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.