APPENDIX F: EPINEPHRINE (NOREPINEPHRINE) - VASPRESSOR GUIDE

Consider starting low dose vasopressors – either epinephrine, or norepinephrine if available -after 30mL/kg of IVF and no changes in MAP, urine output or mentation.1 Epinephrine can improve blood pressure by a) vasoconstriction and b) increasing cardiac contractility, thus improving cardiac output.2 Vasopressors are rarely used outside of a critical care setting and use in an austere environment indicates a dire situation and must be monitored extremely closely. The dose of either epinephrine or norepinephrine are the same for drip calculations. Epinephrine is presented as it is far more available in austere practice settings. These are presented as low-dose starting points and any adjustments should be directly under telemedicine guidance. Of note: if monitoring, levels of lactate may rise with use of epinephrine as a vasopressor.

Epinephrine, as an IV or IO push-dose: A 10mL syringe consisting of 9mL of Normal Saline (0.9% NaCl) with 1mL of cardiac epinephrine (1:10,000 or 100mcg/mL). Administer to acutely correct a blood pressure indicative of shock (systolic <90). Administer a lower-end dose (0.5 – 1mL) while preparing a longer-term IVF drip (below).

- Concentration: 10mcg epinephrine/mL
- Onset: 1 minute
- Duration: 5 – 10 minutes
- Dose: 0.5 – 2mL every 2 – 5 minutes (5 – 20mcg)
- Administration: very slow IV push. 1 cc/min for 10 minutes. Rapid administration can cause rebound tachycardia, hypertensive emergency, and cardiac arrest.

Epinephrine as a vasopressor drip: Epinephrine; 4mcg/min bag reference chart. This dose is a starting/maintenance point in the application of an epinephrine (vasopressor) IV drip bag – Epinephrine Challenge. Gold-standard hospital practice utilizes a central line for this intervention; however, in an austere setting, peripheral antecubital access is acceptable (humeral, tibial, and sternal IO are also acceptable if flow rate can be precisely managed). The drip rate should be adjusted up, down or discontinued depending on the perfusion or vitals status of the patient. Once a vasopressor is started, the patient must be constantly monitored. Whenever possible, telemedicine consultation is required when vasopressor support is initiated.

**This is the least recommended approach as it commits a high volume of epinephrine to a large bag. If the patient’s vital signs (BP/MAP/HR) stabilize, the bag must be discontinued and the medic risks wasting some of his or her resources – “you can mix a drug in an IV bag, but you can’t take it out.”

Key point: If administering epinephrine infusion via a peripheral IV, monitor the IV site with every vital signs check for signs of redness, swelling or induration (firm, chord-like feeling of vessel above IV site). If any of these are present, epinephrine may be leaking out of the IV (“extravasating”) which can cause permanent scarring and damage to the vessel. Stop the infusion immediately and seek telemedicine consultation.

Use IV hydrocortisone, 100 mg every 8 hours, for at least 3 days in a military-aged male to treat septic shock in patients if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability. Due to the low volume and quality of evidence with this intervention, telemedicine is required before IV hydrocortisone is initiated as a treatment.3

References

1. Russell J, Gordon A, Walley K. Early may be better: early low-dose norepinephrine in septic shock. American Journal of Respiratory and Critical Care Medicine Vol. 199, No. 9 May 01, 2019; 1049–1051.
2. Farkas J. Epinephrine Challenge in Sepsis: An Empiric Approach to Catecholamines. EMCrit 2016. https://emcrit.org/pulmcrit/epi/ Accessed Oct 2020.
3. Gibbison B, López-López JA, Higgins JP, et al. Corticosteroids in septic shock: a systematic review and network meta-analysis. Crit Care. 2017 Mar 28;21(1):78.