Question: Pushing a dose epinephrine seems to be very popular in the FOAM world for emergency physician. Its use has been promoted for things such as post cardiac arrest, refractory anaphylaxis, and severe bradycardia (some strong pharmacology reasons supporting it over atropine have been presented). Is this something you see being added to the advanced care paramedic treatment options at some point?
Great question and glad to see that you are utilizing the resources available to you to further your knowledge and understanding, which can then inform your clinical practice. Push-dose epinephrine certainly does have utility in certain clinical scenarios, including the ones mentioned above. To clarify, push-dose epinephrine is generally made by taking 1 ml of 1:10000 epi (giving you 100 mcg), and adding 9 mL of normal saline (giving each mL 10 mcg of epinephrine). This allows the health care provider a relatively controlled method of delivering relatively low doses of epinephrine. Taking advantage of epinephrines effect on alpha- and beta-adrenergic receptors, this can lead to subtle control of things like perfusing pressure, vascular tone and cardiac output.
It is difficult to know if it is something that will be added to the ACP scope of practice. Every attempt is made to ensure that the current medical directives are based on the best and most recent prehospital literature. Another point to keep in mind is that anytime a medication has to be drawn up and diluted with another solution, the possibility of medical errors with drug dosing is introduced. With epinephrine, this can have drastic and even fatal consequences. A miscalculation in the dose or the administration of too much (which is easy to do when a dose may only be 1 mL) can lead to cardiac ischemia and infarction, as well as induce ventricular dysrhythmias and potentially death. Also, when these medications/pressors are employed in the hospital setting, the patients often have invasive arterial BP monitoring to ensure the most accurate and timely BP readings to ensure they are being used appropriately and the response to the BP can be seen in real time.