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JULY 2012 TRICK OF THE TRADE WINNER

Dr ROB BRYANT WINS AGAIN!Dr Rob Bryant of Utah wins again with this simple but powerful tip! Listen to him here:

Here is my late entry:

 I am comfortable mixing and giving push dose pressors, however in the middle of a resuscitation it is hard to directly supervise the nurses mixing up the PDP’s if they have never done it before

Now I carry a laminated card and hand the nurse the card so they can follow the instructions. I have made cards for all the attendings/residents to carry to help spread the word on this technique

 The only problem with handing the nurses the card is that they love the idea and want to keep the card!

And he shared even more information below!

Here is my idiots guide to push dose pressors, this was my sales pitch to my group

 

Use and share at will.

 

>

>

> PUSH DOSE PRESSORS.

>

> FOR TRANSIENT REVERSAL OF HYPOTENSION / REVERSAL OF TRANSIENT HYPOTENSION

>

> There are laminated Push Dose Pressors (epi and phenylephrine) cards in my box at IMC, please help yourselves to one.

>

> Here is Weingarts podcast that explains the rationale, risks, and benefits better than I can:

> Bolus Dose Pressors at EMCrit

>

> The ED pharmacists want us to mix these, and do not want the nurses to mix these without DIRECT supervision. These should only be given under DIRECT physician supervision.

>

> PUSH DOSE EPINEPHRINE

>

> 1cc of crash cart epi (1:10,000) diluted to 10cc with saline.

> This makes a 10mcg/ml concentration which is 1:100,000 (same as the epi in lidocaine with epi) so if it extravates from a bad peripheral iv it is not toxic to the tissues.

>

> 1-2cc up to every 5 minutes. Lasts 5-10 min.

>

> USES:

> 1. Septic patient with full tank who needs a central line and pressors.

> Bridges the 20-30 min it takes to get the CVL in.

>

> 2. Pre / post intubation hypotension.

> In a hypotensive patient that is going to be intubated with a risk of increased hypotension giving a dose with the sedative / paralytic can mitigate the intubation induced hypotension.

> In a normotensive patient that gets hypotensive post intubation this can restore normotension while fluid bolus is being given

>

> 3. Severe Anaphylaxis

> If patient still having significant airway issues / hypotension despite 2 rounds of IM epi, this is a fast way of delivering iv epi prior to CVL and epi drip.

>

> 4. Post procedural sedation hypotension.

> In hemodynamically unstable / drug sensitive / old patients who dump their pressure after propofol.

>

> 5. Profoundly hypotensive patients who are early into their fluid resuscitation.

> Sepsis with BP’s in the 50-60 range who clearly need fluid, this can help their pressure while their tank is being filled.

>

> THIS IS NOT:

> Not for use in hypotension from acute blood loss, those patients still just need red petrol.

> Not an alternative to central line placement and pressor drip in patient who doesnt have an immediately reversible cause for their hypotension.

>

>

>

> PUSH DOSE PHENYLEPHRINE

>

> 1ml of 10mg/ml Phenyephrine vial injected into 100cc bag of saline.

> 10,000mcg in 100ml equals 100mcg / ml. (the usual pharmacy drip bag is 200mcg/ml, that math is hard in a critical care situation)

> Draw 10ml syringe out of 100ml bag: 100mcg /ml concentration.

> 0.5-2ml (50-200mcg) every 2-5 min, duration 10-20 min,

>

> USES:

> 1.Hypotension in pt with tachycardia needing procedural sedation.

> A-fib / V-tach with pressure in 80’s /90’s or lower who needs sedation for cardioversion.

> Give 0.5-1cc prior to sedation meds.

> Works for post procedural hypotension in pt with recent tachycardia.

>

> 2. Septic patient with hypotension and profound tachycardia.

> Patient needs a push dose pressor prior to placing CVL but has v high HR (150’s)

>

> Case example:

> 68 year old new onset a-fib post colonoscopy. States ‘I am very sensitive to sedative medications’

> HR 150’s, BP 91/50 after 3 liters.

>

> Pt given 50mcg Phenylephrine

> BP 107/60

> Pt given 30mg propofol, adequate sedation, no apnea / hypoxia, successful cardioversion.

>

> BP dropped to 80 systolic 10 min after propofol, given 100mcg Phenyephrine

> BP increased to 100systolic, remained normotensive and discharged home.

>

>

>

>

> The nurses love this technique, I will typically mix it myself, or directly supervise the nurses preparing the push dose pressors.

> the benefit of the card in the pocket is that you can hand the nurse the card to have them follow the instructions if you are busy with line placement / setting up for intubation etc.

>

> Please email with any questions, and let me know if you want to be removed from any further educational spam.

>

> enjoy!

>

> Rob Bryant MD

> Utah Emergency Physicians

> 801 633 8453″

 

Rob, awesome stuff..and there is even more coming on DSI..stay tuned!

Minh

 

3 Comments Post a comment
  1. Good stuff

    I found some old pamphlet holders in my consulting room last week when cleaning up (they hold a DL size’d piece of paper, or an A4 paper folded into three)

    So now these pamphlet holders are on the wall in my small rural ED and Operating Theatre, containing simple ‘idiot’s guide’ prompts for things we don’t do often

    – vasopressor dose (bolus and infusion)
    – MgSO4 for eclampsia
    – GTN infusions
    – isoprenaline infusion
    – psych sedation

    as well as

    – RSI checklist
    – Plans A/B/C/D for difficult airway
    – Oxylog set up and CPAP settings (were on the Oxylog 2000 plus)
    – fancy new in-line fluid warmer

    With staff who ‘do’ critical care infrequently, these are now a great resource for an emergency – a nurse can grab the card and wander off to make up an infusion, or call out checklist, whilst I am busy with the punter (and trying to avoid being task loaded)

    A bit like the cards we use in a malignant hyperthermia crisis

    Probably worth sharing. Thanks Rob (and Minh) for giving us inspiration to find local solutions

    August 4, 2012
  2. Cam O'Leary #

    Simply and brilliant. I find people often get confused as to how to draw up M&M for post intubation sedation in the ambulance. I tend to have my mind on other things at the time and don’t really want to take the time to talk them through it. I think I might start making up some cards now. Warm up the laminator!

    August 7, 2012
  3. Fair point Cam. As always, there’s a ‘big book’ tucked away in ED or at the nurses station full of infusion protocols (we tend to use the RFDS ones locally and try to ensure concordance in volume/syringe driver setup with the retrieval service to avoid ‘faff’)

    But one of the problems of a ‘big book’ somewhere is that staff have to leave the patient to find it. ‘Prompt cards’ on the resus trolley/wall of ED/inside ambulance/prehospital bag etc make it easier to give to a nominated nurse and say “I need an M&M infusion – take this card, follow the instructions and report back in 2 minutes” whilst continuing to secure ETT etc…

    Minh, any thoughts on making a little corner of PHARM a repository for such resources? I’d love to be able to rapidly access standard protocols, whether be for infusions, vent settings, push dose pressor or RSI checklists etc…

    August 8, 2012

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