I don’t know how it is in other service areas, but my service is unable to obtain ANY dopamine… what-so-ever! I’m not sure if it is a manufacture problem (think back to 2010 when a huge company of our ACLS drugs changed to erectile dysfunction pills over night). Or maybe our hospitals are having an ordering issue. The real situation is, I LOVE DOPAMINE!
As a new medic, I was terrified of it. The confusing dosage. The simple down and dirty math equation that escaped me in the opportune moment of a ROSC patient. Even it’s shiny aluminum bag made it more intimidating than other meds. Why aluminum? What was in there? Is it looking at me? Radioactive goop? A demon? A dopamine demon? A dopa-demon?
Years later another medic and I were obtaining ROSC with early administration of dopamine. It was something we began testing when running a code in a rural area. Dopamine improves function of the heart (one day I will write some science-y thing on cardiac drugs)? Why not give the heart a helping hand when we are having trouble keeping a pulse?
Witchcraft!! I already hear the torches lighting and the medical villagers chanting.
But it worked. Every time we would lose pulses, we would hang dopamine and get ROSC.
*DISCLAIMER: I am not a doctor. I am street medicine. I do not substitute the decisions or protocols of you medical director. Our protocols differ from national registry and the rest of the country. Do what you will with what I print here. Just food for thought. Shop talk.*
Then… Then the forces that be, the EMS Gods that give you a late call, took my favorite med away. The poachers at the ICU took the last dopamine bird from me. They burned all the dopamine trees.
So what do we have now as a pressor? Witchcraft!!! I mean… push dose epi!!
Push dose epi (PDE) is the newest talk on the pharmaceutical cat walk. Flashing its extra zeros in a 1:100,000 vial… Like it owns this hemodynamic fashion show. Rawr.
Apparently PDE was used by anesthesiologist for years in the OR. It’s a temporary reaction for hypotension, which is perfect in the OR. OR is stabilization of the patient during the surgery. Long term stabilization happens in PACU and ICU. Places where pressor drips are ran so the nurse can get a damn cup of coffee before her other patient crashes.
My trusty dope drip would keep that patient stable while I tripped over cables as we pulled the cot out of the ambulance. Bringing a code into the ambulance bay at the ER is never a smooth task. It’s like that dreaded day in March, when your wife has had enough and forces you to take down the Christmas lights. Cables and cords EVERYWHERE.
PDE has been gaining good scores in the transport world. A study was performed on a 100 pushes during critical care transports (study info at bottom). The goal of the study was to “characterize the hemodynamic effects and adverse events that occur following PDE administration by critical care transport providers to correct documented hypotension.”
*yawn* Please, go on…
The result, 58.5% (55 of 94 pushes) resolved hypotension. Granted, this is a new procedure and EMS is slow to change, and there are no variables discussed in the paper. I can visualize the back of that ambulance, sweating, cracking the tiny vial of tiny epi hoping to keep ROSC. Then an alarm on the monitor goes off. Mind you, this drug is not premixed. While pushing 1 ml out of the flush you notice the patient’s ETCO2 dropping because the rookie firefighter riding in with you is pumping that bag like an excited monkey. Crap. Did I check glucose yet? Five minutes from the hospital now. Push the epi. What’s this guys name? Give report.
The language also states they were looking for a resolution for the hypotension. Tiny epi will create changes for a tiny while. So use it accordingly and continuous. Just know that its effective is limited. 58% of the time, it worked every time.
I am not dissing push dose epi. It’s what I have to use right now and I would rather have it than no vasopressor. This is my review of a new drug in my tool box. I always enjoy feed back! What has your experience been like?
My man crush, EmCrit, made a great .pdf you can keep in your truck: pressor .pdf
MDEdge has something to say on the minimal effects of push dose pressors. minimal at best