PDP Epi Standing orders

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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@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).
 
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).
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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.
 
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.
 
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.
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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).
 
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.
 
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).
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Standing order as in no medical control contact needed.
 
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).
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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.
 
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.
 
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.
 
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.
 
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.
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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.
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A similar transfer device like a 3 way stop cock but it just has two ports, designed for transfer and mixing of meds.
 
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.
 
Tigger said:
Push dose epi is designed as a bridge therapy and some places seem to have entirely missed that.
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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.
 
VentMonkey said:
And FWIW, I don’t think the protocol should be without an infusion bridge included in them.
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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.
 
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.
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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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