Date Published

November 10, 2020

Updated For

ALS PCS Version ALS PCS Version 5.2


Has SWORBHP considered push dose epinephrine for ACP's? This treatment is being used for a variety of indications in many paramedic services throughout the globe and has literature supporting it. I know this was brought up in 2017 and one of the concerns was "anytime drawing up medications, there is a risk for medication error". There was a code epinephrine shortage in 2019/2020 and ACP's were reconstituting epinephrine from 1:1,000 to 1:10,000 during active cardiac arrest situations without complications.


To clarify, all directives are provincial directives and not something that SWORBHP can unilaterally change. In addition to the rationale provided in Ask MAC from 13-Apr-2017, the Ontario Base Hospital Group Medical Advisory Committee (OBHG MAC) reviewed the evidence behind this as part of the Comprehensive Medical Directive Review. In short, it was determined that the use of push dose epinephrine would not be included in the directives.

Epinephrine compared to norepinephrine:

One recent RCT and a recent meta-analysis of cohort data have found that in hospital, epinephrine is associated with a large statistically significant increase in mortality compared to norepinephrine in cardiogenic shock (Levy 2018, Leopold 2018).

In cardiogenic shock managed in-hospital, it appears to be beneficial to utilize norepinephrine rather than dopamine or epinephrine. For other types of shock, there may also be benefit to norepinephrine rather than dopamine, but that benefit is small. It is unclear if the differences between the vasopressors would manifest in the short timeframe involved in prehospital care (excluding inter-facility transfers). Note that norepinephrine does not cause any substantial increase in heart rate and thus cannot be used for bradycardia. Consideration should be given to using prehospital norepinephrine for shock not associated with bradycardia.

Final summary: we suggest we continue to use dopamine as a single agent vasopressor and inotrope for use by ACPs in Ontario.



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