Note: Please listen to the PDP update episode either before or immediately after listening to this one
Finally a non-intubation topic!

Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation.

They also can act as a bridge to drip pressors while they are being mixed or while a central line is being placed.

Click Here for printable sheet with mixing instructions
Epinephrine
Do not give cardiac arrest doses (1 mg) to patients with a pulse

Has alpha and beta-1/2 effects so it is an inopressor

Onset-1 minute

Duration-5-10 minutes

Mixing Instructions:

Take a 10 ml syringe with 9 ml of normal saline

Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml)

Now you have 10 mls of Epinephrine 10 mcg/ml

Dose:

0.5-2 ml every 1-5 minutes (5-20  mcg)

No extravasation worries!

Mixing Video:


Phenylephrine
Phenyl as a bolus dose is clean, quick, and never causes trouble. But...

It is pure alpha, so no intrinsic inotropy; it may increase coronary perfusion which can improve cardiac output. I only use this in tachycardic patients (and even then, only sometimes)

Onset-1 minute

Duration- 5-10 minutes (usually 5)

Mixing Instructions:

Take a syringe and draw up 1 ml of phenylephrine from the vial (vial concentration must be 10 mg/ml)

Inject this into a 100 ml bag of NS

Now you have 100 mls of phenylephrine 100 mcg/ml

Draw up some into a syringe; each ml in the syringe is 100 mcg

Dose:

0.5-2 ml every 1-5 minutes (50-200 mcg)

No extravasation worries!

Mixing Video:


Ephedrine
I don’t use this one, listen to the podcast to hear why. I put it here solely for the anesthesiologists on the blog.

Onset-Near Instant

Duration-1 hour

Mixing Instructions:

Take a 10 ml syringe with 9 ml of normal saline

Into this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml)

Now you have 10 mls of Ephedrine 5 mg/ml

Dose:

1-2 ml every 2-5 minutes (5-10 mg)

No extravasation worries!
Additional Video of a Real Patient
By Larry Mellick's Crew
Update:
This study compares push-dose phenylephrine to continuous infusion--no difference between the two (Anesthesia Analgesia 21012;115(6):1343)
First article in the ED demonstrates efficacy on blood pressure (The Journal of Emergency Medicine Volume 49, Issue 4, October 2015, Pages 488–494)
Here is a review article from the nursing literature

Now on to the Podcast...