Pre-Hospital Pressors

[southerndoc]

The EMS agency where I am medical director currently carries dopamine. I'm thinking of taking it off the trucks. In the last 5 years, it's been used zero times.

Any thoughts on this? Anyone work in a system that doesn't carry a pressor (dopamine, dobutamine, norepinephrine)?

I find it hard to justify a drug that gets no use when the transport time is <30 minutes in almost all cases.

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[DitchDoc73]

The EMS agency where I am medical director currently carries dopamine. I'm thinking of taking it off the trucks. In the last 5 years, it's been used zero times.

Any thoughts on this? Anyone work in a system that doesn't carry a pressor (dopamine, dobutamine, norepinephrine)?

I find it hard to justify a drug that gets no use when the transport time is <30 minutes in almost all cases.

I am NOT a medical director by any means, only a lowly Paramedic but here is the situation that my department encountered...

I can say I work in a system that had a similar track record for a while. We had short transport times, and usually never used Dopamine. Over the last several years our system has begun utilizing EtCO2 capnography very heavily. We found literally hundreds of situations (high volume service) where we could document a ROSC by EtCO2, but the Pt did not have a palpable pulse. With proper education, many of these situations are being caught by the Paramedics, and dopamine is being given to these patients with very good results. I don't have the exact numbers for all of this, but I know that our system now averages an overall ROSC rate in the high 20% range (usually around 27% from what we are told by our QA/QI director). I still would not claim that we use it frequently, but we found that it did have a place in our formulary.

 

[southerndoc]

I am NOT a medical director by any means, only a lowly Paramedic but here is the situation that my department encountered...

I can say I work in a system that had a similar track record for a while. We had short transport times, and usually never used Dopamine. Over the last several years our system has begun utilizing EtCO2 capnography very heavily. We found literally hundreds of situations (high volume service) where we could document a ROSC by EtCO2, but the Pt did not have a palpable pulse. With proper education, many of these situations are being caught by the Paramedics, and dopamine is being given to these patients with very good results. I don't have the exact numbers for all of this, but I know that our system now averages an overall ROSC rate in the high 20% range (usually around 27% from what we are told by our QA/QI director). I still would not claim that we use it frequently, but we found that it did have a place in our formulary.

I never thought about using it post-arrest, so I'll have to look into that.

I see you're in Orlando. I'll email Silvestri and get his thought process on it.

 

[DitchDoc73]

I never thought about using it post-arrest, so I'll have to look into that.

I see you're in Orlando. I'll email Silvestri and get his thought process on it.

Best of luck. I hope he has some beneficial insights for you!

 

[deleted6669]

I think I only used dopamine a few times as a medic:
cardiogenic shock with hypotension
hypotensive dissecting aaa in the field after 2 l of fluids(long transport time)
hypotensive trauma codes after ns with long extrication times(something to consider) or long transports
septic shock after fluids

 

[Paseo Del Norte]

Seems a reasonable consideration. I too can only count a couple of instances in the past four years of flying where I initiated dopamine on a scene call patient. I have flown a fair number of patients who had pressers initiated at sending facility, but I have rarely done so on true pre-hospital patients.

I suspect the evidence would also support your consideration as I do not think any single pressor has been shown to have significant advantages in conditions such as cardiogenic shock. Even considering septic shock will most likely be met with limited pressor use as you still need adequate fluid resuscitation prior to making the pressor transition.

I can only hope my employer will follow the lead of people like you. We currently carry dobutamine, dopamine, norepinephrine and until fairly recently ephedrine. I am very much a KISS kind of dude who prefers a rather conservative approach to patient care in the pre-hospital environment. Not sure if that is the nurse in me or what, but it is what it is.

 

[Altruist]

I might have had a patient or 2 on an interfacility transfer on dopamine, but if so those must not have been memorable patients. Our dopamine bags didn't get used much.

The one time I can remember giving a pressor in the field, it was for a septic patient at a band-aid station out in the sticks 2-3 hours from my base hospital, and I ended up swapping the dopamine they'd started for norepi. It would be hard for me to think of a rarer circumstance than that.

Ditchdoc makes a good case for dopamine in ROSC... But if you do take dopamine off the rigs, I'd suggest putting epi drips in your protocols for extreme cases. The materials are guaranteed to be on the rig, and if the math is put down on a reference for them, it's quick and easy. I know we're all a touch leery of epi drips (rational or not), but in the rare, severe case where a pressor is needed for a <30 minute transport time, I think it would give you a similar outcome.

 

[southerndoc]

Ditchdoc makes a good case for dopamine in ROSC... But if you do take dopamine off the rigs, I'd suggest putting epi drips in your protocols for extreme cases. The materials are guaranteed to be on the rig, and if the math is put down on a reference for them, it's quick and easy. I know we're all a touch leery of epi drips (rational or not), but in the rare, severe case where a pressor is needed for a <30 minute transport time, I think it would give you a similar outcome.

Although he makes a good case, I don't believe there is research to support pressors increasing survival to hospital discharge for ROSC patients.

 

[Altruist]

Although he makes a good case, I don't believe there is research to support pressors increasing survival to hospital discharge for ROSC patients.

True. There's no evidence I'm aware of, not that I'm an expert in this area.

What I was trying to say was that if you decide dopamine isn't worth carrying (and I believe it isn't in most cases), putting an epi drip in as an option would cover that rare contingency without your medics needing any extra equipment or meds.

 

[Dwindlin]

We carry it for ROSC, and cardiogenic/septic shock refractory to fluids. I've used it a handful of times in 6 years.

 

[DitchDoc73]

Although he makes a good case, I don't believe there is research to support pressors increasing survival to hospital discharge for ROSC patients.

Yeah, unfortunately my agency does not track (or at least they don't tell us if they do) successful ROSC to discharge rates. I believe Dr Ralls and Silvestri were doing something with this at one point in time (especially with the EtCO2 component), but I haven't heard anything about it recently...

We used to carry standing orders for Epi drips after Dopamine, but no one EVER used it so it was dropped from our standing protocols. They felt that only 1 pressor was enough. But I do know that at one time they did talk about taking Dopamine off our rigs...

 

[malkboy]

I think this really depends on the composition of staff. Are there lots of basics opposed to paramedics (e.g. Houston) or are all the ambulances MICU?

We carry dopamine, norepinephrine, and epinephrine and have the ability to mix drips for all three (we don't carry pre-mixed bags). I pick the pressor that fits my need and can easily mix it up with 250ml bags of saline (or any other size, but 250ml works well). I wouldn't mind giving up norepinephrine, but I personally would like to have a pressor available to use. I can think of 3 times I used pressors this past year with decent results:

1. dopamine for severe pulmonary edema where CPAP was relatively contraindicated (pt obtunded), and the pt was hypotensive which threw out nitroglycerin and enalapril.

2. dopamine in post cardiac arrest care (I believe the pt was discharged with some neurological deficits).

3. norepinephrine for pt with profound hypotension and bradycardia after CCB overdose. Electrical pacing did not have good results so I moved onto pressors. There really was no particular reason I chose norepinephrine over dopamine.


Overall, with proper education with emphasis on indications and dosing, medics will be less reluctant to use pressors in the field.

 

[DitchDoc73]

Overall, with proper education with emphasis on indications and dosing, medics will be less reluctant to use pressors in the field.

I agree that proper education / continuing education can cause medics to feel less reluctant about utilizing pressors in the field.

 

[leviathan]

The EMS agency where I am medical director currently carries dopamine. I'm thinking of taking it off the trucks. In the last 5 years, it's been used zero times.

Any thoughts on this? Anyone work in a system that doesn't carry a pressor (dopamine, dobutamine, norepinephrine)?

I find it hard to justify a drug that gets no use when the transport time is <30 minutes in almost all cases.

The EMS agency I worked for doesn't use dopamine or other pressors on car. Their ALS providers only work in urban environments and only on ALS calls, but the transport times of course are usually <15 mins. If you want I could email the medical director and see what her rationale is for not having pressors on car. I'm sure it probably has to do with the lack of necessity in that timeframe.

 

[AegriSomnia]

I hung a dopa drip last week on a post arrest... it almost worked :/

 

[malkboy]

Broad question, but what is everyone's view on using pressors opposed to fluids for trauma patients? Head injured patients?

 

[Grape23]

Hey Doc- I've been a medic right outside of Chicago for 7 years now. I'm in a pretty aggressive EMS system too.

Our level 2 trauma centers are a 7-8 min. transport and level 1 is about 13 min. out. In the last 5 years I've used dopamine about a dozen times. It's one of our least used meds. but still. I see alot of trauma's- gang related and industrial. We hang it with saline for quite a bit of our trauma's. And establish a second line with the blood tubing too, so the hospital can get that going right away too when we get there.

But what I'm wondering is if you know how often your system providers have had an opportunity too use it? or if maybe because they don't have the opportunities, they're just not that comfortable with it? There's probably instances that the uses are indicated, and they could use it, but if they're only a minute or two out, they may just be going with extra fluid because their not as familiar with dopamine.

 

[DitchDoc73]

Broad question, but what is everyone's view on using pressors opposed to fluids for trauma patients? Head injured patients?

The system I work in strictly forbids the use of pressors in suspected trauma related hypovolemic shock. In these cases we are only permitted to use normal saline boluses.

 

[AegriSomnia]

Same here. Only NS for trauma where I work.

 

[fiznat]

I'm not sure if frequency of utilization is a good measure for whether or not a particular treatment should be included in an EMS protocol. Unless you are talking about experience/proficiency with the drug (which I don't think you are...?), the fact that we don't use it often doesn't mean that it isn't important to have.

I've never done a surgical airway, but I think it is important that I am capable of it should the need arise.

 

[docB]

I'm not sure if frequency of utilization is a good measure for whether or not a particular treatment should be included in an EMS protocol. Unless you are talking about experience/proficiency with the drug (which I don't think you are...?), the fact that we don't use it often doesn't mean that it isn't important to have.

I've never done a surgical airway, but I think it is important that I am capable of it should the need arise.

That's a good point but with drugs you have to look at the maintenance and restocking costs too. A drug that never gets used still costs because you have to restock it frequently. Devices, like a cric kit, last a lot longer.

 

[leviathan]

The system I work in strictly forbids the use of pressors in suspected trauma related hypovolemic shock. In these cases we are only permitted to use normal saline boluses.

That's reassuring....if you were loading someone with an empty tank up on pressors, then I would be worried!

 

[DitchDoc73]

That's reassuring....if you were loading someone with an empty tank up on pressors, then I would be worried!

lol...I agree completely! To get back to Malkboys inquiry, are there any EMS systems that do use pressors instead of fluids in trauma patients? I understand the thought processes behind both stances (don't necessarily agree with the pressors), but I was just curious...

 

[fiznat]

lol...I agree completely! To get back to Malkboys inquiry, are there any EMS systems that do use pressors instead of fluids in trauma patients? I understand the thought processes behind both stances (don't necessarily agree with the pressors), but I was just curious...

The only exception I can think of for us is trauma related neurogenic shock. We have dopamine for that, but I filed that page under "never gonna happen" a long while back haha.

 

[proman]

Some pressor use is probably reasonable to avoid a flooding with crystalloid and all those consequences. Targeting a BP that is compatible with life is all that's needed during transport (usually around a systolic of 80-90 and a MAP >50). I've treated far more hemorrhagic shock patients from intraoperative blood loss than I did as a paramedic. While waiting for blood I use a combination of fluid and pressor boluses (phenylephrine for starters, moving on to small epi boluses as needed). Regardless, what these patients need is packed cells, plasma and a surgeon.

 

[docB]

Some pressor use is probably reasonable to avoid a flooding with crystalloid and all those consequences. Targeting a BP that is compatible with life is all that's needed during transport (usually around a systolic of 80-90 and a MAP >50). I've treated far more hemorrhagic shock patients from intraoperative blood loss than I did as a paramedic. While waiting for blood I use a combination of fluid and pressor boluses (phenylephrine for starters, moving on to small epi boluses as needed). Regardless, what these patients need is packed cells, plasma and a surgeon.

So from an EMS standpoint how are crews supposed to avoid fluid overload in these patients, ie. how much fluid is too much? What type of protocol would you suggest for when to start a pressor?

 

[DitchDoc73]

So from an EMS standpoint how are crews supposed to avoid fluid overload in these patients, ie. how much fluid is too much? What type of protocol would you suggest for when to start a pressor?

I know my current protocols (for where I work as a medic) only address fluid overload through evidence of CHF and/or a maximum amount of fluids via standing orders.​

"If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 250 ml until systolic BP > 90 mm Hg,
• Contraindicated if evidence of congestive heart failure (e.g. rales), • Total amount of IVF should not exceed 2000 ml (1000 ml for chest trauma)"​

And here is our standing order for when to start pressors (non-trauma Pts only):​

"If systolic BP remains < 90 mmHg after 4th fluid bolus (1000 ml), OR when fluid boluses are contraindicated,
• Dopamine 5 micrograms/kg/minute, titrate infusion to maintain SBP > 90 mmHg (maximum dose 20 mcg/kg/min)"​

 

[proman]

So from an EMS standpoint how are crews supposed to avoid fluid overload in these patients, ie. how much fluid is too much? What type of protocol would you suggest for when to start a pressor?

I don't think there's any way of knowing what the just-right amount is. I think they could almost do what they wanted as long as expeditious transport to a trauma center is the highest priority. The 2-liters then blood from ATLS (assuming it hasn't been modified recently) is bogus. I'd much rather have an under-resuscitated warm trauma then an over-resuscitated one. Once the coagulopathy of trauma sets in it's very difficult to terminate.

I think we should target much lower blood pressures. From other patient populations (like spine/hip replacements/liver resections) lower MAPs absolutely improve patient outcomes without significant morbidity or mortality. I'd be ok with fluid resuscitation to a BP to 70-80 (even less in a young otherwise healthy patient). I'm not a fan of pressor infusions but would include small doses of something like epinephrine (maybe 5-10mcg) to support cardiac output (targeting the same BP). We use phenylephrine in the OR a lot but while it increases the pressure it decreases cardiac output. What are your thoughts?

 

[Paseo Del Norte]

Let's say we add a head injury into the mix? This was something we discussed when our protocols were revised a couple of years back. Would you still follow the permissive hypotension approach?

 

[southerndoc]

Let's say we add a head injury into the mix? This was something we discussed when our protocols were revised a couple of years back. Would you still follow the permissive hypotension approach?

Absolutely not. Even a single episode of hypotension in head injured patients makes the prognosis significantly worse.

 

[csmmedic]

Hypotension in the setting of head injury is one area where paramedic use of saline fluid resus make actually make good things happen.

 

[docB]

I don't think there's any way of knowing what the just-right amount is. I think they could almost do what they wanted as long as expeditious transport to a trauma center is the highest priority. The 2-liters then blood from ATLS (assuming it hasn't been modified recently) is bogus. I'd much rather have an under-resuscitated warm trauma then an over-resuscitated one. Once the coagulopathy of trauma sets in it's very difficult to terminate.

I think we should target much lower blood pressures. From other patient populations (like spine/hip replacements/liver resections) lower MAPs absolutely improve patient outcomes without significant morbidity or mortality. I'd be ok with fluid resuscitation to a BP to 70-80 (even less in a young otherwise healthy patient). I'm not a fan of pressor infusions but would include small doses of something like epinephrine (maybe 5-10mcg) to support cardiac output (targeting the same BP). We use phenylephrine in the OR a lot but while it increases the pressure it decreases cardiac output. What are your thoughts?

Interesting. Now you realize that you started out talking about avoiding fluid overload and now you're talking about the whole permissive hypotension paradigm. That's a big leap in terms of education, assessment and so on for EMS. You're right of course, and being able to address those issues would be better EBM but it will be logistically difficult to achieve.

I do think that we'll get to a point based on the permissive hypotension idea where certain patients are protocoled to have less prehospital resuscitation and probably less intervention in general. We'll move to a scoop and run protocol.

 

[proman]

Interesting. Now you realize that you started out talking about avoiding fluid overload and now you're talking about the whole permissive hypotension paradigm. That's a big leap in terms of education, assessment and so on for EMS. You're right of course, and being able to address those issues would be better EBM but it will be logistically difficult to achieve.

I do think that we'll get to a point based on the permissive hypotension idea where certain patients are protocoled to have less prehospital resuscitation and probably less intervention in general. We'll move to a scoop and run protocol.

Well I think the concept of limiting fluid to a systolic of 90 could be either called permissive hypotension or "avoiding a flooding with crystalloid" (at least in my mind).

What I find frustrating is that we were having this discussion in EMS in the early to mid 90s. Ken Mattox published his seminal article in NEJM (PubID 7935634) in 1994 and much work prior to that. Lower morbidity and mortality rates in the delayed resuscitation group. Research since then has been consistent with these findings in many different "blood-loss" populations (either caused by street or surgeon). The simplest approach would be to give no fluid, but that's probably excessively restrictive.

Patients I'd include in a highly restrictive resuscitation would be the young (<50?) presumably healthy thoracoabdominal penetrating trauma patient. Maybe a systolic of 70-80, or even as low as 60? I don't know how low we could go but it's readily apparent that trauma patients continue to receive too much fluid. And rapid transport to definitive intervention should be a given.

 

[southerndoc]

Patients I'd include in a highly restrictive resuscitation would be the young (<50?) presumably healthy thoracoabdominal penetrating trauma patient. Maybe a systolic of 70-80, or even as low as 60? I don't know how low we could go but it's readily apparent that trauma patients continue to receive too much fluid. And rapid transport to definitive intervention should be a given.

The problem with this is the lawyers are the last to catch on. What makes perfect sense that's supported by research doesn't mean the EMS agency (and its medical director) won't be sued because some gun-for-hire getting $1,000 per hour doesn't say the paramedic didn't deviate from standard of care because every other service administers tons of fluids.

You never want to be the first, nor the last to adopt something.

Georgia has a gross negligence clause, which I'm sure a scumbag lawyer would argue was violated because a paramedic allowed someone to be hypotensive and they had a poor outcome. (Not stating that permissive hypotension is gross negligence, just stating that some idiot would certify the litigation and testify against the medical director and paramedic.)

 

[12R34Y]

I'm a medical director (big city) and we took dopamine off. never used, fast transport times, wasn't met with any resistance.

later

 

[Neup]

Granted this is not necessarily directly related to pre-hospital care, but considering the topic I thought some may be interested.

Abstract
http://content.nejm.org/cgi/content/short/362/9/779

Full Article
http://content.nejm.org/cgi/content/full/362/9/779

It would be nice if there was a study regarding pressors vs. fluids, but considering how long it took for this study to come out...

 

[malkboy]

I just wanted to tell everyone of the upcoming Annual Trauma Symposium. Here are some of the questions that will be addressed:

-Should we ever use fluids in the prehospital setting?
-Should we perform needle thoracotomy?
-What is optimal vascular access: IO/IV/Central Access?
-What is the optimal crystalloid for fluid resuscitation?
-What is the optimal colloid for fluid resuscitation?
-Should we use hypertonic saline for fluid resuscitation?
-Are pressors valuable in the setting of hemorrhagic shock?
-Whole blood versus components, which is better?



I talked to a military trauma doc and he recommend the following protocol:

MAP=65 is the goal in trauma with signs of good tissue perfusion

-warm extremities
-radial pulse (debatable)


MAP=65 -> GOOD

MAP<65 -> 500ml crystalloid under pressure -> 1:1:1 FFP, pRBC, platelets

MAP>65 without good perfusion -> Fentanyl (counter endogenous catecholamines)


Head Injury -> MAP=80

 

[proman]

Sounds like nothing's changed. Same questions, same arguments. There's no magic answer. In my opinion there's zero rationale to using a specific MAP number (outside of head injury which does have evidence supporting a CPP target).

 

[UKParamedic]

I am new to this site and have read with interest your comments on dopamine. I am currently looking at the UK paramedic practice for the treatment of symptomatic bradycardia. The use of dopamine was one area to look at however, I cannot find any evidence for or against its use. I can see some of you are using this drug, do you know of any supporting evidence for its use? Thanks for time, UKParamedic