Nov 27, 2020
In part 1 of her interview with Dr. Haney Mallemat,
Dr. Jessie Werner discusses using pressors in the ED.
Stay tuned for part 2 on managing the ventilator!
As Emergency Medicine physicians we’re tasked with taking care
of the sickest of the sick, often before we even have a
diagnosis to clarify the clinical picture. Stabilizing critically
ill patients may require placing a definitive airway and
providing hemodynamic support with pressors. When faced
with these challenging situations, how do you choose the right
pressor? What’s the dose? When do you add another agent? What
about fluids? We answer all these questions and more in this
episode of EMRA CAST. Also, stay tuned for the follow-up to
this episode which covers vent management in ED. We’ve
got you covered with all the tips you need to become a critical
care beast in the ED!
- The RUSH protocol (which
includes the HI-MAP technique Dr. Mallemat mentions) – Rapid
Ultrasound for Shock and Hypotension.
- Perfusion is composed of the tank
(preload), the pump (cardiac output), and the pipes (systemic
vascular resistance). Hypotension or shock can be caused by
ANY of these, so consider performing ultrasound using the HIMAP
protocol: HEART, IVC, MORISON’S POUCH, AORTA, and PULMONARY to
determine the cause of the hypotension and tailor your
- Pressor Algorithm:
- As long as there is not evidence of a decreased EF or another
cause of hypotension, Haney recommends starting with fluids to
resuscitate a hypotensive patient.
- If a patient is critically ill and/or not responsive to fluids,
consider starting norepinephrine. It’s okay to start it
- If the patient is profoundly vasoplegic and norepinephrine is
not working, consider adding vasopressin at a dose of 0.03
- After that point, you can consider starting epinephrine at a
higher dose, or greater than 0.05 mcg/kg/min to get the most
vasopressive effect. There is no known maximum dosing, but organ
ischemia - particularly gut ischemia - can occur.
- Dopamine has fallen out of favor due to concern over
arrhythmogenic properties; however, you could consider using
dopamine if a patient is bradycardic AND hypotensive (for example,
if they’re beta-blocked). If a patient has a “pump” problem with a
significantly reduced EF, you should consider dobutamine in
conjunction with cardiology or an intensive care specialist.
References / Resources
Professor of Emergency Medicine at Cooper Medical School
Triple boarded in EM, IM, CritCare Medicine.
Internationally recognized educator in CC Medicine.
Hospital Affiliation: Cooper Medical School