Show Notes - How to Manage Pressors and Vents in the ED Like A Boss (part 1)

Pressors_Heart.jpg

Flashback Friday: How to Manage Pressors and Vents in the ED
Like A Boss (Part 1)

Originally Published: December 15, 2018
In this episode, Dr. Jessie Werner sits down with Dr. Haney Mallemat to discuss using pressors in the ED.
Tune in to Part 2 on managing the ventilator!

iTunes

Listen on Google Play Music

Spotify

Pandora

iHeartRadio

Amazon Music

Audible

Host

Jessie Werner, MD

University of California San Francisco – Fresno
Fellow - Emergency Medicine Education
@JessWernerMD
EMRA*Cast Episodes

Guest

Haney Mallemat, MD

Associate 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
@CriticalCareNow
EMResident Articles

Overview:

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!

Key Resources:

  • The RUSH protocol (which includes the HI-MAP technique Dr. Mallemat mentions) – Rapid Ultrasound for Shock and Hypotension.

 Key Points

  • 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 resuscitation.
  • 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 peripherally!
    • If the patient is profoundly vasoplegic and norepinephrine is not working, consider adding vasopressin at a dose of 0.03 mg/kg.
    • 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

 

Related Content

Apr 07, 2025

10 Must-Know Proposed Changes to Emergency Medicine Program Requirements from the ACGME

The EMRA Education Committee breaks down 10 key changes proposed by the ACGME Review Committee for Emergency Medicine. Public comments on the proposal will be accepted until May 1. EMRA urges you to understand the issues and make your voice heard with the ACGME.

Nov 02, 2022

Critical Care Alert: A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest

Every minute counts for long-term outcomes in out-of-hospital cardiac arrest. Does the route of administration for lifesaving medications play a role? This EMRA Critical Care Alert dives into the PARAMEDIC-3 trial, comparing outcomes in OHCA patients who were treated with intraosseous access versus intravenous access.

May 18, 2024

Getting Started in EM Research: Lessons from Rising Stars

The EMRA Research Committee interviewed 4 soon-to-be legends in the emergency medicine research community, from residents to established faculty, to understand their experiences. Our interviewees — Mat Goebel, MD, MAS; Corey Hazekamp, MD, MS; Vinitha Jacob, MD, PhD; and Laura Harding-Jackson, DO, PhD — discussed how they got their start in EM research, relevant training, current focuses and niches, and more.