Guidance for patients in post-ROSC uncorrected hypotension

Clinical Instruction

Please find below updated guidelines for the management and treatment regime of post-ROSC uncorrected hypotension.

This document outlines the process which clinicians must follow when administering adrenaline to a patient who has uncorrected hypotension following return of spontaneous circulation.

Medicines Use Guidance

Adrenaline 1:100,000 Post ROSC Hypotension

 

Clinical Details

Define situation/condition

Management and treatment regime of post ROSC uncorrected hypotension

Criteria for Inclusion

 

 

UNDER THE GUIDANCE AND PERMISSION OF THE CLINICAL ADVICE LINE (CAL) 07753 950 843:

Post ROSC patients where fluid boluses (up to 1000mls) have failed to correct hypotension (<90mmHg systolic)

 

Criteria for Exclusion

<18 years of age

BP >90mmHg systolic. At 90mmHg systolic, pressure is sufficient to maintain CPP, ICP and perfusion of kidneys and liver.

Cautions

Heart disease, hypertension, arrhythmias, cerebrovascular disease, elderly patients

 

Action if patient excluded

 

Continue with normal post ROSC treatment considerations

Action if patient declines

 

n/a

 

Description of Treatment

Name and form of medicine

Adrenaline 1:100,000 = 10mcg/ml  (diluted from 1mg, 1:10,000, see below for instructions)

Legal Status P/POM/GSL

Schedule 17, Human Medicines Regulations 2012

Licensed or Unlicensed

Unlicensed

Route of Administration/Method of Administration

Given IV in 1-2 ml boluses (a dose of 10-20mcg) as necessary to achieve desired effect every 3-5 mins

To prepare the correct concentration, draw 1ml (100mcg) of 1:10,000 Adrenaline in to a 10ml syringe. This is best achieved by utilising a 3-way tap. Attach the empty syringe to one of administration ports and the Adrenaline to one of the others and draw it through.

Dilute with 9mls NaCl to make a 10ml Adrenaline solution. This will now have 100mcg diluted to 10 mls achieving:

10mcgs per ml

Syringe must then be labelled showing contents and dose per ml

Dose

1-2 mls, 10-20 mcgs bolus doses

Frequency

Given every 3-5 mins to achieve and maintain the desired 90mmHg systolic BP

Duration of treatment

As required whilst en-route to hospital

Quantity to supply

n/a

Adverse Effects

Arrhythmias, hypertension, tachycardia, dizziness, palpations, vomiting, dyspnoea, pulmonary oedema, headache, tremor, restlessness

Written/verbal advice for patient/carer before/after treatment,

  • Clinicians must call the CAL for permission to give.

This is to provide oversight and support of the rational for administration, offer guidance and support for drawing up and confirm intended next steps.

Information on follow up treatment if needed

The patient must be conveyed to hospital

A full patient record must be completed and left with the hospital documenting clearly the use of Adrenaline for post ROSC vasoconstrictor support

 

 


 

Notes for CAL providers:

Post ROSC Adrenaline has the sole purpose of raising blood pressure to achieve and maintain cerebral and coronary perfusion pressures without causing undue harm by inducing a possibly detrimental hypertension.

Target pressures are what would be considered ‘normal’ for the patient age and medical history. As a rule of thumb, CPP and ICP are achievable at 90mmHg + systolic, however, with a hypertensive patient that is used to running at higher pressures, this may not be sufficient. A balancing act of gauging what is achievable, time to ED, competence of the crew and how they are coping is needed. If BP is already 90mmHg+, the risk of adding a vasoconstrictor outweighs any potential reduction in CPP flow as they should be perfusing at that pressure adequately for the journey to ED.

Indications:

  • Must be post ROSC!
  • Must have tried fluid boluses as a first line treatment. All adult patients including those with pulmonary oedema including cardiogenic shock should be able to receive up to 1000mls 0.9% NaCl. If not responsive to fluid resuscitation, this could be an indication that Adrenaline would be of benefit.
  • Rule out bradycardia as a source of low cardiac output. Any bradycardia should have been attempted to be resolved with O2 and atropine up to 3 mg. This may negate the need for adrenaline once heart rate goes up
  • Absolute bradycardia (3rd degree block) won’t respond to atropine and adrenaline may assist raising BP showing one or more of the 4 adverse features as per RC(UK) bradycardia algorithm. Ultimately these pts need pacing. Refer to CCD or expedite transport to ED/PPCI as appropriate.
  • Adults only. Paediatric dosing for this is complicated as such administration of inotropic support in children is to be avoided.
  • Ensure full monitoring is applied and confirm BP readings are auto-cycling every 2 mins on the Corpuls and pay close attention for manifestation of arrhythmias.
  • 10-20mcgs at a time depending on initial reaction to administration. Post ROSC vasoconstrictor support is ideally done via an IV infusion providing steady and constant flow. Essentially we are trying to replicate that with low dose frequent boluses. Infusion rates are normally 2-10mcgs per min so depending on effect, 10-20 mcgs every 3-5 mins will be safe but could cause spikes and dips in BP that may be missed with NIBP readings. Any administration of Adrenaline as a vasoconstrictor should be done with extreme caution.
  • Drawing up can be done in several ways. Easiest is via a 3-way tap. Put empty syringe and the adrenaline each on one of the ‘giving’ ports, close off the end that would otherwise be attached to the patient and then draw it through. Alternatively they could use an IM needle to draw directly through the hole in the end of the adrenaline syringe. The red drawing up needles don’t fit. This is more risky as it brings more sharps in to play but in the absence of a 3-way tap is manageable.

This Clinical instruction can be downloaded as a PDF file below, or can be viewed on the JRCALC app.

Produced by: Clinical Leads
Authorised by: Chris Martin

 

Published 7th July 2020


Review date: 06/07/2021

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