PDP Epi Standing orders

[NomadicMedic]

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.

 

[DrParasite]

What is a PDP?

 

[VentMonkey]

What is a PDP?

Push Dose Pressor.

 

[CANMAN]

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.

 

[VentMonkey]

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.

 

[PotatoMedic]

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.

 

[StCEMT]

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

 

[VFlutter]

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

 

[PotatoMedic]

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.

 

[CANMAN]

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.

 

[VFlutter]

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

 

[NomadicMedic]

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.

This is almost exactly what I put together.

 

[NomadicMedic]

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.

 

[Carlos Danger]

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 ?

 

[CANMAN]

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.

 

[CANMAN]

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.

 

[VFlutter]

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"

 

[Tigger]

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.

 

[Underoath87]

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)?

 

[VentMonkey]

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.