# PDP Epi Standing orders



## NomadicMedic (Apr 13, 2018)

Hi... If you have Epi as a PDP and have a standing order for it, (not just a protocol entry) I'd like to see it.


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## DrParasite (Apr 13, 2018)

What is a PDP?


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## VentMonkey (Apr 13, 2018)

DrParasite said:


> What is a PDP?


Push Dose Pressor.


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## CANMAN (Apr 13, 2018)

NomadicMedic said:


> Hi... If you have Epi as a PDP and have a standing order for it, (not just a protocol entry) I'd like to see it.



Don't have a copy of it anymore but my old program was 100mcg 1:10,000 every 5 mins for systolics less than 70mmHG, as you were actively working on setting up other vasopressors or therapies to correct the hypotension. POC lactate testing was also used to guide fluid resus in conjunction with hypotension/PDP.


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## VentMonkey (Apr 13, 2018)

This thread topic is of particular interest to me as well. 

@CANMAN how effective was the PDP as a bridge for the peri-arrested patients in-flight overall at your last service? How often did it prevent full cardiac arrest in-flight?

@NomadicMedic you seem to be making quite the run at headlining a premier system. Maybe one day you’ll have all the like-minded folks from the board under your regime.


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## PotatoMedic (Apr 13, 2018)

E. Profound Bradycardia or Hypotension:
1. Give epinephrine-push-dose IV-Mix 1 mL of 1:10,000 epi with 9 mL NS in a 
10mL syringe (10 mcg/mL) and administer 0.5-2 mL of push-dose epi every 
2-5 minutes; or 
2. Give epinephrine infusion IV-Mix 1 mg in 250 mL NS; administer at 2-10 
mcg/minute (0.5 mL-2.5 mL), titrating to effect.

It is from Pierce county Washingtons protocols under medical emergencies.


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## StCEMT (Apr 13, 2018)

Are there generally any steps before using these where yall have seen them implemented? Fluid for hypotension, atropine for bradycardia, etc.


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## VFlutter (Apr 13, 2018)

I'm jealous. There was talk about getting PDPs at some point but haven't heard much recently.


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## PotatoMedic (Apr 13, 2018)

StCEMT said:


> Are there generally any steps before using these where yall have seen them implemented? Fluid for hypotension, atropine for bradycardia, etc.


Here is the full protocol:

VI. Vasogenic/Neurogenic Shock, or Hypotension of Unknown Etiology.
A. Immobilize based on mechanism /nature of illness.
B. Transport patient in the supine position as soon as possible.
C. Keep patient warm by controlling the ambulance temperature (use heat packs 
and reflective blankets PRN).
D. Initiate large bore IV(s) or I0(s) with warm NS or LR.
1. Adult: Give 250-500 mL fluid challenge if BP < 90/S; consider additional 
fluid boluses depending upon clinical impression.
2. Pediatric: Push 20 mL/kg; may repeat x 2.
E. Profound Bradycardia or Hypotension:
1. Give epinephrine-push-dose IV-Mix 1 mL of 1:10,000 epi with 9 mL NS in a 
10mL syringe (10 mcg/mL) and administer 0.5-2 mL of push-dose epi every 
2-5 minutes; or 
2. Give epinephrine infusion IV-Mix 1 mg in 250 mL NS; administer at 2-10 
mcg/minute (0.5 mL-2.5 mL), titrating to effect.
F. Consider dopamine 10 mcg/kg/minute IV/I0. Titrate to maintain BP > 90/S.


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## CANMAN (Apr 14, 2018)

VentMonkey said:


> This thread topic is of particular interest to me as well.
> 
> @CANMAN how effective was the PDP as a bridge for the peri-arrested patients in-flight overall at your last service? How often did it prevent full cardiac arrest in-flight?
> 
> @NomadicMedic you seem to be making quite the run at headlining a premier system. Maybe one day you’ll have all the like-minded folks from the board under your regime.



To be honest man I had this in protocol for about two years before I left. During that time probably used PDP’s about 15 times or so, and only once did a patient arrest, and that was at the bedside and not in the aircraft. 

That patient was a saddle PE we were working with the ED MD trying to get intubated for transport. They insisted on doing the intubation but wouldn’t let us get some PDP or Levophed on board proactively prior to intubation (we had already given one dose upon arrival to patient side for severe hypotension). As soon as they started bagging, increasing intrathoracic pressure, patient ended up tanking out and coded. We coded for a minute and gave a full mg of Epi and then were able to get stabilized and packed up.

Other then that situation, every other time we used PDP it worked flawlessly and got us out of severe hypotension and enabled us a few extra minutes to get something mixed up and started.


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## VFlutter (Apr 14, 2018)

Ya I avoid intubating massive PE patients at all costs. And early aggressive Epi drips seem to help with RV dysfunction.


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## NomadicMedic (Apr 14, 2018)

PotatoMedic said:


> E. Profound Bradycardia or Hypotension:
> 1. Give epinephrine-push-dose IV-Mix 1 mL of 1:10,000 epi with 9 mL NS in a
> 10mL syringe (10 mcg/mL) and administer 0.5-2 mL of push-dose epi every
> 2-5 minutes; or
> ...




This is almost exactly what I put together.


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## NomadicMedic (Apr 14, 2018)

VentMonkey said:


> This thread topic is of particular interest to me as well.
> 
> @CANMAN how effective was the PDP as a bridge for the peri-arrested patients in-flight overall at your last service? How often did it prevent full cardiac arrest in-flight?
> 
> @NomadicMedic you seem to be making quite the run at headlining a premier system. Maybe one day you’ll have all the like-minded folks from the board under your regime.




I’m lucky that I have some clinical freedom make changes. It’s rewarding.


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## Carlos Danger (Apr 14, 2018)

Do you really need a protocol to give epi in a peri-arrest scenario?

Why bother diluting it? Why not give 1cc (100mcg) boluses of the normal 1:10,000 that you already carry ?


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## CANMAN (Apr 14, 2018)

Remi said:


> Do you really need a protocol to give epi in a peri-arrest scenario?
> 
> Why bother diluting it? Why not give 1cc (100mcg) boluses of the normal 1:10,000 that you already carry ?



This is exactly what we would do. Quick and easy.


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## CANMAN (Apr 14, 2018)

VFlutter said:


> Ya I avoid intubating massive PE patients at all costs. And early aggressive Epi drips seem to help with RV dysfunction.



Yeah I agree but the MD wanted to be a cowboy and go it alone without anything prior to RSI. I remember the lady being morbidly obese, unable to lay flat, and a really crappy PaO2 already on bipap so we didn’t have too many options unfortunately.


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## VFlutter (Apr 14, 2018)

CANMAN said:


> Yeah I agree but the MD wanted to be a cowboy and go it alone without anything prior to RSI. I remember the lady being morbidly obese, unable to lay flat, and a really crappy PaO2 already on bipap so we didn’t have too many options unfortunately.



Ya that is a tough situation to be in. I've had a "Hey Doc the ETC02 is Zero and the ET tube is in....think we may have a perfusion issue"


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## Tigger (Apr 15, 2018)

We have the "dirty epi drip" as standing orders (everything but the fourth and subsequent doses of Ketamine are on standing order). It's the same concentration as you're usual push dose epi (1:100). 20-50ml boluses until you get to where you want to be and are able to transition to an actual epi (or dope) infusion. 

I am not sure how "ok" this is but I like to put a 10 or 20cc syringe in the bag of 1:100 epi and keep that handy. It's just easier than having to watch the drip.


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## Underoath87 (Apr 15, 2018)

Tigger said:


> We have the "dirty epi drip" as standing orders (everything but the fourth and subsequent doses of Ketamine are on standing order). It's the same concentration as you're usual push dose epi (1:100). 20-50ml boluses until you get to where you want to be and are able to transition to an actual epi (or dope) infusion.
> 
> I am not sure how "ok" this is but I like to put a 10 or 20cc syringe in the bag of 1:100 epi and keep that handy. It's just easier than having to watch the drip.



1:100 would be 10mg/ml of epi...
Is that supposed to read 1:100k (0.01mg/ml)?


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## VentMonkey (Apr 15, 2018)

Remi said:


> Do you really need a protocol to give epi in a peri-arrest scenario?
> 
> Why bother diluting it? Why not give 1cc (100mcg) boluses of the normal 1:10,000 that you already carry ?


It may make complete sense to you and I, sure, but let’s think about who the protocol is aimed at...a lot of EMS providers have yet to even here of, let alone appreciate the pharmacokinetic value of PDP’s.

So, maybe even a tie in to a hypoperfusion/ bradycardic protocol on a system-wide level will help promote current change/ trends in progressive medicine, foreward thought processes, and encourage (nudge) some of its providers to research and question things. That’s hardly a bad thing.

Sure, there will always be pushback from the stuck-in-their-ways old salts too lazy to even draw up a simple dose such as you’ve suggested, but change has to occur somewhere, at some point, on some level.

For the general paramedic who’s—initially—hardly encouraged to think of such basic and seemingly simple procedures without guidance or direction, it certainly encourages avenues beyond what’s taught in a condensed course that meets “national standards” and that’s all.

Again, not a bad thing for the field in general, IMO.


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## wanderingmedic (Apr 16, 2018)

We are getting it for hypotension. Supposedly Epi PDP will be an upcoming change to the Michigan statewide protocols. 

http://www.saginawvalleyems.org/protocols/awaiting/1-5 - Shock - STATE.pdf


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## NPO (Apr 17, 2018)

We have dopamine, epi drips, norepi, and push-dose epi. 

Push dose epi is 10-20mcg/min as needed for shock.


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## VentMonkey (Apr 17, 2018)

@NPO so to play devil’s advocate, how frequently would you say any of these meds are actually being utilized in your services system (including Ancef)? I like options, but I also feel reasonable limitations UFN carries a decent amount of rationale.

I’m always curious about these sort of things since we’re always asking for broader guidelines, only to find meds end up sitting on the shelves more often than not (e.g., Procainamide as a 3rd line antidysthymic).


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## NPO (Apr 18, 2018)

VentMonkey said:


> @NPO so to play devil’s advocate, how frequently would you say any of these meds are actually being utilized in your services system (including Ancef)? I like options, but I also feel reasonable limitations UFN carries a decent amount of rationale.
> 
> I’m always curious about these sort of things since we’re always asking for broader guidelines, only to find meds end up sitting on the shelves more often than not (e.g., Procainamide as a 3rd line antidysthymic).


System wide, push dose epi is being given several times per week per our education/QA guy. 

Epi drips, dopamine, levo, all require a pump which only about 50% of trucks have, usually in the rural areas. So if you don't have a pump your only option is epi push dose. It's also faster to set up.

Ancef is only given for open fractures. Our infections disease docs don't want us giving antibiotics for sepsis prior to cultures. It's given occasionally, but not frequently. I don't have numbers on that one.

Push dose epi is so stupid easy and effective I really think it's the obvious choice for quick pressure support, at least until you can get something hanging either in the truck or at the hospital.


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## NPO (Apr 18, 2018)

I just spoke to our education/QA guy again. He said ancef is usually a few times a month on the ground, but for our air service, not giving ancef for open fractures is a QA flag, so they give it much more frequently.


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## Tigger (Apr 19, 2018)

Underoath87 said:


> 1:100 would be 10mg/ml of epi...
> Is that supposed to read 1:100k (0.01mg/ml)?


Yes.


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## NPO (Apr 19, 2018)

I got our specific protocol for you.


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## jbiedebach (Apr 30, 2018)

NomadicMedic said:


> Hi... If you have Epi as a PDP and have a standing order for it, (not just a protocol entry) I'd like to see it.


I guess I don't understand the difference between a standing order and a protocol entry in EMS.  We have standing orders (not for PDP) in the ER (because as a medic I am not allowed to order anything in the hospital). But on the ambulance, our protocols are, in essence, standing orders.  Nonetheless, we do use PDP in many of our protocols (Epi 1:100,000 0.5-2.0 ML (5-20mcg) . Every 2-5 Min, titrate to SBP of 90 mmHg).  We removed Dopamine from all the trucks (we never did carry Levofed).


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## NPO (Apr 30, 2018)

I think he's making the distinction because some areas have things in protocols, but state that you must make base hospital contact prior to proceeding that far in the protocol.


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## Tigger (May 3, 2018)

jbiedebach said:


> I guess I don't understand the difference between a standing order and a protocol entry in EMS.  We have standing orders (not for PDP) in the ER (because as a medic I am not allowed to order anything in the hospital). But on the ambulance, our protocols are, in essence, standing orders.  Nonetheless, we do use PDP in many of our protocols (Epi 1:100,000 0.5-2.0 ML (5-20mcg) . Every 2-5 Min, titrate to SBP of 90 mmHg).  We removed Dopamine from all the trucks (we never did carry Levofed).


Standing order as in no medical control contact needed.


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## Carlos Danger (May 3, 2018)

jbiedebach said:


> I guess I don't understand the difference between a standing order and a protocol entry in EMS.  We have standing orders (not for PDP) in the ER (because as a medic I am not allowed to order anything in the hospital). But on the ambulance, our protocols are, in essence, standing orders.  Nonetheless, we do use PDP in many of our protocols (Epi 1:100,000 0.5-2.0 ML (5-20mcg) . Every 2-5 Min, titrate to SBP of 90 mmHg).  We removed Dopamine from all the trucks (we never did carry Levofed).


A protocol is a list of assessments and interventions that should be completed for a patient with a given presentation. A standing order is part of a protocol that the paramedic is allowed or instructed by the protocol without contacting a medical control physician.

For instance, an asthma protocol might look something like this:

If in extremis:
1) Administer epinephrine IM or IV
2) Intubate if mental status deteriorates

If not in extremis:
3) Place supplemental oxygen via NC
4) Start albuterol via nebulizer

For continued wheezing or difficulty breathing, consult with medical control for consideration of:
5) Magnesium sulfate
6) Bipap

In this example, the first four interventions in the protocol would be "standing orders", as they are to be completed, when indicated, without consulting a physician. The last two interventions are part of the protocol, but are not standing orders, as they require consultation.


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## ParamagicFF (May 4, 2018)

Push dose epi seems very well suited for pre-hospital care and I wish I had a standing order for it. I've had success with getting orders for it in the past, but that's always a crap shoot on which physician answers the radio. There are some physicians who simply won't authorize anything due to their distrust of EMS providers.

During transport on terrible city streets, infusion rates can be inconsistent with out a pump. This can be made even worse if your system uses terrible drip sets such as mine. I think this alone is a good argument for push dose epi.


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## NomadicMedic (May 4, 2018)

Tigger said:


> Standing order as in no medical control contact needed.



Exactly right.


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## Colt45 (May 5, 2018)

Push dose Epi  for me is squirting 1 CC from a 10 CC NS flush and adding 1CC of Epi 1:10. You're basically making Epi 1:100, and the put some tape around the flush and label it as Epi so that nobody mistakes it for normal saline. Every CC at that point is 10MCG which is in that dosage range required. Titrate to your systolic. Boom.
Not in protocol per day but our Medical director loves it and had basically signed off on us doing that rather than the normal drip.


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## Colt45 (May 5, 2018)

Also a trick I use is grabbing a 3-way stop cock and have your epi just hooked onto the end. If you use all 10 CC of your first flush hook another one up that had 9CC in it and push another CC of epi into it using the stop cock. Saves time getting and safer than using multiple needles.


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## NPO (May 5, 2018)

Colt45 said:


> Push dose Epi  for me is squirting 1 CC from a 10 CC NS flush and adding 1CC of Epi 1:10. You're basically making Epi 1:100, and the put some tape around the flush and label it as Epi so that nobody mistakes it for normal saline. Every CC at that point is 10MCG which is in that dosage range required. Titrate to your systolic. Boom.
> Not in protocol per day but our Medical director loves it and had basically signed off on us doing that rather than the normal drip.


This is essentially what we do, but with....





Colt45 said:


> Also a trick I use is grabbing a 3-way stop cock and have your epi just hooked onto the end. If you use all 10 CC of your first flush hook another one up that had 9CC in it and push another CC of epi into it using the stop cock. Saves time getting and safer than using multiple needles.


A similar transfer device like a 3 way stop cock but it just has two ports, designed for transfer and mixing of meds.


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## Tigger (May 6, 2018)

Somewhat less germane, but it bothers to me that one of my agencies only has PDP (dirty epi drip) in the guidelines. There is no guideline for an actual epi infusion, which means there is no guideline for any sort of vasopressor infusions at all. Push dose epi is designed as a bridge therapy and some places seem to have entirely missed that.


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## VentMonkey (May 6, 2018)

Tigger said:


> Push dose epi is designed as a bridge therapy and some places seem to have entirely missed that.


You’re absolutely right, it is. But, there seems to be some mix of EMS agency opinions on this topic given the setting at hand (rural vs. urban).

I think having your respective hospitals on board with such a protocol in an urban setting, so that they can have the infusion ready on arrival with patients that have relatively short transport times is not unreasonable.

And FWIW, I don’t think the protocol should be without an infusion bridge included in them.


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## NPO (May 6, 2018)

VentMonkey said:


> And FWIW, I don’t think the protocol should be without an infusion bridge included in them.



Agreed, when reasonable. Eyeballing drips isn't great. We have Levophed, epi, dopamine and dobutamine drips in protocol, but only if we have a pump, and only half of the trucks have pumps; usually the outlying stations.

TXA is the exception. We can give that via free flow drip.


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## Tigger (May 7, 2018)

VentMonkey said:


> You’re absolutely right, it is. But, there seems to be some mix of EMS agency opinions on this topic given the setting at hand (rural vs. urban).
> 
> I think having your respective hospitals on board with such a protocol in an urban setting, so that they can have the infusion ready on arrival with patients that have relatively short transport times is not unreasonable.
> 
> And FWIW, I don’t think the protocol should be without an infusion bridge included in them.


I think that would be ok. It would just be nice if it was introduced as a bridge and not a replacement. It makes sense in urban EMS, unfortunately our ambulances still get called way out into the county, so it goes when the city fire department wants joint (their way) medical direction.


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## VFlutter (May 7, 2018)

Agreed. PDP should be bridge either for short term hypotension (Peri-intubation) or until a formal vasopressor drip can be initiated. Using it as a sole treatment is a crutch and usually just delays the arrest until it's some other provider's problem.

It is still crazy to me that places actually have vasopressor drips in the protocols without infusion pumps.


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