A: Shock

Question 1

What is mix and dosing for PUSH EPI, does it need a Patch ?

Answer 1

1 mL of 1:10 000 (cardiac arrest epi) + 9 mL NS ——> 1: 100 000 = 10 mcg/mL EPI

1 mL of 1: 1000 (=1 mg) (IM EPI) + 100 mL NS ——> 1: 100 000 = 10 mcg/mL EPI

DOSING: 5-20 mcg q 2-5 min PRN ; (MP)

Question 2

MDSO: Hypovolemic Shock: Treatment:

Answer 2

1) 20 mL/kg to Max 1 L bolus (50 kg or above = 1 L), reassess and can repeat. (IP)

2) NE 0-0.5 mcg/kg/min (usual dose)

3) Consider Blood Products if evidence of Bleeding +/- TXA 1 g > 10 min +/- Coag Reversal
**as per flow chart, if “Hemmorhage” start with #3, then 1 - - - - #2 not even mentioned on that side of the flow chart — - that being said in real life, bloods won’t come that fast.

Question 3

MDSO: Septic Shock: Tx: doses, mix and clinical considerations

Answer 3

1) NS or RL 30 mL/kg (consider RL if large volumes — to avoid hyperchloremic acidosis) - - - NO PATCH

2) NE @ 0-0.5 mcg/kg/min (usual dose) (IP)

3) VASOPRESSIN (MP)
0.04 u/min (2.4 u/hr)
Mix 40 units/100 mL = 0.4 u/mL

4) EPI Infusion (MP)
0-0.5 mcg/kg/min (usual dose)

5) Hydrocortisone (MP)
100 mg IV

Clinical Consideration:
**If Ca++ low, replace Ca++ 1 g in 100 mL > 1 hr (not the usual , usual is 1 g> 20 min in volume not specified)
**Patch to ask for use of Push EPI if needed.
**If Hydrocortisone not available , can use METHYLPREDNISOLONE 125 mg

Question 4

MDSO: Cardiogenic Shock : Treatment and Considerations

Answer 4

1) 250 cc Challenge up to 10 cc/kg (No Patch)

2) Dopamine is an option (IP) from 5-20 mcg/kg/min - - - but we don’t use

3) NE - usual dose 0-0.5 mcg/kg/min (IP)

Then Mandatory Patch for

4) Dobutamine @ 5-20 mcg/kg/min , start at 5, T to signs of perfusion MIN MAP TO START: 60

***off MDSO, but as alternative to DOPAMINE - patch for EPI Infusion

Considerations:
Consider other MDSO - ACS/STEMI; TOX ; SYMPTOMATIC BRADY; TACHY HEART; ACUTE PULM EDEMA, MYOCARDITIS ?
Treat Shock Part First +/- Pacing +/- be careful with BiPAP

Question 5

MDSO: Neurogenic Shock: Meds / Considerations:

Answer 5

1) NS / RL 20-40 mL/kg , Target MAP > 80 (No Patch)

2) NE - standard dose (o - 0.5 mcg/kg/min) (IP)

3) Atropine @ 0.5 mg x 6 max 3 mg (if bradycardic) (IP)

4) Dopamine 5-20 mcg/kg/min (IP ) - option but we don’t use

5) PATCH (MP) for EPI INFUSION at usual 0-0.5 (Target MAP > 80)

CONSIDERATIONS:
TARGET > 80 in Neurogenic
Unopposed Alpha could cause Reflex Bradycardia, avoid Phenylephrine, EPI&raquo_space;> NE, this is why Dopamine is considered too.
**no movement below shoulders (other than biceps curling), consider intubation…..loss of muscle use, will tire.
**Don’t forget C-collar and SMR, use MILS assistant for Intubation

Question 6

MDSO: Traumatic Hemorrhagic Shock : Treatment and Considerations:

Answer 6

1) NS 20 - 40 cc/kg (but avoid hemodilution if you can) ; Target 65 (no patch)

2) Blood + TXA + Coag Reversal

Considerations:
*TRAUMA - keep warm, Ccollar/SMR, Pelvic Binding, Rule Out Pneumo
*TXA given if < 3 hrs since trauma
*If associated with Head Injury MAP 80
*If no obvious head injury, can consider permissive hypotension (MAP 60) assuming it’s enough to maintain LOA and palpable pulse