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

[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]

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]

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]

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]

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]

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

LOL good question

 

[omak42]

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]

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]

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]

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]

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]

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.

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?

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]

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.