# Epinephrine Drip During Arrest



## cannonball88 (Dec 3, 2016)

Good Afternoon

I'm looking into the idea of using an epinephrine drip in a cardiac arrest rather than using one dose of 1:10,000 epinephrine every 3-5 minutes. If you mix 10mg of 1:1000 epinephrine in 100mL and run at 3mL /min, it comes out to 1mg epinephrine every 3 minutes.

Does anyone have this or something similar in their protocols (or have you done this personally). I'm looking for some pros/cons for this topic, or better yet, some sort of documentation encouraging or opposing it. I found one system that had it in their protocols in 2003, but nothing else.


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## NomadicMedic (Dec 3, 2016)

I know some medics that used to draw up epi 1:000 and attach it to the high med port on the tubing and use that over the course of a code. 

 old school baby.


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## Carlos Danger (Dec 3, 2016)

If you are using an infusion pump, sure. Otherwise there is no way to guarantee that you'll be running 3 ml/min. You could be giving significantly more or less epi than that.


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## VFlutter (Dec 3, 2016)

I understand the rationale and I am usually a big fan of Epi drips however a continuous infusion is not necessarily the same as multiple rapid IV pushes. Is there any difference to giving 1 mg of Epi IV push and rapidly saturating the adrenergic receptors every 3 minutes vs 1mg over 3 minutes possibly resulting in a continuous but lower effect? I am not sure, doubt it makes much of a difference, but it is something to think about. For example Adenosine, you could give someone a drip running at 6mg/min but will never have the therapeutic effect of an IV push even tho you are technically giving the same dose.


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## Underoath87 (Dec 3, 2016)

What's the point?  The main con here is that trying to set up and dial in a drip during a code is going to be SO much harder than just slamming 1mg every 3-5 minutes.  Drips work well when you're transporting a post-code, but not while you're on a busy scene and the IV bag keeps being passed around and changing in elevation.


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## StCEMT (Dec 3, 2016)

I think I would rather just go with the prefilled syringes unless there was something that showed a drip was better, mostly for the same reason Underoath gave. Just less stuff in the way.


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## SpecialK (Dec 4, 2016)

I think something like this is probably the future.

Single aliquots of 1 mg IV adrenaline haven't been shown to have benefit in primary cardiac arrest, and there is a growing evidence they might be harmful.  It will be very interesting to see what the PARAMEDIC-2 trial shows.  

For everybody else who is not in cardiac arrest but such extremely poor perfusion they are near death and needs their ticker flogged along or a bit of vasosqueeze the norm is for a 1 mg in 1 litre NaCl infusion.  Never would it be considered reasonable or safe to give any of these people 1 mg of IV adrenaline as a bolus because of its side-effects, yet, when the person is in cardiac arrest suddenly it is OK?


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## medichopeful (Dec 5, 2016)

Google "dirty epi drip." Pretty cool concept, very similar to what you're talking about. 

I've used an epi drop during a code, interesting concept, but patient still died. I'd be interested to get more experience with it, because it seems like a much better idea than epi blouses.


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## EpiEMS (Dec 5, 2016)

medichopeful said:


> Google "dirty epi drip." Pretty cool concept, very similar to what you're talking about.



Agreed! This is pretty cool. Seems like it came from ALiEM first. Curious if it would be deemed acceptable in an EMS setting, though.


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## VFlutter (Dec 5, 2016)

Do you have a protocol for Epi drips as a vasopressor? Take a 1mg code Epi, pop off the green luer lock adapter, and insert the needle into the med port of a 250ml or 100ml bag of D5W giving you 4mcg/ml or 10mcg/ml. Titrate to effect, 2-20mcg/min. Quick and easy. Great for refractory hypotension, periarrest, and post ROSC.


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## EpiEMS (Dec 5, 2016)

Chase said:


> Do you have a protocol for Epi drips as a vasopressor? Take a 1mg code Epi, pop off the green luer lock adapter, and insert the needle into the med port of a 250ml or 100ml bag of D5W giving you 4mcg/ml or 10mcg/ml. Titrate to effect, 2-20mcg/min. Quick and easy. Great for refractory hypotension, periarrest, and post ROSC.



Yep - epi infusions are in our paramedic protocols for anaphylaxis refractory to IM epinephrine (>3 doses IM have been ineffective), cardiogenic shock, bradycardia, septic shock, and post-ROSC...max dosage 10 mcg/min is permitted.

Whoops. I really should've looked...


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## medichopeful (Dec 5, 2016)

EpiEMS said:


> Agreed! This is pretty cool. Seems like it came from ALiEM first. Curious if it would be deemed acceptable in an EMS setting, though.



I think it would take some time for it to make its way into the protocols, but with pumps coming to many services I don't think it would be impossible or all that impractical. The dosing would have to be a little different than the true "dirty epi drip" (which isn't exactly for cardiac arrest "per se", but could be modified for that). 

The argument that many are making is a good one (that it would get in the way), but I think an epi drip during a code has a few major advantages that a few authors have pointed out:
1) The idea of cognitive offloading. Codes can be hectic, if we can take away tasks during them it cuts down on the amount of things going on. 
2) If you need someone to be on a pressor gtt, you don't do boluses every 3-5 minutes, you give them a constant infusion (titrated, of course). So why in a cardiac arrest are we giving boluses, which doesn't leave a constant amount of epi in the bloodstream? Than on top of that, we're stressing an already sick heart and circulatory system by slamming a whole mg of epi. Talk about a wake up! Probably not all that healthy for the heart. Then it wears off anyways in a few minutes, at which point we again slam more epi. 
3) An epi drip (whether it's an adapted "dirty epi drip" or a different concentration/dose) can be titrated. Low ETCo2 with good compressions? Titrate it upwards. Still no pulses? Try titrating upwards then consider other options such as stopping the code. There's a very interesting discussion out there about this somewhere using the idea of "titrated boluses," but I think the thinking could be adapted for a drip instead. 

I think that there needs to be more research, but I think that an epi drip has a lot of benefits when compared to boluses. Pumps would definitely be needed, however, and transport/movement might be complicated.


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## Summit (Dec 5, 2016)

I'll say I don't think setting an epi drip during a code is cognitive offloading unless you have buku extra personnel and a big ICU room or trauma bay. Lot of effort into that setup and watching the drip (kinked tubing?)

On the other hand, the thing that I've seen in a few codes where epi got us a pulse back (along with something else like volume or whatever) and a patient has immediate hemodynamics where you want them... people are shocked SHOCKED I tell you (pun intended) when 3-5 minutes alter that epi wears off and the patient is hypotensive or pulseless. I remember one where I was pushing 1/2 amps of epi q3 after ROSC while drips were mixed and central lines placed etc. 

Does anyone get that thing where all the codes start to smear together in your mind?


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## Carlos Danger (Dec 5, 2016)

medichopeful said:


> Google "dirty epi drip." Pretty cool concept, very similar to what you're talking about.
> 
> I've used an epi drop during a code, interesting concept, but patient still died. I'd be interested to get more experience with it, because it seems like a much better idea than epi blouses.





EpiEMS said:


> Agreed! This is pretty cool. Seems like it came from ALiEM first. Curious if it would be deemed acceptable in an EMS setting, though.



So there are a couple problems with this approach in a scenario like the one described in the blog post.* It makes a lot more sense to simply give 1ml (100 mcg) boluses of your 1:10,000 epi.

First, you need two IV's to do this. Because once you squirt a mg of epi into your liter bag, you've contaminated that bag and really shouldn't give anything else through that line (not that you can't, but you shouldn't), and even more importantly, the rate that you give your IVF is now dependent on the rate that you need to give the epi. You can't just give a fluid bolus, or choose to slow your fluid rate way down.

Second, you probably aren't giving epi very fast with this approach. 1 mg in 1000ml = 1 mcg per ml. So giving 100mcg of epi requires 100ml of IVF. It takes longer to give 100ml than you might think, unless you have a REALLY good IV. And even if you do, it will still take a lot longer than simply giving 1ml of 1:10,000 epi. In the profoundly hypotensive or bronchoconstricted patient, time is your enemy.

Third, you have less control over your dosing. Boluses are nearly instantaneous, and you know how much you've given and how much you have left. With your dirty drip, the amount you've given and still can give depends on all the factors that affect the flow rate of your IVF.

Where I do think this might be helpful is _after_ you've stabilized the patient with boluses. Start a second IV, put a mg of epi in a 500 or 1000 bag, and run it slowly, titrating it up and down as needed.




*In cardiac arrest, it doesn't matter how you give the epi. Given the lack of evidence that it helps and all the reasons we have to believe that it might even be harmful, we probably shouldn't even still be giving it - at least not in the massive doses that we do.


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## EpiEMS (Dec 6, 2016)

Remi said:


> *In cardiac arrest, it doesn't matter how you give the epi. Given the lack of evidence that it helps and all the reasons we have to believe that it might even be harmful, we probably shouldn't even still be giving it - at least not in the massive doses that we do.



I'm glad you mentioned this - I wish I had been quicker on the EBM ball in this thread!


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## E tank (Dec 16, 2016)

Are drips a great idea in full arrest, epi or otherwise? A continuous infusion presupposes decent venous return unless there is a carrier infusion going at a good clip. CPR doesn't really provide that. Boluses don't need much cardiac output.


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## Carlos Danger (Dec 16, 2016)

E tank said:


> Are drips a great idea in full arrest, epi or otherwise? A continuous infusion presupposes decent venous return unless there is a carrier infusion going at a good clip. CPR doesn't really provide that. Boluses don't need much cardiac output.



Good point about the circulation. It might be true that relatively little of what we give during arrest reaches the target receptors, at least in a timely fashion.


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## agregularguy (Dec 30, 2016)

Long time lurker here, I've been looking into jobs with Wake County EMS and found this interesting. On page 271 of their protocols, they have an Epi infusion under standardized medication delivery for cardiac arrest (all the way near the bottom of the protocols). They have 12mg of Epi 1:1000 in a 250mL bag, run 60 drops/min through a 10gtt set being approximately equal to 1mg every 4 minutes. 
Apparently I can't post links until 5 comments, but search Wake County EMS and you'll find their protocols on their website.


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## DrParasite (Dec 30, 2016)

Remi said:


> *In cardiac arrest, it doesn't matter how you give the epi. Given the lack of evidence that it helps and all the reasons we have to believe that it might even be harmful, we probably shouldn't even still be giving it - at least not in the massive doses that we do.


I was actually going to ask about this.... I'm glad someone else was thinking the same thing I was.


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## Bullets (Dec 30, 2016)

Beyond the lack of evidence for epi in arrests, I find it easier to just hang a bag and give the code epi every 4 minutes. 

For not  dead people who need epi we have stated push dose epi instead of drips and I love it.


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## Midazzled (Jan 26, 2017)

Remi said:


> we probably shouldn't even still be giving it - at least not in the massive doses that we do.


Perhaps one day we will no longer carry 1:10,000 1mg amps. I would like to see prefilled 100mcg/10ml syringes in its place if PARAMEDIC 2 determines 1mg boluses are worthless in cardiac arrest. At least then we could cut a step out of prepping push doses for other uses.


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## SunshineRay (Jul 25, 2017)

What about placing a drip for fast narrow PEA with sudden increases in ETCO2?


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## VFlutter (Jul 25, 2017)

SunshineRay said:


> What about placing a drip for fast narrow PEA with sudden increases in ETCO2?



Narrow complex tachycardia PEA usually means an issues that Epi isn't going to fix, I.e massive hypovolemia, PE, septal rupture.


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## SunshineRay (Jul 25, 2017)

How about with a medical arrest that went PEA after 8 defibs for V-fib and with heart tones still present? Maybe it was a septal rupture... ultrasound would have been nice but we work with the tools we have.


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## NomadicMedic (Jul 25, 2017)

I don't think Epi going to help you there. What was the Final determination of the cause of his arrest? That would be an indicator.


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## E tank (Jul 25, 2017)

SunshineRay said:


> What about placing a drip for fast narrow PEA with sudden increases in ETCO2?


 
I'd sure try it. Barring a catastrophic bleed, I really wouldn't hesitate to give epinepherine here. Tamponade, PE...just to get them to the OR/ECMO.  Even in the extremely unlikely event of a septal or ventricular blow out (a narrow QRS would be unlikely) you'd have nothing to lose.


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## Bullets (Mar 27, 2019)

We dont have epi bristojets right now. Pharmacy has given us 1:1000 epi with a water vial and a 10ml syringe in a premade kit, so we have to draw both up into the syringe and push that during arrests. Since that throws cognitive offloading out the window, Ive been wondering about putting epi into a bag and running it during arrests given Paramedic-2


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