Thanks for the question. We do not have phenylephrine in the ER PYXIS system and have to order it from pharmacy...which takes too much time in the setting of these patients.
I was in septic shock and it took 7L of fluids and pressors to get my BP up. I was awake and coherent and talking the whole time. Never felt faint. Weirdest thing ever as I have postural orthostatic tachycardia syndrome and will "grey" out then black out at those low BPs. I'm thankful to be alive.
Good question. The air was put in to allow bubbles to cause mixing of the solution. The air was expelled from the syringe prior to treating the patient.
Hi Dr Mellick! From the clocks on the wall, it looks like the first push dose epi went in at 08:27 h with good response in BP. The last segment where it's "time for more epinephrine" was at 10:20 h. Were you guys giving push dose epi for those two hours? Why not use an epi or norepi drip, if so? Thanks! Jason
I can see your point about creating habits. I have certain habits I have come up with over the years, some good and some bad. Mainly we have used the needles with the shields for our injections, fingersticks, and IVs. You recap the same way I do. Where I work, we would get reprimanded if we had an uncapped needle to carry into a room. It was not my intention to come off as being mean. I apologize. Have a good night!
That might have been necessary on some patients, but several small boluses of epinephrine was all he ever needed and that is a lot less work. This technique is often an intermediate step to give you some time before you start a drip.
I had a case of acei toxicity and gave 4 mg narcan ivp with good results in blood pressure. Something worth trying for yourself next time you are faced with this scenario.
Hi Dr. Mellick. Why exactly does the epinephrine solution need to have some air in the system? My initial concern is that air bubbles in blood vessels would cause complications. Does the IV apparatus cancel this out? Thank you.
Thoughts on this method for making and administering 1:100k epi: Use 1mL of 1:1000 (1 anaphylaxis ampule) and add to a 100mL bag of your choice of crystalloid. Flow the IV continuously at 0.5mL/min (titrated to effect). Maybe not in hospital when you could just as easily hang an infusion of Levophed, but a good option for EMS who might carry no other pressor but epi. (If an EMS agency were to ever only carry epi in code ampules- 10mL of 1:10,000- they could do the same by first wasting 10mL of fluid from the bag. Wasting 1mL when using 1:1000 epi probably isn’t necessary as the difference in concentration of 1mg in 100mL vs 1mg in 101mL is negligible)
Push dose is better to see if they can stabilize pt rather than starting a drip and sending the pt to ICU just because of hypotensive overdose. If then, the hypotension persist then a drip will be started and pt will be sent to ICU. It is a process, not just jumping to big guns. Process people, process.
It was a clean needle, if he stuck himself, he would not be exposed to any blood bourne pathogens. I have recapped many clean needles, but I lay the cap on a hard clean surface and scoop the cap up with the needle. I do not recap dirty needles. Never have. In 17 years I have had 2 clean sticks, and that is it. He did fine.
my understanding was that air in an IV wasnt a very big deal. something about the blood absorbing small volumes of air without a problem? Im an emt and a paramedic was talking to me about this.
There is less evidence of dopamine as push dose. Also, it vasodilates renal arteries which causes diuresis and may cause hypovolemia which can exacerbate hypotension. Epi has a lot of evidence as push dose.
I have a patient with no detectable pulse or blood pressure while being on a dopamine drip. I'm wondering why shouldnt we give him epinephre as a push dose pressor
sre it was a clean needle no problem with that, im just saying that doing that might create the habit of doing it, i work in EMS and the very few times that we recap needles is putting the cap on a table and then we recap it never holding the cap with our fingers because of creating a habit. just talking about what how i see thing no intention of starting anything. have a nice day.
Thanks for the question. We do not have phenylephrine in the ER PYXIS system and have to order it from pharmacy...which takes too much time in the setting of these patients.
I was in septic shock and it took 7L of fluids and pressors to get my BP up. I was awake and coherent and talking the whole time. Never felt faint. Weirdest thing ever as I have postural orthostatic tachycardia syndrome and will "grey" out then black out at those low BPs. I'm thankful to be alive.
Thanks. We agree. We love our work...most of the time. :-)
I came to UA-cam to watch a video of yours and just uploaded a new one 3 seconds ago
Good question. The air was put in to allow bubbles to cause mixing of the solution. The air was expelled from the syringe prior to treating the patient.
Why don’t you start a noradrenaline infusion rather than giving pulse adr?
Hi Dr Mellick! From the clocks on the wall, it looks like the first push dose epi went in at 08:27 h with good response in BP. The last segment where it's "time for more epinephrine" was at 10:20 h. Were you guys giving push dose epi for those two hours? Why not use an epi or norepi drip, if so?
Thanks!
Jason
Ahh, didn't see the tubing. Thanks for these videos!
I can see your point about creating habits. I have certain habits I have come up with over the years, some good and some bad. Mainly we have used the needles with the shields for our injections, fingersticks, and IVs. You recap the same way I do. Where I work, we would get reprimanded if we had an uncapped needle to carry into a room. It was not my intention to come off as being mean. I apologize. Have a good night!
That might have been necessary on some patients, but several small boluses of epinephrine was all he ever needed and that is a lot less work. This technique is often an intermediate step to give you some time before you start a drip.
Crazy on how potent Epi is.
I had a case of acei toxicity and gave 4 mg narcan ivp with good results in blood pressure. Something worth trying for yourself next time you are faced with this scenario.
Curious as to if the line was flushed after the first dose... wouldn't a good portion of that mL still be trapped in the line?
That would be great!
Hi Dr. Mellick. Why exactly does the epinephrine solution need to have some air in the system? My initial concern is that air bubbles in blood vessels would cause complications. Does the IV apparatus cancel this out? Thank you.
Thoughts on this method for making and administering 1:100k epi:
Use 1mL of 1:1000 (1 anaphylaxis ampule) and add to a 100mL bag of your choice of crystalloid.
Flow the IV continuously at 0.5mL/min (titrated to effect).
Maybe not in hospital when you could just as easily hang an infusion of Levophed, but a good option for EMS who might carry no other pressor but epi.
(If an EMS agency were to ever only carry epi in code ampules- 10mL of 1:10,000- they could do the same by first wasting 10mL of fluid from the bag. Wasting 1mL when using 1:1000 epi probably isn’t necessary as the difference in concentration of 1mg in 100mL vs 1mg in 101mL is negligible)
Yes
cool!!
IV running full open. No need for flush.
Push dose is better to see if they can stabilize pt rather than starting a drip and sending the pt to ICU just because of hypotensive overdose. If then, the hypotension persist then a drip will be started and pt will be sent to ICU. It is a process, not just jumping to big guns. Process people, process.
I don't remember that detail.
It was a clean needle, if he stuck himself, he would not be exposed to any blood bourne pathogens. I have recapped many clean needles, but I lay the cap on a hard clean surface and scoop the cap up with the needle. I do not recap dirty needles. Never have. In 17 years I have had 2 clean sticks, and that is it. He did fine.
If you don't mind I'd like to create a simulation case for my residents from this case.
Your intro music is too loud.
my understanding was that air in an IV wasnt a very big deal. something about the blood absorbing small volumes of air without a problem? Im an emt and a paramedic was talking to me about this.
Why epi over dopamine? I like the epi idea just looking for educational angel.
There is less evidence of dopamine as push dose. Also, it vasodilates renal arteries which causes diuresis and may cause hypovolemia which can exacerbate hypotension. Epi has a lot of evidence as push dose.
Was that a fifty shades reference at 4:20? "We aim to please"
lol you said 420
I have a patient with no detectable pulse or blood pressure while being on a dopamine drip. I'm wondering why shouldnt we give him epinephre as a push dose pressor
Mohammed Munjy Absolutely, you can do it!
did this come in by ambulance with iv
Was this a self harm attempt?
why not a dopanime drip? and titrate to a stable bp and hr
Why not atropine for symptomatic bradycardia?
sre it was a clean needle no problem with that, im just saying that doing that might create the habit of doing it, i work in EMS and the very few times that we recap needles is putting the cap on a table and then we recap it never holding the cap with our fingers because of creating a habit. just talking about what how i see thing no intention of starting anything.
have a nice day.
so its 1:100,000 epi?
a d 1:10000, 1ml = 1mcg
He was uning blunt access cannula, not a needle..
Lol
I think he is an attempted suicide as they gave him charcoal
4:50 am?
easiest way to have a needle stick is to recap a needle like that guy... sorry but quite dangerous way to recap needles
Hah!
Music awful and distracting
Stupid fiddle de la music
IV running full open. No need for flush.