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Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport

  • Casey Patrick (a1), Brad Ward (a1), Jordan Anderson (a1), Joe Fioretti (a1), Kelly Rogers Keene (a2), Carri Oubre (a2), Rebecca E. Cash (a3), Ashish R. Panchal (a4) (a5) (a6) and Robert Dickson (a1) (a2)...

Abstract

Background:

The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.

Methods:

This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.

Results:

Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.

Conclusion:

These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

Copyright

Corresponding author

Correspondence: Casey Patrick, MD, 1400 Loop 336 West Conroe, Texas77304USA, Email: cpatrick@mchd-tx.org

References

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1.Almahmoud, K, Namas, RA, Zaaqoq, AM, et al.Prehospital hypotension is associated with altered inflammation dynamics and worse outcomes following blunt trauma in humans. Crit Care Med. 2015;43(7):13951404.10.1097/CCM.0000000000000964
2.Jones, AE, Stiell, IG, Nesbitt, LP, et al.Nontraumatic out-of-hospital hypotension predicts in-hospital mortality. Ann Emerg Med. 2004;43(1):106113.10.1016/j.annemergmed.2003.08.008
3.Green, RS, Butler, MB, Erdogan, M.Increased mortality in trauma patients who develop postintubation hypotension. J Trauma Acute Care Surg. 2017;83(4):569574.10.1097/TA.0000000000001561
4.Campbell, RL, Bellolio, MF, Knutson, BD, et al.Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract. 2015;3(1):7680.10.1016/j.jaip.2014.06.007
5.Heffner, AC, Swords, D, Kline, JA, Jones, AE.The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e419-413.10.1016/j.jcrc.2012.04.022
6.Jones, AE, Yiannibas, V, Johnson, C, Kline, JA.Emergency department hypotension predicts sudden unexpected in-hospital mortality: a prospective cohort study. Chest. 2006;130(4):941946.10.1016/S0012-3692(15)51124-0
7.Singh, JM, MacDonald, RD, Ahghari, M.Critical events during land-based interfacility transport. Ann Emerg Med. 2014;64(1):9-15.e12.10.1016/j.annemergmed.2013.12.009
8.Singh, JM, Ferguson, ND, MacDonald, RD, Stewart, TE, Schull, MJ.Ventilation practices and critical events during transport of ventilated patients outside of hospital: a retrospective cohort study. Prehosp Emerg Care. 2009;13(3):316323.10.1080/10903120902935264
9.Panchal, AR, Satyanarayan, A, Bahadir, JD, Hays, D, Mosier, J.Efficacy of bolus dose phenylephrine for peri-intubation hypotension. J Emerg Med. 2015;49(4):488494.10.1016/j.jemermed.2015.04.033
10.Swenson, K, Rankin, S, Daconti, L, Villarreal, T, Langsjoen, J, Braude, D.Safety of bolus dose phenylephrine for hypotensive emergency department patients. Am J Emerg Med. 2018;36(10):18021806.10.1016/j.ajem.2018.01.095
11.Hassani, V, Movaseghi, G, Safaeeyan, R, Masghati, S, Ghorbani Yekta, B, Farahmand Rad, R.Comparison of ephedrine vs. norepinephrine in treating anesthesia-induced hypotension in hypertensive patients: randomized double-blinded study. Anesth Pain Med. 2018;8(4):e79626.10.5812/aapm.79626
12.Wang, X, Mao, M, Liu, S, et al.A comparative study of bolus norepinephrine, phenylephrine, and ephedrine for the treatment of maternal hypotension in patients with preeclampsia during cesarean delivery under spinal anesthesia. Med Sci Monit. 2019;25:10931101.
13.Reiter, PD, Roth, J, Wathen, B, LaVelle, J, Ridall, LA.Low-dose epinephrine boluses for acute hypotension in the PICU. Pediatr Crit Care Med. 2018;19(4):281286.10.1097/PCC.0000000000001448
14.Overgaard, CB, DzavÌk, V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation. 2008;118(10):10471056.10.1161/CIRCULATIONAHA.107.728840
15.Cardenas-Garcia, J, Schaub, KF, Belchikov, YG, Narasimhan, M, Koenig, SJ, Mayo, PH.Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581585.
16.Nawrocki, PS, Poremba, M, Lawner, BJ.Push dose epinephrine use in the management of hypotension during critical care transport. Prehosp Emerg Care. 2020;24(2):188195.10.1080/10903127.2019.1588443
17.Guyette, FX, Martin-Gill, C, Galli, G, McQuaid, N, Elmer, J.Bolus dose epinephrine improves blood pressure but is associated with increased mortality in critical care transport. Prehosp Emerg Care. 2019;23(6):764771.
18.Cole, JB.Bolus dose vasopressors in the emergency department: first, do no harm; second, more evidence is needed. Ann Emerg Med. 2018;71(1):9395.
19.Holden, D, Ramich, J, Timm, E, Pauze, D, Lesar, T.Safety considerations and guideline-based safe use recommendations for “bolus dose” vasopressors in the emergency department. Ann Emerg Med. 2018;71(1):8392.10.1016/j.annemergmed.2017.04.021
20.Rotando, A, Picard, L, Delibert, S, Chase, K, Jones, CMC, Acquisto, NM.Push dose pressors: Experience in critically ill patients outside of the operating room. Am J Emerg Med. 2019;37(3):494498.10.1016/j.ajem.2018.12.001
21.Weingart, S.Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131132.10.15441/ceem.15.010
22.Wang, X, Shen, X, Liu, S, Yang, J, Xu, S.The efficacy and safety of norepinephrine and its feasibility as a replacement for phenylephrine to manage maternal hypotension during elective cesarean delivery under spinal anesthesia. Biomed Res Int. 2018;2018:1869189.10.1155/2018/1869189
23.Dellinger, RP, Levy, MM, Rhodes, A, et al.Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580637.10.1097/CCM.0b013e31827e83af
24.Beck, V, Chateau, D, Bryson, GL.Timing of vasopressor initiation and mortality in septic shock: a cohort study. Crit Care. 2014;18(3):R97.

Keywords

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport

  • Casey Patrick (a1), Brad Ward (a1), Jordan Anderson (a1), Joe Fioretti (a1), Kelly Rogers Keene (a2), Carri Oubre (a2), Rebecca E. Cash (a3), Ashish R. Panchal (a4) (a5) (a6) and Robert Dickson (a1) (a2)...

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