By Philip Neuwirth, BS, MICP, CCEMTP, FP-C

If you are a HEMS program using push-dose pressors for patients who become critically hypotensive in flight, you have a Medical Director at the forefront of pre-hospital medicine. Unfortunately, many programs are not and dismissing the reality that whether due to a patient’s disease state or induced inadvertently; we must act immediately. Giving fluids, even when infused under pressure takes time to exert a significant effect, and setting-up vasopressor infusion in flight requires more time for mixing, pump set-up, etc.

Push-dose pressors [epinephrine] have been used in the Emergency Department and pre-hospital setting for years in patient’s suffering from severe anaphylaxis (just the wrong dose) for patients refractory to SC/IM administration.  In fact, I have witnessed many physicians administer the cardiac dose of epinephrine for patients who become critically hypotensive to prevent cardiac arrest.

Why is push-dose epinephrine at the forefront of many pre-hospital discussion groups; because we know that epinephrine is an inopressor in addition to a vasoconstrictor for raising blood pressure quickly. We use it now as soon as someone loses their pulse. Why not use it in a diluted form when a patient’s blood pressure becomes dangerously low? Hasn’t recent literature shown critically low blood pressures associated with hemodynamic collapse? Haven’t we been taught, one episode of hypotension or hypoxia in the TBI patient increases mortality by nearly 50%?

The following link is an article, posted in January by Brendon Browning of, regarding Push-Dose Pressors.

Just a reminder that epinephrine will no longer be labeled as a “ratio” and labeled as a mass concentration, as most drugs are. So, Epinephrine 1:1000 will be labeled as 1.0 mg/ml and 1:10,000 would be labeled as 0.1 mg/ml. It would be great if they manufacture 1.0 mcg/ml for push-dose applications. If not, you would draw up 0.1 mg and mix it with 9 ml of NS, which will give you 10 mcg per ml.

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