epi 1:10000. Most of us just gave 1ml out of a syringe into a running IV line. In fact during the last prefill shortage our hospital pharmacy supplied us with bags containing a 10ml syringe, filter needle, a 1mg amp of 1:1000 epi and a strip vial of saline and told us to mix the drug.
> 
> 
> Again, your mixing up concentration and dose. If I determine I need to give 3mls of 1:10000 solution, but pull the wrong med and give 3mls of 1:1000 solution, yes I have MASSIVELY overdosed the patient (3mgs vs 300mcgs). But if I give 0.3mls of 1:1000 solution or 3mls of 1:10000 solution, I have given 300mcgs either way. The dose is EXACTLY the same, the volume needed to do so is less.
> 
> 
> 
> Epi is no different from any other drug. For instance I have carried Midazolam in 10mg in 1ml (1:100 solution) and 5 mgs in 5mls (1:1000) solution. If I give 0.5mls of the 10 in 1 and 5mls of the 5 in 5 have I not given the EXACT SAME DOSE?
> 
> The reason for 1:1000 on EMS units is subcutaneous and intramuscular injection.



Indeed we carry mainly 1mg/1ml adrenaline

we have also started carrying 1mg/10ml for paediatric arrests
Another wonderful pile of Joint Commission crap.


----------



## mycrofft

*Thermodynamics and pharmacology are not comparable*

press on


----------



## Ecgg

usalsfyre said:


> Considering epi has never proven to be helpful in ensuring survival to discharge in the setting of arrest AND 1mg of epi is 1mg of epi is 1mg of epi no matter how much solution it's dissolved in AND even 1:10000 should be followed with a flush to ensure all of the medication makes it into circulation, I highly doubt there's any data like what you seek out there. I'm certainly not aware of any.
> 
> The only reasons I can think of for 1:10000 are a.) ease of use and b.) so it's easier to dilute down for use as a bolus dose pressor.
> 
> What are you seeking this info for?



After reading what I could find on the Internet it has to do with ease of use in emergency setting, and safety measures not to draw up excess amounts. Also with 1:10000 you can push the drug further into circulation because it has the added saline in the bristojet. (None of this is science based)

I am seeking the science/research supported info so I have an educated/case supported basis to speak from. Don't want to continue with the old paradigm blind leading the blind.


----------



## Ecgg

usalsfyre said:


> Anyone remember 30mgs in 30ml vials?



Those are still carried in all ambulance units I work at.


----------



## usalsfyre

Ecgg said:


> I am seeking the science/research supported info so I have an educated/case supported basis to speak from. Don't want to continue with the old paradigm blind leading the blind.


That's what I'm saying, I don't think you'll find any. Your giving the same dose at the same administration rate, just in a slightly different concentration. It's also difficult to show one concentration as being superior to the other when the drug itself hasn't ever shown effectiveness in the first place.

You could give me the vial above and it would pretty well inspire no change in my practice. In fact, I'm firmly convinced you could take epi out of ACLS completely and not have a change in cardiac arrest survival to discharge.

I know this isn't what your looking for, but if you look into the data on epi you'd see that studying this is like rearranging deck chairs on the Titantic.


----------



## sir.shocksalot

usalsfyre said:


> when the drug itself hasn't ever shown effectiveness in the first place.



Out of curiosity, what makes you think Epi has no effect on cardiac arrest? I was under the impression that Epi was one of the only (if not *the* only) drug that had any proven benefit in cardiac arrest as a pressor.

I understand the thoughts of long term outcomes, and from my understanding thats really where we (as medical providers in general) are falling flat on our faces for cardiac arrest. However, I have always heard and read that Epi is a really important drug for arrests.

Not trying to be argumentative, I just want to see what your thoughts are.


----------



## mgr22

sir.shocksalot said:


> Out of curiosity, what makes you think Epi has no effect on cardiac arrest? I was under the impression that Epi was one of the only (if not *the* only) drug that had any proven benefit in cardiac arrest as a pressor.
> 
> I understand the thoughts of long term outcomes, and from my understanding thats really where we (as medical providers in general) are falling flat on our faces for cardiac arrest. However, I have always heard and read that Epi is a really important drug for arrests.
> 
> Not trying to be argumentative, I just want to see what your thoughts are.



I think the point is that epi administered during cardiac arrest has not been shown to improve survival to discharge. From the 2010 ACLS literature: "...there is no placebo-controlled study that shows that the routine use of any vasopressor during human cardiac arrest increases survival to hospital discharge."


----------



## usalsfyre

mgr22 said:


> I think the point is that epi administered during cardiac arrest has not been shown to improve survival to discharge. From the 2010 ACLS literature: "...there is no placebo-controlled study that shows that the routine use of any vasopressor during human cardiac arrest increases survival to hospital discharge."



Bingo. We've been giving epi on expert recommendation since the beginning of ACLS. If it was going to work, we would have seen an outcome difference by now. It may be important in certain settings, but the "all epi all the time" philosophy that's currently being followed is not helpful and probably harmful. To vaguely quote Rogue Medic "we don't give epinephrine to STEMI patients when they're alive, what changes when they're dead"


----------



## CUjays34

usalsfyre said:


> Bingo. We've been giving epi on expert recommendation since the beginning of ACLS. If it was going to work, we would have seen an outcome difference by now. It may be important in certain settings, but the "all epi all the time" philosophy that's currently being followed is not helpful and probably harmful. To vaguely quote Rogue Medic "we don't give epinephrine to STEMI patients when they're alive, what changes when they're dead"




Not for nothing but organized electrical activity!  Epi can prolong that activity in VF pulseless V-Tach so defibrillation can take place.


----------



## usalsfyre

CUjays34 said:


> Not for nothing but organized electrical activity!  Epi can prolong that activity in VF pulseless V-Tach so defibrillation can take place.


Even though the most common cause of vfib is AMI?

Remember, it's not about delivering a pulse to the ED...


----------



## 18G

Without a pulse though there isn't anything to work with. Getting a pulse is a step in the right direction.


----------



## usalsfyre

18G said:


> Without a pulse though there isn't anything to work with. Getting a pulse is a step in the right direction.



Ehhh, maybe...

Resuscitating someone who in all likelihood will be planted in a vegetable patch or die 48 hours later isn't good medicine.


----------



## 18G

usalsfyre said:


> Ehhh, maybe...
> 
> Resuscitating someone who in all likelihood will be planted in a vegetable patch or die 48 hours later isn't good medicine.



I agree and a lot of arrest patients are just old and well... its just their time to die so no matter what we do it doesn't make a difference. 

But there are some who can be resuscitated and have a return to a normal quality of life. Unfortunately we aren't able to determine very well who does return to a good quality of life and who doesn't.


----------



## rogersam5

usalsfyre said:


> Epi is no different from any other drug. For instance I have carried Midazolam in 10mg in 1ml (1:100 solution) and 5 mgs in 5mls (1:1000) solution. If I give 0.5mls of the 10 in 1 and 5mls of the 5 in 5 have I not given the EXACT SAME DOSE?.



Yes but with a 10 fold difference in concentration, that 10 fold difference in concentration can make a large difference in local effects through sheer pharmicokenetics. Not having any experimental data I couldn't say if there actully is a scientific reason to use 1:10000 over 1:1000. but I woul speculate the reason ould revolve around without having normal blood circulation to move the drug when injected (and thus diluting it) you would do significantly more harm injecting 1:1000 as you would see (asuming 1st order kenetics) a 10 fold increase in the rate of local vasoconstricution compaired to 1:10000. If the kenetics are a higher order your looking some significant increases is kinetics.


----------



## usalsfyre

rogersam5 said:


> Yes but with a 10 fold difference in concentration, that 10 fold difference in concentration can make a large difference in local effects through sheer pharmicokenetics. Not having any experimental data I couldn't say if there actully is a scientific reason to use 1:10000 over 1:1000. but I woul speculate the reason ould revolve around without having normal blood circulation to move the drug when injected (and thus diluting it) you would do significantly more harm injecting 1:1000 as you would see (asuming 1st order kenetics) a 10 fold increase in the rate of local vasoconstricution compaired to 1:10000. If the kenetics are a higher order your looking some significant increases is kinetics.



Epi 1:1000 is used exclusively for arrest in other parts of the world. Their patient's limbs are not falling off. You should be flushing any drug you give in an arrest patient, no matter the concentration.


----------



## usalsfyre

18G said:


> But there are some who can be resuscitated and have a return to a normal quality of life. Unfortunately we aren't able to determine very well who does return to a good quality of life and who doesn't.



Which is why resuscitation requires more thought than the most cookbook of cookbooks, the ACLS algorithm. "Push epi on every arrest" completely ignores good sense. These patients very often had medical conditions that administering epinephrine to would be considered malpractice when they had a pulse. What do you think is going to happen if there is a ROSC and the epi that has likely not made it to central circulation hits the patients vital organs? 

I don't have a problem with epi as a vasopressor, but it needs to be given at vasopressor doses, a few (2-10)mcg a min. 1 milligram is quite honestly, an overdose.


----------



## Ecgg

*Epinephrine shortage*

Something to consider

So in 2010 Agencies were advised about Epinephrine shortages. A quick look online tells that many agencies all passed the same memos stating the following:



> EPINEPHRINE SHORTAGE
> Due to manufacturing and approval issues, prefilled one (1) mg epinephrine syringes 1:10,000 are on back order and may be difficult to obtain. Shipments were expected by the first part of July 2010, but there is no guarantee.
> If you do not have epinephrine prefilled syringes for use, please follow these procedures for dilution of epinephrine to obtain a 1:10,000 concentration for use in cardiac arrest patients:
> •
> Draw up on (1) mg of epinephrine from an epinephrine 1:1000 ampule. This is one (1) mL of volume
> •
> Add to the epinephrine nine (9) mL of normal saline from a vial or the IV line.
> •
> The resulting ten (10) mL solution may be used in place of a prefill.
> EPINEPHRINE IS A HIGH ALERT MEDICATION AND MAY CAUSE SIGNIFICANT PATIENT HARM WHEN USED IN ERROR; THE FOLLOWING STEPS SHOULD BE FOLLOWED TO MINIMIZE THE POTENTIAL FOR ERROR:
> •
> Have another crew member confirm the dilution
> •
> Do not save the solution or prepare it in advance
> •
> Use of the one (1) mg ampule is recommended
> •
> It is better if you always prepare the dilution using the same source of epinephrine to avoid confusion
> If you have multi-dose vials of 1:1000 epinephrine make sure you DO NOT draw up 9 mL of epinephrine solution. We recommend the epinephrine solution for dilution and normal saline should be kept together in a clear plastic “baggie” with a label on the epinephrine that says one (1) mL use, along with the 10 mL syringe and brief instructions for dilution.



http://www.mvemsa.com/Drug Shortage Memo.pdf

If you search online you will find many of such advisories for multiple agencies. 

Why go with the time of dilution on a code if you can just push 1:1000 and follow up with a flush. Just some food for thought...


----------



## rogersam5

Ithink the big problem they talkabout there is giving the wrong dose (1mg vs 9mg) by drawing up too much rather then the wrong dilutions being given


----------



## Ecgg

rogersam5 said:


> Ithink the big problem they talkabout there is giving the wrong dose (1mg vs 9mg) by drawing up too much rather then the wrong dilutions being given



Sure that aspect is included. However I seen a few where that is not mentioned.

http://www.mlrems.org/e107_files/downloads/advisory_10-11_epinephrine_shortage-2.pdf



My only observation is that, if 1:1000 amps  and 1:10000 do the same job in a cardiac arrest, why waste time diluting? When I can just draw up 1mg/1ml epi bolus it and follow up with bolus pre made NS flush


----------



## usalsfyre

Ecgg said:


> Why go with the time of dilution on a code if you can just push 1:1000 and follow up with a flush. Just some food for thought...


Perhaps because EMS is extremely rigid in its thought process and so hung up on following protocols we forget what we're trying to accomplish?  Perhaps because the administrators writing this stuff don't really understand it? Perhaps because we're so scared of a dead person suing us from extravasation we do stuff that doesn't make sense?

I don't know the reason. As noted above other parts of the world have no prefills and haven't seen an issue.


----------



## usalsfyre

Has your agency stopped carrying prefills and your trying to get them back? 

If your really worried about time, grab a 50ml syringe, pull off 5mls if epi from the multidose vial you mentioned you carried, then draw up 45mls of saline. Walla, enough epi 1:10000 to work an arrest for 20 minutes.


----------



## Ecgg

usalsfyre said:


> Has your agency stopped carrying prefills and your trying to get them back?
> 
> If your really worried about time, grab a 50ml syringe, pull off 5mls if epi from the multidose vial you mentioned you carried, then draw up 45mls of saline. Walla, enough epi 1:10000 to work an arrest for 20 minutes.



Absolutely not. The prefills and 30mg/30ml vials, single use vials are of plenty. Speaking with seasoned medics and physicians I herd different things regarding this matter. I just wanted to see if there is any evidence to all this.


----------



## usafmedic45

> I've done it and never noticed a difference between the two, they all get jittery as hell.



Same here.  I'm thinking it's a selection bias he is seeing there.


----------



## Melclin

18G said:


> I agree and a lot of arrest patients are just old and well... its just their time to die so no matter what we do it doesn't make a difference.



Its not about age, its about not continuing to perpetuate uselessly modalities that are as useless as they are expensive. Epi itself is of course not expensive. What I'm getting at is that idea of pumping enough juice into a corpse to create a pulse, get to ED use resources, time, beds, maybe even and ICU, if everyone who needed epi to get a pulse dies anyway. Its like how some traumatic Asystole and PEA < 40 survive to hospital, some even make it to the ICU, but none survive to discharge, so why waste the considerable resources? 



18G said:


> I've seen services that carry vials of "high-dose" 1:1000 epi when it had to be given down an ET tube so your not putting all that fluid into the lungs with the pre-filled 1:10,000 syringes. But I have never heard of 1:1000 epi EVER being given IVP.
> 
> Maybe I'm not hearing you correctly, but several high-profile and lethal cases have resulted from 1:1000 epi being given IVP instead of 1:10,000. And hospitals and EMS services are always cautioned about having the epi concentrations marked appropriately so there is no chance for the wrong concentration to be administered.



Mate, you need to break out the old junior school chemistry notes about solutes, solvents and concentration. 

Marking concentrations is important because it has implications for dosage. The concentration itself is not _generally_ that important. 

We don't carry 1:10000 adrenaline, or pre-filled syringes. Usually the done thing is to draw up several mgs into a 3,5 or 10ml syringe and give 1mg (1ml) increments, flushed though by opening your fluid for a few moments.


----------



## Aidey

I honestly think it would be easier to draw up 3 or 5 mg in one syringe and give it like that. Plus less garbage. But then we wouldn't be able to look cool flipping off the end caps to the pre-fills.


----------



## Melclin

Aidey said:


> I honestly think it would be easier to draw up 3 or 5 mg in one syringe and give it like that. Plus less garbage. But then we wouldn't be able to look cool flipping off the end caps to the pre-fills.



That's the whole f***ing reason I became a paramedic...to pull caps off pre-filled syringes with my teeth, rambo style. So upset. B)


----------



## abckidsmom

Melclin said:


> That's the whole f***ing reason I became a paramedic...to pull caps off pre-filled syringes with my teeth, rambo style. So upset. B)



We still get to do it with the D50.  You guys don't even have that, do you?

I love to take a moment to enjoy flipping off the caps of the D50 syringes.  Best done if you pause with the double thumbs up and a cheesy grin at your partner over the unconscious patient.


----------



## Smash

Aidey said:


> I honestly think it would be easier to draw up 3 or 5 mg in one syringe and give it like that. Plus less garbage. But then we wouldn't be able to look cool flipping off the end caps to the pre-fills.



That's what I've been doing for... Well, forever. Drawing up several milligrams of 1:1000 for arrests that is, not looking cool. I've never looked cool. Whenever I used to pop the tops on the prefilled syringes all that would happen is that I would whack myself in the eye with one, then then stab myself in the leg. 

We carry 1:10000 ampoules as well, used for incremental epi to help maintain BP post arrest and the like. If I want lower concentration (10mcg/ml) for kiddies or more delicate increments I whack 1mg of epi into a 100ml bag of D5W and draw it out of there. 

I'm not sure what all the fuss is about drug errors in cardiac arrest. All the arrests I work are calm, quiet and considered affairs (family members excepted).  There is plenty of time to check drugs, discuss whether we should be giving them at all, options for treatment, when we should call a halt to our efforts and so on. Let's face it, they're not going to get any sicker if we take our time and do it right.

Actually, that holds true for all jobs. If I have to raise my voice to my crews, I've already lost.


----------



## johnrsemt

The reason for the multidose vials is if you have protocols for epi 1:1000 nebulized for croup or asthma that doesn't respond to Albuterol.    or if you have 50 people stung by bees/wasps.


----------



## Melclin

abckidsmom said:


> We still get to do it with the D50.  You guys don't even have that, do you?
> 
> I love to take a moment to enjoy flipping off the caps of the D50 syringes.  Best done if you pause with the double thumbs up and a cheesy grin at your partner over the unconscious patient.



NO! We don't :sad: Australian EMS is the worst.

My preference would be double pistol hands with a wink and tongue click, but I believe every clinician has to make their own considered decision based on their knowledge and pt condition.


----------



## squrt29batt12

usalsfyre said:


> How does 1 mg of epi cause more vasoconstriction than 1 mg of epi?



LOL good question


----------



## omak42

usalsfyre said:


> Anyone remember 30mgs in 30ml vials?



We still carry them over here in WA.


----------



## cwmedic

Lots of posts here but I can tell you 1:1,000 epi is far too concentrated to directly enter circulation. 1:10,000 is far too dilute to be given SC or IM. 1mg of each is, in fact, the same dose either way but a different concentration. I guess you could argue that you will push the higher concentration more slowly and that may be plausible but probably still not safe. 

I heard of a patient receiving high concentration epi IVP for an allergic reaction and then was flown to a cath lab with an MI as a result.


----------



## usalsfyre

cwmedic said:


> Lots of posts here but I can tell you 1:1,000 epi is far too concentrated to directly enter circulation.



I give up.

I only ask you to explain to me ONE thing. How is 1:1000 too concentrated to enter circulation?


----------



## Smash

usalsfyre said:


> I give up.
> 
> I only ask you to explain to me ONE thing. How is 1:1000 too concentrated to enter circulation?



Ok, here is my hypothesis:  1mg of epi that is in 1ml of fluid is a lot more cramped than 1mg of epi that is in 10mls.  It's all cooped up and can't move so much, so it gets angry.  When we let it out by injecting it, it lets out all that pent up frustration and somehow goes bat :censored::censored::censored::censored: crazy through the body, causing limbs to fall off, eyes to pop out, heads to explode and so on.

Admittedly I don't have any evidence to support this hypothesis, but I have no idea otherwise how 1mg does not equal 1mg.


----------



## Smash

Oooohhhhh, hang on, I think we need to get all quantum physics on this, weird stuff happens down there where maybe 1 does not equal 1.  I'll try to work out a formula... h34r:


----------



## cwmedic

So would you be willing to inject 40mEq of potassium in 5cc into your own vein vs 40mEq in 250cc?  It is precisely the same concept. It is the same dose but a different concentration. If that doesn't make sense, I suggest you read the definitions of the words.


----------



## Smash

cwmedic said:


> So would you be willing to inject 40mEq of potassium in 5cc into your own vein vs 40mEq in 250cc?  It is precisely the same concept. It is the same dose but a different concentration. If that doesn't make sense, I suggest you read the definitions of the words.



Potassium would not be my drug of choice... However I think you are missing the context here. I would not give a 1:1000 IV bolus of epi to a live patient, but nor would I give a 1:10000 bolus of epi either. However we aren't talking about live patients here, we are discussing cardiac arrest patients. What is it you are worried about when giving 1mg boluses of epi in an arrest? Phlebitis? They might have other things to worry about at that stage...

Now, granted, I don't think that epi is the most useful of drugs in cardiac arrest (but then probably no drugs are), but nonetheless, in the past thirteen years I have worked many hundreds of cardiac arrests, and given multiple doses of 1:1000 epi in almost all of them.  I have yet to encounter any issues I could reasonably attribute to the administration of 1:1000 epi via a peripheral line.  Granted, that's the anecdote of one ambulance driver, but when we consider the hundreds of thousands of arrests that have been worked throughout Australia, New Zealand and Europe, one would imagine that there would be some epidemiological data to suggest that 1:1000 epi is making people explode. 

So my question is: given the context (dead person) what is the problem with giving 1mg of epi as opposed to 1mg of epi?


----------



## usalsfyre

cwmedic said:


> So would you be willing to inject 40mEq of potassium in 5cc into your own vein vs 40mEq in 250cc?  It is precisely the same concept. It is the same dose but a different concentration. If that doesn't make sense, I suggest you read the definitions of the words.


I wouldn't "inject" (i.e. push) K+ no matter how dilute it is.

The variable you don't take into account is administration rate. If I could somehow give the 40mEq in 5mls over two hours as it's supposed to be given, then there would be no difference than giving it in 250mls. But I challenge you to prove to me th 0.25 seconds that 1mg of epi 1:1000 vs the 0.5 seconds 1mg of epi 1:10000 is given over makes any semblance of difference. If I give 1 mg of epi over an hour (such as is in say an infusion) it makes a difference. The concentration differences (say 1mg in 100mls) simply facilitate administration rate differences (which is basically a dose change). 

Consider this, in ICUs, various patient populations who have fluid restrictions have concentrated pressors mixed and administered via syringe pump. Are you saying this is wrong?

I also challenge the thought that 1:10000 couldn't be injected IM. Your only talking about between 3 and 5mls for a standard dose, which is commonly a volume given gluteally when antibiotics are concerned, albeit an uncomfortable volume.


----------



## cwmedic

Just because a patient is in cardiac arrest doesn't mean they are not at risk for MI or other complication from the high concentration. Remember we are trying to perfuse tissue with CPR. I think a closed coronary artery would make our efforts difficult. 

Yes, I suppose you could give the higher concentration drug more slowly and have an equal outcome if there is blood flowing for it to mix to a lower concentration. Basically, you are lowering the concentration with blood and not saline.  Yes, it could be done but there is no reason to. 

True, vasoactive drips are concentrated sometimes to reduce undesired fluid intake. The differences I would think of right off hand would be that these are delivered by machines which provide a much more precise rate than injecting by syringe. Also, the typical concentrated versions are 5x. The example given would be 10x. Twice the normal maximum concentration is a lot. We are talking about books doses and not drip rates. You really can't compare the two.


----------



## usalsfyre

cwmedic said:


> Just because a patient is in cardiac arrest doesn't mean they are not at risk for MI or other complication from the high concentration. Remember we are trying to perfuse tissue with CPR. I think a closed coronary artery would make our efforts difficult.


The most common reason for cardiac arrest IS AMI, you can be pretty d@mn sure there's going to be cardiac damage involved no matter what.



cwmedic said:


> Yes, I suppose you could give the higher concentration drug more slowly and have an equal outcome if there is blood flowing for it to mix to a lower concentration. Basically, you are lowering the concentration with blood and not saline.  Yes, it could be done but there is no reason to.


Do you REALLY think 10 vs 1 ml of saline makes any difference at all? Do you really think there is a difference in administration rate?



cwmedic said:


> True, vasoactive drips are concentrated sometimes to reduce undesired fluid intake. The differences I would think of right off hand would be that these are delivered by machines which provide a much more precise rate than injecting by syringe. Also, the typical concentrated versions are 5x. The example given would be 10x. Twice the normal maximum concentration is a lot. We are talking about books doses and not drip rates. You really can't compare the two.


There's anesthesitis that push vasoactives all day with no pump. 

Where are you getting 5 times? 

How is 1mg of epi given IVP less likely to cause coronary vasospasm than 1mg of epi give IVP? Do you really think the administration rate is different?


----------



## Smash

cwmedic said:


> Just because a patient is in cardiac arrest doesn't mean they are not at risk for MI or other complication from the high concentration. Remember we are trying to perfuse tissue with CPR. I think a closed coronary artery would make our efforts difficult.



Do you really think that the concentration of the drug in this setting has anything to do with it's effects?  How?
Do you give epi in an arrest over a period of several minutes, or do you just push it?
I'm still at loss as to how 1mg does not equal 1mg.


----------



## MrBrown

While that white light Garth Brooks was on about is coming closer to your cardiac arrest patient, the fail in this thread is getting stronger.

It was 1992 and twas foretold in Mobile Intensive Care Officer training that drugs in cardiac arrest do little .... and nobody seems to have really picked up on that nye 20 years later.

1mg of adrenaline is 1mg of adrenaline - the concentration of solute in solvent is going to be slightly different but it's still 1mg of adrenaline at the end of the day.


----------



## cwmedic

Yep. I have offered what I can to explain the rationale. Could it be done?  Probably. Is it a good idea?  Probably not. Talk to your OMD and try to get it approved. Hell, give it a shot next time and see what happens.


----------



## Smash

MrBrown said:


> It was 1992 and twas foretold in Mobile Intensive Care Officer training that drugs in cardiac arrest do little .... and nobody seems to have really picked up on that nye 20 years later.



That's not entirely true Brown.  Drugs in cardiac arrest make barely homestasing paragod wannabes think that they are somehow locked in mortal combat with death itself, using all the fearsome tools that modern science provides... 

All epi in dead people does is keep earthworms up at night!

But yes, at this stage 1mg=1mg.  I'm still working on my proof that 1mg does not equal 1mg, but I'm getting bogged down with the Bosonic Fields while attempting to expand the path integral formalism before attempting Poincare transformation, which are of course covariant with the Feynman propagtor, which doesn't make life any easier.


----------



## Smash

cwmedic said:


> Yep. I have offered what I can to explain the rationale. Could it be done?  Probably. Is it a good idea?  Probably not. Talk to your OMD and try to get it approved. Hell, give it a shot next time and see what happens.



But you haven't explained a rationale as to why people use 1:10000 as opposed to 1:1000.  How is it that 1mg is not the same as 1mg?


----------



## MrBrown

Smash please ... stop talking sense 

You know there is no room for sense in the 100 hour curricula


----------



## Melclin

Smash said:


> All epi in dead people does is keep earthworms up at night!



Hahaha, I'm stealing this and claiming that I was witty enough to think of it myself. 




> I'm still working on my proof that 1mg does not equal 1mg, but I'm getting bogged down with the Bosonic Fields while attempting to expand the path integral formalism before attempting Poincare transformation, which are of course covariant with the Feynman propagtor, which doesn't make life any easier.



Well duh. Geez, thanks captain obvious.


----------



## Smash

Melclin said:


> Well duh. Geez, thanks captain obvious.



Yeah, I know, but I got a bit tied up with the Feynman representation of the Wicks expansion in the pertubative s-matrix before I realised that if I just substituted a scalar field Lagrangian equation I would come up with a clearer probability amplitude to apply to the Fourier transformations. :wacko:

Look, it was late and I hadn't had any coffee, so you'll have to excuse my ridiculous, basic error.

While I work on this, has anyone else come up with a reason why 1mg of epi does not equal 1mg of epi?  Have we worked out why it is "too concentrated" or anything?  It concerns me; I have been giving 1:1000 epi IV for over a decade and I had no idea I was making people explode or whatever it is it is meant to do.  (Maybe I would have noticed the exploding thing, but...)


----------



## usalsfyre

cwmedic said:


> Yep. I have offered what I can to explain the rationale. Could it be done?  Probably. Is it a good idea?  Probably not. Talk to your OMD and try to get it approved. Hell, give it a shot next time and see what happens.



You know I actually had a conversation about this with clinical services personel about two days ago. They agreed, completely pointless that we carry 1:10,000, other than to make 1:100,000 to use as a push dose pressor. Good luck getting it off of our trucks though. I can hear the howls of derission now....


----------



## Shishkabob

I'm one to take the less liked position and say you can't have more survivals without having more ROSCs, and more ROSCs have been proven to come from the drugs.


Clearly there's a disconnect between ROSC and survival... a piece of the puzzle we're missing.  Therapeutic Hypothermia is a part of that.  Now what else?


----------



## usalsfyre

Linuss said:


> I'm one to take the less liked position and say you can't have more survivals without having more ROSCs, and more ROSCs have been proven to come from the drugs.
> 
> 
> Clearly there's a disconnect between ROSC and survival... a piece of the puzzle we're missing.  Therapeutic Hypothermia is a part of that.  Now what else?



There's "good" survival and there's "bad" survival. Theraputic hypothermia is a piece of the puzzle to prevent cell apoptosis. BUT...when you have 20+ minute response times like we do, you can probably get a ROSC, but MODS has already been set in motion.


----------



## Shishkabob

Agreed, and I'm not the biggest fan of running 25 minutes to a cardiac arrest that should have been picked up by another agency but NOOO it was out of their service area... And work a code that I know is futile, but meets ALL the criteria to work.


But as I said, A gets C, F gets H... now we just need to find B, D, E, and G.


ACLS drugs get a pulse back.  Plenty of evidence to back that up.  The problem is KEEPING the pulse... and with a good neural outcome.


----------



## usalsfyre

Linuss said:


> Agreed, and I'm not the biggest fan of running 25 minutes to a cardiac arrest that should have been picked up by another agency but NOOO it was out of their service area... And work a code that I know is futile, but meets ALL the criteria to work.


Hate this as well...for instance today one of my arrest had 40 minutes of CPR done PTA.




Linuss said:


> But as I said, A gets C, F gets H... now we just need to find B, D, E, and G.


I'm not sure in a lot of cases there is a B,D,E and G. Maybe in some cases, but not all. 




Linuss said:


> ACLS drugs get a pulse back.  Plenty of evidence to back that up.  The problem is KEEPING the pulse... and with a good neural outcome.


Some of these drugs do enough damage to other end organs that a good neural outcome may still not equal a good outcome. Kidneys, liver and gut in particular.


----------



## Shishkabob

usalsfyre said:


> Hate this as well...for instance today one of my arrest had 40 minutes of CPR done PTA.



Though there are always the outliers that get an hour of CPR and have good outcome....



> Some of these drugs do enough damage to other end organs that a good neural outcome may still not equal a good outcome. Kidneys, liver and gut in particular.



Shhh.  The less drugs I have to push, the more I'm expected to do CPR.


----------



## usalsfyre

Linuss said:


> Shhh.  The less drugs I have to push, the more I'm expected to do CPR.


:unsure:
They took away our intubations, they made IOs an EMT-I skill, crap what's next, medics doing CPR....h34r:

:lol::lol::lol:


----------



## Smash

usalsfyre said:


> :unsure:
> They took away our intubations, they made IOs an EMT-I skill, crap what's next, medics doing CPR....h34r:
> 
> :lol::lol::lol:



Christ, why would you even say something like that?! Can we have this post moderated please, there is no need for that sort of talk.  I need a shower now...


----------

