Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What About IV Epinephrine for Patients Who Are Not Dead

Is IV (IntraVenous) epinephrine acceptable for anaphylaxis?

Is IV epinephrine acceptable for asthma?

Is IV epinephrine acceptable for bradycardia?

Is IV epinephrine acceptable for heart block?

Is IV epinephrine acceptable for shock?

5 items? Could it be something from Dr. Slovis?

At the Gathering of Eagles (the conference of the medical directors of the largest cities in the US), Dr. Corey Slovis (Nashville, TN) gave a presentation on using IV epinephrine expertly.

We may be accustomed to giving SC (SubCutaneous) or IM (IntraMuscular) epinephrine for asthma or for anaphylaxis, but maybe IV is a route that allows for better titration. When is the last time any of us gave a medication by the subcutaneous route? I don’t use the SC route for anything. IM is much simpler and faster and does not appear to have a higher rate of complications than SC.

Dr. Slovis suggests that we should be using the IV route, if possible.

First, he wants us to avoid using the concentration terms that we have had drilled into us.

Not 1:1,000, but 1 mg in 1 ml (mg = MilliGram and ml = MilliLiter).

How many of us think in the terms of 1:1,000?

Similarly, 1:10,000 would be the much more obvious 1 mg in 10 ml, but he doesn’t really want us to use that either. Dr. Slovis even uses an image that I like to discourage the use of these more concentrated forms of epinephrine.

Physicians and paramedics make dosing mistakes in using IM and IV epinephrine, especially when dealing with severe anaphylaxis and asthma.[1]

Dr. Slovis points out that the biggest problem may not even be the dosing mistakes, but the failure to give epinephrine at all. Patients die in the presence of EMS, or even in the ED (Emergency Department) because doctors, nurses, and medics are too uncomfortable, or too afraid, or too inexperienced, or too whatever to give epinephrine.

Maybe by simplifying the dosing, and by allowing for titration, this will not happen too often.

The starting dose epinephrine by IV infusion is 1-2 micrograms/minute.[1]

1-2 mcg/minute to start. (mcg = MiCroGram or μg)

Start at 1 mcg/minute and turn it up (or down) every minute, if the dose does not appear to be working.

When it appears to be working, start turning it down, and eventually off.

Is this too complicated?

We can put 1 mg of 1:10,000 epinephrine 1 mg in 10 ml epi into a 1 liter (1,000 ml) bag of NSS (Normal Saline Solution).

We can put 1 mg of 1:1,000 epinephrine 1 mg in 1 ml epi into a 1 liter (1,000 ml) bag of NSS.

The result is the same. There is no significant difference between 1,001 ml from adding 1 mg in 1 ml epi to 1 liter and 1,010 ml from adding 1 mg in 10 ml epi to 1 liter.

The concentration is 1 mg in 1 liter or 1 mcg in 1 ml.

Where does it say that the liter is NSS? It doesn’t but I do not carry liters of D5W (5% Dextrose in Water) and I am not going to use Ringer’s Lactate.

The liter with epinephrine is the Slow Drip.

Even though you have 1 liter of fluid, do not use the epinephrine mix for a fluid bolus.

Too simple? Not simple enough? Just right?

Read the PDF and you should become comfortable with it.

Footnotes:

[1] Using IV Epinephrine Expertly
Dr. Corey Slovis
2012 Gathering of Eagles
Presentation in PDF format

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Comments

  1. Our 2012 NC protocols finally acknowledge epi drips without med control, but given how unfamiliar providers are with this it will likely not get utilized as much as it should be…that is unless we educate ourselves!

    Big fan of Dr. Slovis’ epi presentation.

  2. Is there a recording of the actual presentations from this conference? The PDF files are excellent no doubt, but it would be even better to hear the actual presentations. Not sure if this is possible?

  3. Thanks for publicizing this!

    I try to teach this method to my residents (http://doccottlesdesk.blogspot.com/2011/09/anaphylactic-reactions-5-things.html) after I heard it on a lecture by Dr. Slovis.

    You can get a free download of a lecture where Dr. Slovis describes this method of giving IV epi. You simply MUST download this lecture – there is no speaker like Corey out there! Go to http://freeemergencytalks.net/2011/02/corey-slovis-care-of-the-wheezing-patient/

    By the way, there are studies out there that try to scare the bejesus out of people, with titles like “Acute myocardial infarction after administration of low-dose intravenous epinephrine for anaphylaxis.” (http://www.ncbi.nlm.nih.gov/pubmed/17324313). You should realize that they gave a whooping dose of epi – 100 µg IV. By contrast, this method you present here starts at 1 µg/minute. That’s a hundred-fold difference.

    In the one study out there where they used IV epi in a controlled setting, they used the “Slovis-method,” starting out at 5 µg/minute. Actually, they didn’t use steroids or antihistamines ether! All their anaphylactic patients did well. (http://www.ncbi.nlm.nih.gov/pubmed/14988337) Free download – check out the protocol.

  4. Most chemists (at least in Europe; not sure about USA) (and NO, readers in the UK, I don’t mean pharmacists) learned this idea of specifying mass/volume some time ago, rather than just quoting a ratio. For some reason the brain appears to accept these concentrations more readily than the ratios. Possibly it’s just easier to mentally “see” the units, whereas the ratio is just a number.

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