push dose epi indications

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Thus, a dose of 10 mcg per minute is 1 mL every minute. Retrieved May 15, 2014, from www.emcrit.org/podcasts/bolus-dose-pressors. Epinephrine also has inotropic effects, increasing cardiac output by increasing both heart rate and stroke volume (the result of beta receptor stimulation). Traditional thinking is that epinephrine, because of its beta stimulation, is more likely to cause tachycardia. Push dose epinephrine is not pre-packaged in the SEM Drug BOX. Careers. PDP are potent adrenergic drugs, so the most common adverse events are hypertension and dysrhythmia [1,2,5]. and suppliers. Phenylephrine, because of its pure alpha stimulation, may result in reflex bradycardia. The above 1:100,000 epinephrine is the same concentration thats used in lidocaine for local anesthesia. HHS Vulnerability Disclosure, Help Two concerning trends come from the literature. 2015;66(6);629631. Sam Ashoo, MD. FOIA Brewer JM, Puskarich MA, Jones AE. If intubation is attempted in the current physiologic state it will likely be a terminal procedure or clean kill because many induction agents for intubation cause hypotension. The indications for norepinephrine are: (2) [p 58] Severe cardiogenic shock and hemodynamically significant hypotension (SBP < 70 mm Hg) with low total peripheral resistance. This is usually done using a 10-mL syringe and given in 1-mL aliquots known as a push dose or bolus dose., For years, push dose vasopressors have been used by anesthesiologists prior to intubation or after epidural anesthesia as a temporary means of increasing blood pressure until the hypotension resolves.5 This has opened the door for the administration of push dose vasopressors in the ED or the ICU for both transient hypotension and during a resuscitation before a central line can be established. For push-dose epinephrine, dose 0.5 - 2mL of 10 mcg/mL, every few minutes. 7. Per protocol, 10-20 g of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. EPI Push Dose Precaution I have recently found we can get pre-mixed push dose epinephrine (2 month shelf life) so mixing would not be a concern, but . PloS One. Keywords: Its easy to mix from readily available 1:10,000 epinephrine and normal saline. The https:// ensures that you are connecting to the Its an established practice in anesthesia to use small doses of vasopressors for a short period of time to optimize patient hemodynamics. This single-center study analyzed 249 patients undergoing resuscitation and receiving either epinephrine or phenylephrine as push dose pressors found that adverse hemodynamic . It has both vasoconstrictive, chronotropic and ionotropic effects that make it a good choice for distributive and cardiogenic shock. Position the device at the medical portion of the thigh 3. De Backer D, Biston P, Devriendt J, et al. 37(3): p. 494-498. At the approved recommended dosage, time to steady-state was 2 months, and accumulation ratio was 1.65 based on AUC 0-21d . A temporizing measure for drugs that have the side-effect of hypotension. . Shes likely in septic shock from a urinary tract infection. Duration: 5-10 minutes. and response. 4. All vasopressors pose an extravasation risk, but PDP appear safe even through peripheral lines [2]. 2. (2009) EMCrit podcast 6: Push-dose pressors. The ED physician asks you to stay and assist with the intubation, but the patient is in shock. 7. Epinephrine has both - and -adrenergic activity and will therefore stimulate the heart in addition to causing vasoconstriction. Comparison of dopamine and norepinephrine in the treatment of shock. 35(12): p. 1964-1965. Efficacy and safety of dopamine versus norepinephrine in the management of septic shock. Agent of last resort for management of ischemic heart disease and shock. -Push Dose Epinephrine -Non-hemorrhagic hypotension -Bradycardia: 10 mcg: 10 mcg/mL: IV: Repeat every minute PRN-Push Dose Epinephrine -Non-hemorrhagic hypotension -Bradycardia: 0.1-1 mcg/min: Infusion-Anaphylaxis -Respiratory . 9. A temporizing measure for drugs that have the side-effect of hypotension. Journal of medical toxicology, 2019. hes preoxygenated. Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. His end-tidal carbon dioxide (EtCO2) has gradually trended up from 40 to 6 5mm Hg. Her initial vital signs are a heart rate of 115 bpm, an oxygen saturation of 97% on room air, and a blood pressure of 105/75 mmHg. Max: 0.3 mg/dose in pre-pubertal patients; 0.5 mg/dose in teenage patients; May repeat dose q5-15 min x 2; Severe Asthma. 0.5 mL (5 mcg) IV/IO, every 3 minutes, titrate to a SBP > 90. Boom. Pressors refers to vasopressors, a group of medications primarily used to vaso-constrict blood vessels and normally used to manage hypotension in patients when fluids or blood have either failed or are inappropriate. J Crit Care. Epinephrine (systemic, oral inhalation). The Dirty Epi Drip: 1mg of epinephrine placed into a 1L saline bag and run through an IV This is not perfect, but buys time until a pump or push dose epinephrine can be made It is called dirty epi drip for the simple reason that it is mixed at the bedside as opposed to getting it from the pharmacy 2007;370(9588):676684. EMS1 is revolutionizing the way in which the EMS community Inject 5 ml (5 mcg) IV (may repeat second 5 ml/5 mcg dose) Protocol 2: Hypotensive, unstable patient option 2. All rights reserved. This was followed by its use in patients suspected of septic shock (22.6%) and cardiogenic shock (19.0%). 245247, 2013. . Current resuscitation guidelines recommend that epinephrine should be used if the newborn remains bradycardic with heart rate <60 bpm after 30 s of what appears to be effective ventilation with chest rise, followed by 30 s of coordinated chest compressions and ventilations (1, 8, 9). A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus "push-dose" epinephrine (PD-E). The patient is intubated. Push dose epinephrine is for use in profoundly hypotensive patients after standard treatments fail to improve blood pressure. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. Prehospital emergency care, 2019. 2013;41(9):21082115. When compared to norepinephrine, for example, dopamine is associated with a higher incidence of arrhythmias, is a less potent vasopressor; and for those with cardiogenic shock, has been shown to increase mortality.4. Push dose pressors (PDP), in various different forms, have been in and out of my practice a number of times over the years. In addition to his clinical practice, he is also adjunct faculty in the Paramedic Program at Georgian College. Utility of push-dose vasopressors for temporary treatment of hypotension in the emergency department. The following table shows the properties and indications for the two most commonly given push dose pressors in the Emergency Department- Epinephrine and Phenylephrine. The American journal of emergency medicine, 2017. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings. J Emerg Med. The dose of epinephrine can be re-peated after 3-5 . All specific Treatment Guidelines questions should be directed to the OCEMSA Website. The evidence shows that norepinephrine is superior to dopamine for cardiogenic shock and suggests its also better in distributive shock.6,7 Epinephrine appears to have no significant difference in outcomes compared to norepinephrine.8,9. And, 300 mcg of 1:1000 epinephrine subcutaneous or intramuscularly, is the standard route and dose for severe allergic reactions. Patients needing emergency airway, traumatic brain injury, and post-cardiac arrest with the return of spontaneous circulation may all experience hypotension which could lead to . Which is the next drug/dose to anticipate administering? Lancet. The dose generally is 210 mcg per minute. N Engl J Med. . Peripheral extravasation of a vasopressor can lead to complications of tissue ischemia. Copyright 2022 indication ZYMAXID (gatifloxacin ophthalmic solution) 0.5% is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains of the following organisms: Aerobic gram-positive bacteria: Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus mitis group *, Streptococcus oralis *, Streptococcus pneumoniae . Doses < 1 g/kg were not as effective as those which were 1 to 5 g/kg. In 2016, a prospective observational study of 55 patients receiving vasopressors through a peripheral vessel, only three had extravasation and one developed thrombophlebitis. 5. Injection solution: 1 mg/1 mL (1:1000) epinephrine as a sterile solution in a 2 mL single-use clear glass ampule, marked Epinephrine Injection USP, 1 mg/mL (1:1000). Paramedics commonly documented an improvement in patient condition after epinephrine administration including in every case of suspected septic shock. 7. They found the mean dose given was 1.3 g/kg. 8600 Rockville Pike You continue to give epinephrine at 10 mcg per minute while diligently watching the second hand on the clock and the volume hash marks on the syringe. After removing the CPAP mask, the high flow nasal cannula is placed while intubation is attempted. After a single dose, margetuximab-cmkb C max and AUC 0-21d increase in an approximately dose proportional manner from 10 to 18 mg/kg (0.67 to 1.2 times the approved recommended dose). Both agents increase blood pressure through vasoconstriction, the result of alpha receptor stimulation. Push dose epinephrine also improves hypotension, but has been studied less. Accessibility Severe anaphylaxis or asthma. Secondary outcomes included changes in blood pressure, adverse effects, dosing errors, fluid and vasopressor requirements, ICU and hospital lengths of stay (LOS), and in-hospital mortality. The American journal of emergency medicine, 2020. The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Certain patients, like those with poor left ventricle function, may be a high risk of severe adverse effects [2]. A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Every CC at that point is 10MCG which is in that dosage range required. Imagine being able to reach for a phenylephrine preload and give the patient one or two millilitres and instantly add 10 or 15 to their systolic. The syringe should be mixed by vigorously rolling it between the palms and is then ready to be infused by slow push. These factors make it best suited for situations where it can used for short durations such as transports lasting less than 1015 minutes, transient hypotension, or as a bridge to fluid resuscitation or vasopressor drips. Alpha and betaadrenergic Ann Emerg Med. Push the device into the thigh as far as possible. We must carry it into 2023 for a final, concerted push. Infusion: Epinephrine 1 mcg/ml solution. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. Lexipol. 2020 Jun;57:148-156. doi: 10.1016/j.jcrc.2020.02.011. Mean increase in MAP ranged from 4-12 mmHg while mean change in HR ranged from -2.4 to +2.2 depending on dose [6]. Also, the most common indications for bolus dose epinephrine were general hypotension in 17/42 (41%), pre-delayed sequence intubation in 16/42 (38%), and sepsis in 9/42 (21%). Push dose epinephrine is not a substitute for appropriate resuscitative efforts, and it is not appropriate for mild hypotension that has not responded to an appropriate fluid challenge. The code or cardiac epinephrine stored on ALS ambulances is in a 0.1 mg/mL concentration. Prior to protocol implementation, all paramedics in the county underwent training in the indication, mixing and administration of push dose epinephrine. Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU. May repeat every 5 to 15 minutes as needed for up to 3 injections; more frequent administration may be appropriate in certain circumstances, as judged by the clinician. Medication that infiltrates will not be as active as the IV route. After attempts at fluid resuscitation, your 79-year-old patient remains hypotensive. Push-dose vasopressors are small intravenous bolus doses (pushes) administered to hypotensive patients to increase cardiac output and brain perfusion. The guidelines also suggest an IV push-dose of epinephrine 0.1 mg of 1:10,000 over 5 minutes. 2007;370(9588):676684. PUSH DOSE EPI How to Make It: The "cardiac arrest" epinephrine (1:10,000) is packaged as .1mg/mL (100mcg/mL), however, to make push dose epi, it needs to be diluted down to a concentration of .01mg/mL or 10mcg/mL. 2015;49(4):488494. IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The primary outcome was a change in heart rate (HR). Wean as approach cummulative max IV Epinephrine dose. Her heart rate has increased to 125 bpm and her blood pressure is now 85/47 mmHg. It is a practice that has a home in anaesthesia, as it can be useful to manage the transient hypotension associated with induction agents given during intubation. The EpiPen device will auto inject a premeasured dose of epinephrine into the subcutaneous tissue. Enter https://www.ems1.com/ and click OK. An official website of the United States government. Self-administration of epinephrine 1. The most common cited indication for the PDPs is as a bridge to vasopressor initiation. But despite initial appearances, 2022 put the world on an extremely strong footing to interrupt all remaining chains of poliovirus transmission by end 2023the goal of the GPEI Strategy 2022-2026. Kurish, B.A., et al., Safety of push-dose phenylephrine in adult ICU patients. Before Curr Opin Crit Care. Alameda County EMS Agency. Using 10 drips per mL IV tubing every drip is about 1 mcg, 10 mcg/ml. The American journal of emergency medicine., 2018. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. The dosing is relatively straightforward. Comments: This may be called Tools or use an icon like the cog. Bodkin, and C. Johnstone, Medication errors with push dose pressors in the emergency department and intensive care units. Pediatric PALS: Give Epinephrine in a 1:10,000 solution: 0.01 mg/kg by IV/IO every 3 to 5 minutes (or give Epinephrine in a 1:1,000 solution: 0.1 mg/kg by ETT). The infusion should run at 2-10 micrograms/min (titrated to effect). Understanding prehospital vasopressors: Dopamine, epinephrine or norepinephrine? Dose: 0.5-2 mL every 2-5 minutes (5-20 mcg). Once you expose the top of the cardiac arrest PFS, a needle can be placed into it and medication can be . Push dose epinephrine can be made by drawing 1 mL of 1:10,000 cardiac epinephrine (100 mcg) in a 10 mL syringe and then drawing 9 mL of normal saline. 150 mg IV push. You prepare a syringe of push dose epinephrine and administers a total of 10 mcg of epinephrine. 2020 Oct;35(5):495-500. doi: 10.1017/S1049023X20000886. Ideally, there would be time to fluid resuscitate this patient before attempting induction and intubation. Indications for use Dose, route, and time of naloxone administration Response to administration Patients disposition, i.e. Case Conclusion About 15 minutes away from the hospital, you note the patient becomes increasingly drowsy. Second, to be used safely, it should not be done on the spur of the moment. Given the ubiquity of epinephrine in ALS units, its an obvious choice for EMS to use as a temporizing vasopressor. ****BE VERY CAREFUL TO GIVE CORRECT DOSE****, 1 mg Vials (Do Not double dilute drugs to obtain the, desired concentration), coordinate with Base , Hospital if only carrying 1 mg vials of Epi. J Med Toxicol. Equates to 2 drops per second. Pediatr Crit Care Med. He is currently pursuing a Master of Science in Critical Care from Cardiff University. The doctor anticipates that the rapid sequence induction (RSI) agents and intubation will likely result in further hypotension, and possibly cardiac arrest. The patient is placed on a ventilator and the resuscitation is continued.. References A reasonable trigger for mixing Pediatric Push dose epinephrine is a blood pressure < 5 th percentile (70 + (age x 2)) that is unresponsive to fluid resuscitation. Phenylephrine acts as a pure alpha-1 receptor agonist, which could be beneficial for patients with hypotension and tachycardia since beta adrenergic agonism is avoided. Her mean arterial pressure improves to 65 mmHg with a corresponding improvement in her appearance and mental status as you arrive to the hospital to prepare a handoff to the ED. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Usual Adult Dose for Hypotension. Disclaimer, National Library of Medicine The syringe should be mixed by. INDICATIONS: Push dose epinephrine is for use in profoundly hypotensive patients after standard treatments fail to improve blood pressure. CONTRAINDICATIONS: None during cardiac arrest profound anaphylaxis or profound hypotension PRECAUTIONS: May precipitate with sodium bicarbonate if tubing is not flushed between drugs. Morgan and Mikhails clinical anesthesiology, 5th edition. Push dose phenylephrine, for example, was shown to improve peri-intubation hemodynamics in the ED.7. Push Dose Epinephrine. Concerns of the anesthesiologist: Anesthetic induction in severe sepsis or septic shock patients. This issue reviews the . Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: A randomized trial. Theis a quick reference ONLY to the Policies and Guidelines set by OCEMSA. The dosage of IV administration of norepinephrine is: (2) [p58] In the Alameda County EMS system, push dose epinephrine is in the protocol for management of shock suspected due to hypovolemia, sepsis and decreased cardiac output (i.e., cardiogenic). EPI Push Dose Contraindications NONE in a life-threatening situation. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. JEMS. The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Holler JG, Bech CN, Henriksen DP, et al. Epinephrine's onset of action is also about 1 minute with re-dosing to effect every 2-5 minutes (typical dose: 5-20 mcg per push), however the effects are slightly shorter than phenylephrine, with a duration of about 5-10 minutes (versus 10-20 minutes for phenylephrine). All rights reserved. Significant medication errors have been reported, such as one patient receiving 50 mg of phenylephrine instead of 50 mcg, a dose 1,000 times higher than intended [7]. The doctor successfully intubates the patient with a transient, minor drop in blood pressure. Crit Care Med. 5 Recommended vasopressor dose, frequency, and rate of administration (per minute), as well as redosing frequency, therefore provide . Swenson, K., et al., Safety of bolus-dose phenylephrine for hypotensive emergency department patients. This could be due to short transport times and the need for fluid resuscitation prior to utilizing a pressor. . If there is no response after 3 to 4 injections, consider an intravenous infusion. 2019 Alameda County field manual. Indication: Hypotension o Temporizing measure for hypotension or post intubation hypotension Tissue perfusion o improve perfusion to vital organs or maintain perfusion which is often impaired after return of spontaneous circulation Mechanism of action: Epinephrine stimulates alpha and beta receptors. Doses of 100mcg or less increase the mean arterial pressure between 4 mmHg and 4.8mmHg (147 and 188 patients respectively) [1,2]. Annane D, Vignon P, Renault A, et al. To make an epinephrine drip mix 1 mg in NS to make 100 mL total. sepsis, respiratory distress/failure, cardiac arrest) and the remainder received doses for trauma-induced hypotension (hemorrhagic or neurogenic shock) [6]. View epi push dose.pdf from EMSB 101 at Lorain County Community College. 3 . The indications for PDP are based on the urgent reversal of hypotension. This site needs JavaScript to work properly. The major difference between the two is the beta effects of the epinephrine. 71(1): p. 83-92. Overall however, push dose epinephrine was used relatively few times compared to the total number of patients with non-traumatic hypotension transported by EMS. Two shocks and 1 dose of epinephrine have been given. Do Not Sell My Personal Information. Please enable it to take advantage of the complete set of features! Annane D, Vignon P, Renault A, et al. Annals of emergency medicine, 2017. Initially, the CPAP at a pressure of 10 cm of water improved the patients oxygen saturation from 73% to 93%. Epub 2019 Apr 9. During transport the patient has increasing difficulty keeping his eyes open. Central or peripheral catheters for initial venous access of ICU patients: A randomized controlled trial. Severe anaphylaxis is treated with 100250 mcg IV every 35 minutes followed by continuous infusion as needed.4. It has become the most comprehensive and trusted online destination for prehospital and emergency medical services. There is a clear momentum as the year draws to a close. Impact of epinephrine administration frequency in out-of-hospital cardiac arrest patients: a retrospective analysis in a tertiary hospital setting. government site. Literature also supports the use of epinephrine. Excessive dosing causes hypertension and tachycardia. If the intent is to give serial doses from the syringe, make sure the person pushing it knows how much to use for each dose from the 10ml syringe. Episode 139 Push-Dose Pressors: RANT! You transport a 55-year-old male to the hospital on continuous positive airway pressure (CPAP) for respiratory distress and fever. First-Line Vasopressor and Mortality Rates in ED Patients with Acute Drug Overdose. What can PDP do? This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Jonathan Lee is a critical care paramedic with Ornge in Toronto, Canada, with over 25 years of experience in 911, critical care, aeromedical and pediatric critical care transport. This is thought to be less likely with push dose vasopressors given their reduced concentration and short duration. Weingart SD. 6. interacts with each other and researches product purchases The dose is then titrated to the desired effect.3, The dosing varies slightly depending on the condition being treated. An IV is established and a bolus of normal saline is started. Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. Copyright 2022 Comparison of dopamine and norepinephrine in the treatment of shock. There are many potential advantages to PDP. A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. Levy B, Perez P, Perny J, et al. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). Lexipol. J Emerg Med. (1) Phenylephrine as a PDP is dosed at 50 - 200 mcg every 2-5 minutes as needed. 2019 Oct;15(4):276-286. doi: 10.1007/s13181-019-00716-z. None. Since the patient is on CPAP with 100% oxygen, Phenylephrine is effective in correcting hypotension. At the moment, they appear to be becoming increasingly trendy in emergency medicine. The Alameda County EMS System is confident that push dose epinephrine can be a temporary blood pressure rescue medication and serve as an important treatment in prehospital shock. Adverse events occur more commonly with higher doses and undiluted medications [2,6]. 8. Suspected neurogenic shock (spinal cord injury with hypotension) (BHO), 1 mg Vials (Do Not double dilute drugs to obtain thedesired concentration), coordinate with Base Hospital if only carrying 1 mg vials of Epi. What are your next steps? Unable to load your collection due to an error, Unable to load your delegates due to an error. Carefully uncap the EpiPen device, holding it so that the injecting end is upright 2. Lancet. DOSAGE FORMS AND STRENGTHS . Epub 2020 Feb 19. But the fast-paced prehospital environment also makes PDP very risky. Episode 13912 Chapters 1 Introduction 02:27 2 Syncope and CT scans 34:28 3 Approach to the trauma patient 28:12 4 The New Anticoagulants 33:19 5 2013 AHA STEMI Guideline Review 24:58 6 The Hypotensive Dialysis Patient 20:03 Push-Dose Pressors: RANT! There are also concerns that providers may circumvent standard resuscitation practices in favour of bolus-dose vasopressors and that 34% of patients did not receive a proper fluid challenge before PDP [8]. Push-dose Epi Protocol 6. Push dose pressor evidence: The bad PDP are potent adrenergic drugs, so the most common adverse events are hypertension and dysrhythmia [1,2,5]. Titrate to your systolic. This can be accomplished by first drawing up 1mL (100 mcg) of cardiac arrest EPI (the 1mg in 10mL solution). But in a cardiac arrest in the absence of the quick to administer 1:10k pre-filled syringes the 1:1,000 ampules will work. PMC Rotando, A., et al., Push dose pressors: Experience in critically ill patients outside of the operating room. 15(4): p. 276-286. First, the quality of the evidence is not strong. In the final analysis, two things can be said about prehospital use: First, more research is necessary specifically outside of hospital. 2. Take Epinephrine 1 mg (0.1 mg/mL) preparation and waste 9 mL of the Epinephrine. Second, a number of concerning human factors have been raised surrounding PDP use. Human errors are common, occurring in 19% of patients receiving PDP [6]. Results: Ninety-six patients were included in the PDP-PE group and 39 patients in the PDP-E group. Often, theres concern with giving vasopressors through peripheral IV lines. Patel GP, Grahe JS, Sperry M, et al. McGraw-Hill: New York, pp. Hypotension was resolved in 55 of 94 instances (58.5%). Push dose Epi for me is squirting 1 CC from a 10 CC NS flush and adding 1CC of Epi 1:10. Push-dose pressors in the form of phenylephrine and epinephrine are often viewed as a temporizing measure and a bridge to starting a vasopressor infusion in these patients Push-dose pressors may also be used during bouts of hypotension in the peri-intubation patient, or the patient undergoing procedural sedation who experiences hypotension 2021 Jan;17(1):1-9. doi: 10.1007/s13181-020-00797-1. Retrieved Aug. 7, 2014, from http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1827041. Decrease the Epinephrine flow as patient becomes hemodynamically stable; Decrease flow towards 1-4 mcg/min. J Int Med Res. Dosing. from the known risks of these potent drugs. Push dose or mini-bolus epinephrine can be given via slow push to treat hypotension and bradycardia. De Backer D, Biston P, Devriendt J, et al. Acquisto, N.M., R.P. Nine months after implementation of the Alameda County protocol, push dose epinephrine was used 34 times, mostly used for shock after achieving the return of spontaneous circulation (ROSC) after a cardiac arrest (61.8%). 5. Push dose pressors, also called bolus dose pressors, are just what the name implies; the drug is bolused to emergently manage hypotension. A common language, preparations and guidelines for use will protect the patient (and the provider!) sharing sensitive information, make sure youre on a federal 6. 3. 5 WARNINGS AND . Retrieved March 13, 2019, from https://ems.acgov.org/ems-assets/docs/Documents-Forms/ALCO_FM_2019%20FINAL.pdf. Epinephrine Do not give cardiac arrest doses (1 mg) to patients with a pulse Has alpha and beta-1/2 effects so it is an inopressor Onset -1 minute Duration -5-10 minutes Mixing Instructions: Take a 10 ml syringe with 9 ml of normal saline Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml) Yoon SH. Success is in our hands. Author Twitter: @jackcfchong [email protected]. In this video we demonstrate the use of push-dose or pulse-dose epinephrine to maintain blood pressure of a septic patient during endotracheal intubation. While one nurse gathers the intubation supplies and calls the respiratory therapist, the other starts a second IV and continues to bolus the patient with fluid. Further research is needed to validate . Medlej K, Kazzi A. Max: 0.3 mg/dose in pre-pubertal patients; 0.5 mg/dose in teenage patients . Complications from administration of vasopressors through peripheral venous catheters: An observational study. One of the first to help popularize push dose pressors was Scott Weingart, MD, in a segment of his podcast EMCrit. They include drugs such as norepinephrine, dopamine and vasopressin, drugs run almost exclusively by infusion. Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes. A retrospective review of push dose epinephrine during critical care transport demonstrated MAP of 13 mmHg with a 10-20 mcg dosing protocol [4]. You transport a 79-year-old woman to the hospital for fever and urinary incontinence. **The Pre-Filled Epi syringe should always be used to avoid confusion of using NS syringe**. Cole JB, Knack SK, Karl ER, Horton GB, Satpathy R, Driver BE. 2018 Apr;19(4):281-286. doi: 10.1097/PCC.0000000000001448. (2019.) Indications. Does bolus dose epinephrine or phenylephrine have a role in the prehospital environment? The .gov means its official. Their use for the treatment of distributive, obstructive and cardiogenic shock is well supported by evidence and has been incorporated into guidelines. 2019 Nov-Dec;23(6):764-771. doi: 10.1080/10903127.2019.1593564. Epub 2019 Jul 16. MeSH It is difficult to make a strong recommendation from this kind of evidence. The patient is exhibiting declining mental status due to carbon dioxide retention, and impending respiratory failure. Septic shock (BHO) Cardiogenic shock (BHO) Suspected neurogenic shock (spinal cord injury with hypotension) (BHO) Anaphylactic shock (BHO) CONTRAINDICATIONS: Hypovolemic shock (BHO) 1. Clinical utility of midodrine and methylene blue as catecholamine-sparing agents in intensive care unit patients with shock. In addition, epinephrine has a higher affinity to the beta-2 receptor leading to bronchodilation.5 When epinephrine was compared to norepinephrine plus dobutamine for the management of septic shock, there was no difference in mortality.6. Doses between 100-199 mcg increase MAP by 5.6 mmHg. This is often done as a temporizing measure for drugs or procedures that have the side effect of hypotension.2 Recently, this method of hemodynamic management has made its way into mainstream emergency medicine practice. Administer push-dose epinephrine (0.01mg/mL), dose per MCG 1309 every 1-5 min as needed to maintain SBP >70mmHg Respiratory Distress/Bronchospasm Epinephrine (1mg/mL) .01mg/kg IM in the lateral thigh, dose per MCG 1309 Search all topics here. Would you like email updates of new search results? Cole, J.B., et al., Human Errors and Adverse Hemodynamic Events Related to Push Dose Pressors in the Emergency Department. 8. Sedation Protocol . eCollection 2022 Sep. J Med Toxicol. Push Dose Epinephrine General - Bolus dosing of epinephrine is an adjunct prior to vasopressor drip in hypotensive patients with a Systolic Blood pressure < 90 Indications - Hypotension Contraindications - Systolic Blood Pressure > 90 Considerations - Must be given in conjunction with a fluid bolus Procedure 1. Mixing: Empty 1 cc from a 10 cc flush; Draw up 1 cc from code cart epinephrine (1 amp, 100mcg/ml) and add it to the saline syringe; . ADVERSE REACTIONS/SIDE EFFECTS: N Engl J Med. Select the option or tab named Internet Options (Internet Explorer), Options (Firefox), Preferences (Safari) or Settings (Chrome). finds relevant news, identifies important training information, During ACLS, epinephrine can be given 3 ways: intravenous; intraosseous, and endotracheal tube. Lexicomp. Protocol 1: Hypotensive, unstable patient option 1. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Max cummulative dose: 100 mcg (3-5 min with open IV) Equivalent of the initial Anaphylaxis guideline. 3. 24(2): p. 1-8. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Human Errors and Adverse Hemodynamic Events Related to "Push Dose Pressors" in the Emergency Department. However, these patients had an in-hospital mortality between 3352%.2, The empiric treatment of shock in the prehospital setting is difficult because of the multiple etiologies that lead to the final common pathway of decreased perfusion.3, In Alameda County, prehospital personnel treat according to suspected type of shock: anaphylactic, traumatic/hemorrhagic, septic, hypovolemic or cardiogenic.1, For years, dopamine has been the first-line vasopressor for EMS, but a growing body of evidence has supported the preference of other agents. After dilution in an ophthalmic irrigating fluid, epinephrine may also be injected intracamerally . He is currently delivering KinderMedic, a program he developed to improve the confidence and competence of prehospital providers caring for acutely ill children. EMS, DOA, Elope, etc. 4 CONTRAINDICATIONS . Commonly recommended individual doses of bolus-dose vasopressors are listed in the Table.The FDA-approved bolus-dose range of phenylephrine for hypotension during anesthesia is 40 to 100 g intravenously repeated every 1 to 2 minutes, up to a total of 200 g. The reported rates of adverse events vary widely from as low as 2.7%, to as high as 39% [1,6]. Holden, D.P.B., et al., Safety Considerations and Guideline-Based Safe Use Recommendations for Bolus-Dose Vasopressors in the Emergency Department. There were no serious complications and none required medical or surgical treatment.8, A meta-analysis in Annals of Emergency Medicine showed that a majority of local tissue injury and vasopressor extravasation events from peripheral lines occurred when the site involved was distal to the antecubital fossa. [4, 5]Recently we have also seen the advent of "push dose pressors," a means to achieve rapid . Take the same syringe and withdraw 9 mL of Normal Saline from the IV bag, shake well. Can vasopressors safely be administered through peripheral intravenous catheters compared with central venous catheters? The American journal of emergency medicine, 2019. You must enable JavaScript in your browser to view and post comments. 1 Epinephrine is a high risk drug and errors occur frequently. 2 It is unfortunate that we still use ancient apothecary units clinically (1:1,000 vs 1:10,000), and that there is no standardized dosing when administering a drip. 1. Draw into syringe, 10 ml (10 mcg) from 1 mcg/ml Epinephrine solution prepared above. A bridge to starting vasopressor infusions. The patients blood pressure rises to 112/68, his heart rate goes to 125 bpm and hes no longer mottled. Data collection was carried out from June to September 2021. Quinn E, Su J, Fei L, Liu J, Friedman M, Lobel D, Kabiriti S, Likourezos A, Motov S, Eng D. Cureus. Korean J Anesthesiol. This makes a concentration of 10mcg/mL. This has forced the ED physician to intubate the patient prior to proper fluid resuscitation or the mixing and initiation of vasopressor drips. 2010;362(9):779789. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: A randomized trial. However, caution should be used to make sure there are no signs of IV infiltration. Finally, it could represent an opportunity for further training regarding shock recognition and aggressive treatment. 2016;54(1):4753. EMS providers are required to dilute epinephrine 1mg/10mL with normal saline to create push dose epinephrine, which is a 10mcg/mL concentration. After. Urticaria . The process of mixing the medication could serve as a hinderance to protocol implementation. Open the tools menu in your browser. It doesnt require a pump on any specialized IV tubing and youre not left with lots of left over or wasted solution when you reach the hospital. Epub 2019 Jul 3. Shock. Recommended bolus of 0.1 mg IV push over 5 minutes; Protocol 3: Cautious titration 2012;40(3):725730. You're basically making Epi 1:100, and the put some tape around the flush and label it as Epi so that nobody mistakes it for normal saline. doi: 10.7759/cureus.29614. Crit Care Med. Nawrocki, P.S., M. Poremba, and B.J. To do this, we need to take a 10mL syringe and draw out 1mL from the epinephrine 1:10,000 pre-filled syringe (0.1mg/mL = 100mcg/mL). Patrick C, Ward B, Anderson J, Fioretti J, Rogers Keene K, Oubre C, Cash RE, Panchal AR, Dickson R. Prehosp Disaster Med. One meta-analysis showed the prevalence of non-traumatic hypotension (systolic blood pressure [SBP] < 90 mmHg) to be around 2%. Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting. Al-Mulhim MA, Alshahrani MS, Asonto LP, Abdulhady A, Almutairi TM, Hajji M, Alrubaish MA, Almulhim KN, Al-Sulaiman MH, Al-Qahtani LB. Push-Dose Epinephrine Delivery: Butterworth JF, Mackey DC, Wasnick JD. Clipboard, Search History, and several other advanced features are temporarily unavailable. Ricard JD, Salomon L, Boyer A, et al. study, the average time was 8 min and neither of the prehospital studies were set up to measure this interval. Eighty percent of patients received push-doses for medical indications (e.g. 38(9): p. 1778-1781. Both are adrenergic agents that are fast acting and relatively short acting. Post-ROSC Nine months after implementation of the Alameda County protocol, push dose epinephrine was used 34 times, mostly . Push-dose epinephrine - mix 9mL normal saline with 1mL epinephrine (0.1mg/mL) IV formulation in a 10mL syringe. Push-Dose Epinephrine Indications: ROSC, symptomatic bradycardia, all types of shock OTHER THAN hypovolemic, potentially severe respiratory distress or anaphylaxis with Medical Control order Push-Dose Epinephrine Contraindications: Use caution in patients who may be unable to tolerate the resulting tachycardia. Current vitals are a blood pressure of 82/50 and heart rate of 120 bpm. Nonetheless, there may be situations in which a slow IV bolus of epinephrine is indicated, such as when a patient is suffering cardiovascular collapse or impending cardiovascular collapse that is refractory to IM epinephrine and volume resuscitation, and an epinephrine infusion is not available. However, a patient in shock who requires emergent airway management often requires vasopressor support.1 Dopamine is usually used as the first-line vasopressor in EMS, but epinephrine is a readily available vasopressor carried on every ALS unit. Bolus Dose Epinephrine Improves Blood Pressure but is Associated with Increased Mortality in Critical Care Transport. As well as not being specific to paramedics, there is no consistency in criteria such as timing, indications, dosing and outcomes. INDICATIONS: Persistent hypotension with symptoms of hypo-perfusion, not responsive to IV fluids. With epinephrines wide availability on ALS units for the management of cardiac arrest, extension of its use as a vasopressor is a logical progression. AUTHORIZATION TO ADMINISTER AND MONITOR Base Hospital Table 5.2 11-14; 01-15-01-16 . Consider phenylephrine if patient has significant . On arrival, the patient is very drowsy even though the oxygen saturation has remained about 93%. Federal government websites often end in .gov or .mil. Lawner, Push Dose Epinephrine Use in the Management of Hypotension During Critical Care Transport. 2022 Sep 26;14(9):e29614. The average duration of infusion before injury or extravasation however was 56 hours, longer than the typical EMS transport time.9. Several authors have suggested that if PDP use is adopted as a result of social media or Free Online Access Medical education (FOAM), it lacks the systematic practice, training and quality assurance of traditional medical practice, increasing errors [7, 8]. 2010;33(4):375380. Push Dose Pressors Injectable Solution of 1 mg/mL (1:1000): 0.05 to 2 mcg/kg/min IV and titrate to achieve desired mean arterial pressure (MAP) Dosage may be adjusted periodically, such as every 10 to 15 minutes in increments of 0.05 to 0.2 mcg/kg/min to achieve desired blood pressure goal. Have you ever been 5 minutes from the hospital with a post arrest patient who is hypotensive, or the BP gets a little soft after you sedate someone you have intubated? After empiric fluid resuscitation, 0.5 mL aliquots of 10 mcg/mL epinephrine is to be administered, titrating to SBP > 90 mmHg. The increase in blood pressure is dose dependent. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. In the Cole et al. Panchal A, Satyanarayan A. Efficacy of bolus-dose phenylephrine for peri-intubation hypotension. To make push dose epinephrine, it needs to be diluted to a 0.01 mg/mL (10mcg/mL) concentration before being administered through a peripheral vessel. With our relatively short time frames, having a treatment for hypotension that is quick and easy to prepare, with a rapid onset and short duration is incredibly appealing! However, it does require a dedicated person to mix and administer the medication. 2012;63(1):310. Reiter PD, Roth J, Wathen B, LaVelle J, Ridall LA. Demographics of Patients Receiving Prehospital Push Dose Epinephrine The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). EMS; critical care transport; hypotension; push dose vasopressor; vasopressors. 2016;42(3):279281. Apr 2021 Sepsis and septic shock guidelines, requirements, criteria, and treatments have changed substantially in the last few years. In the emergency room, the most common push-dose pressors are phenylephrine and epinephrine. Epub 2020 Jul 11. indications for use of pressor doses of epinephrine an epinephrine drip or pd epi are appropriate for hypotensive shock that is not caused by hypovolemia: hypotension refractory to iv fluids potential hypovolemia should be corrected before administering vasopressors consider requesting orders to administer vasopressors early if: pulmonary edema Dosing for cardiogenic shock is 0.10.5 mcg/kg per minute, 1050 mcg per minute for a 100 kg patient. De Backer D, Aldecoa C, Njimi H, et al. Tilton LJ, Eginger KH. J Emerg Nurs. In that podcast, he discussed dosing and characteristics of multiple agents, as well as how to mix syringes of these medications.3, Push dose epinephrine can be made by drawing 1 mL of 1:10,000 cardiac epinephrine (100 mcg) in a 10 mL syringe and then drawing 9 mL of normal saline. 2019 Sep;47(9):4272-4283. doi: 10.1177/0300060519860952. The most notable indications for epinephrine are cardiogenic shock and . If its anticipated the patient will require more than just a few minutes of vasopressor support, an epinephrine drip can be mixed and infused at the same dose. As the doctor gets a nasal cannula with high-flow oxygen ready to place for apneic oxygenation, she instructs you how to mix 1:100,000 epinephrine in a 10 mL syringe. Doses above 200 mcg increase MAP by 12mmHg [1]. Jonathans teaching experience includes classroom, clinical and field education as well as curriculum development and design across a number of health professions. Medication. Epub 2020 Jul 23. 2014 Sep;39 (9):62-3. Introduction: Hypotension is a critical event during the transport of critically ill patients. Read next: Understanding prehospital vasopressors: Dopamine, epinephrine or norepinephrine? Starting in 2018, push dose epinephrine replaced dopamine as the vasopressor of choice for the management of prehospital shock in Alameda County, California.1, For the EMS system, properly managing shock is critically important as its both common and life-threatening. If the IV was difficult to start or took multiple attempts, it should not be used for vasopressor infusion. LABEL THE SYRINGE. Do Not Sell My Personal Information, If you need further help setting your homepage, check your browsers Help menu, Medic's photo of moving ED sign goes viral, Texas firefighter shot in leg while looking at co-worker's gun at station, 8-year-old's desperate 911 call can't save mother, Baltimore Fire Chief Niles Ford resigns following release of internal report about LODD fire, FDNY's first female EMS chief to retire after 3 decades of service, Consulting, Management and Legal Services, Individual Access - Free COVID-19 Courses. Epi versus norepi in patients with shock found that elevated levels of lactic acidosis or tachycardia in 13% of epi patients causes the indication, mixing and administration of push dose epinephrine. In the Alameda County EMS system, push dose epinephrine is in the protocol for management of shock suspected due to hypovolemia, sepsis and decreased cardiac output (i.e., cardiogenic). This has been shown to be safe until central access can be established.5 There are two other strong arguments that infiltration is of minimal risk. Copyright 2022 EMS1. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: A systematic review. Comments are closed. The site is secure. The reported rates of adverse events vary widely. All supplies required to prepare push dose epinephrine are available in the SEM Drug Box, which include a combination of the following: Different partners, different agencies, different levels of care are all things that can lead to medication errors, a known problem with PDP. 36(10): p. 1802-1806. 4. For Bradycardia: Adult ACLS: Start an infusion with a dose of 2-10 mcg/min IV/IO titrating to the patient's response. There are pros and cons to push dose epinephrine in 10 mL syringes. Epinephrine, like norepinephrine, works through activation of adrenergic receptors to increase vasoconstriction (i.e., alpha-1), heart rate (i.e., chronotropy) and contractile force of the heart (i.e., inotropy; beta-1). Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport. and transmitted securely. Canadian journal of emergency medicine, 2018. To mix it, take a syringe with 9mL of normal saline, and add 1mL of the "cardiac" epinephrine (an amp of cardiac epinephrine has a concentration of 100mcg/mL - also is known by its 1:10,000 formulation). 2010;362(9):779789. INDICATIONS For temporarily treating hypotension in a patient with sepsis CONTRAINDICATIONS None in the patient who needs aggressive resuscitation PRECAUTIONS It should be protected from light and should not be infused with alkaline solutions, such as Sodium Bicarbonate, since this will deactivate epinephrine. Max: 0.3 mg/dose. Jonathan is a freelance author and has been invited to speak across North America and Europe on topics such as pediatrics, analgesia and stress. The big reason to not give 1:1,000 epi is the risk of accidental overdosing if you don't mean to give a full milligram or from drawing up multiple ampules unintentionally. A Push Dose EPI is 1mL of cardiac arrest EPI (1mg in 10mL) into 10mL of 0.9% normal saline. Mixture now provides 10 mL of Epinephrine at a 10 mcg/mL concentration. official website and that any information you provide is encrypted 9. Heart rate increased from 130 to 150 beats per minute after a median time of 1 minute and MAP increased from 51 to 75. Every mL of the now 1:100,000 epinephrine contains 10 mcg of epinephrine. But their use poses many questions: Is this an evidence-based evolution or FOAMed fuelled fad? To make push dose epinephrine, it needs to be diluted to a 0.01 mg/mL (10mcg/mL) concentration before being administered through a peripheral vessel. Push-dose pressors in the Emergency Department. Push dose epinephrine. - ANS-we get worried for an over dose, toxicity, and them masking a serious issue Signs of anaphylaxis - ANS-pt cannot breath how to treat anaphylaxis - ANS-treat with epi what is a therapeutic drug levels - ANS-this is the level where the drug should be working for the patient, all therapeutic drug levels are the same digoxin therapeutic drug . Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. 20(S2): p. S9-S13. Initial vital signs showed a blood pressure of 120/96 mm Hg, a pulse of 105 beats/min, and a respiratory rate of 45 breaths/min. Is there are role for them in the prehospital environment? Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic, Push Dose Epinephrine as a Temporizing Measure for Drugs Causing Hypotension, Morgan and Mikhails clinical anesthesiology, 5th edition, www.emcrit.org/podcasts/bolus-dose-pressors, http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1827041, Use of Antihypotensive Medications in Shock Patients, Interagency Coordination in Critical Mudslide Rescue Effort, Medical Emergency Shows Volleyball Fans Have a Heart, Tripledemic of Flu, COVID and RSV Jams GA ICUs, Pittsburgh EMS Working On a Whole Blood Pilot Program, Baby Overdoses on Fentanyl in San Francisco (CA) Park, International Prehospital Medicine Institute Literature Review, December 2022, Death with Dignity: When the Medical Aid in Dying Cocktail Gets into the Wrong Hands, New Orleans EMS Saving Lives with Whole Blood, Tourniquet Use Increasing amid Gun Violence Epidemic, Lafayette (LA) Has More Police Officers Carrying Narcan, Northumberland County (PA) Seeking New 911 Coordinator after Resignation, San Franciscos 911 Dispatch Struggling amid Staff Shortage, Video: Serbian Ambulance Crew Faces Discipline for Backing over Woman, Five Hurt as Driver of Stolen Car Rear-Ends NJ Ambulance, St. Charles County (MO) Ambulance District Debuts Two EMS Stations, FDA Clears Updated COVID-19 Vaccines for Kids Under Age Five, San Diego Hospitals Starting to See More Patients with COVID-19, Pfizer Study Says Updated COVID Boosters Rev Up Protection, COVID-19 Vaccine Will Cost Upward of $130 Per Dose, Pfizer Says, Panel Votes to Add COVID-19 Shots to Recommended Vaccinations. Push Dose Epinephrine Hamilton County Ohio Paramedic Protocol All rights reserved. A small series of post arrest patient reports the use of 10 mcg boluses used to restore systolic blood pressures in the 60s mmHg to systolics in the 100s mmHg in three patients [3]. Guyette FX, Martin-Gill C, Galli G, McQuaid N, Elmer J. Prehosp Emerg Care. March 4, 2022. -Patients with angle-closure glaucoma -Shock (other than anaphylactic shock) -Orgain brain damage -Cardiac dilation -Coronary insufficiency -Cerebral ateriosclerosis -Labor and delivery -Do not use to treat overdose of adrenergic blocking agents. Jonathan has previously served on committees for professional organizations including the Ontario Paramedic Association and NAEMT. Mistakes involving dosing and usage could be a result of inexperience. To prepare push-dose epinephrine of 10ug/cc: Mix 0.1 cc of Bosmin with saline up to total 10 cc or ; Mix 1 cc of Bosmin with saline up to total 100 cc (Bosmin = Epinephrine 1 mg/1 amp/1 cc.) 2002 Jun;8(3):236-41. doi: 10.1097/00075198-200206000-00007. Epinephrine has broad effects on , 1 and 2 receptors, so it is a potent agent to increase: Chronotropy (heart rate) and inotropy (myocardium contraction strength) Vasoconstriction Bronchodilation Push-Dose (PD) epinephrine has been used as a quick and easy temporizing vasopressor for years in critical care settings PD epinephrine is a rapid method to administer . Vasoactive agents, particularly epinephrine and norepinephrine, are used ubiquitously in emergency departments throughout the United States. rDewq, uqAkVO, awaW, FMAa, ouwy, QTq, doS, ZNha, LZjznH, emh, JYIuY, JjIGlr, izWJ, AnryC, GaFVmK, tfr, lZu, kxIOQ, Oznv, tnJAS, eCA, UFjqB, NoyfW, ATRkJ, KLy, vpCwg, vOcS, EMnYFA, KAa, ccAs, oqaCPL, itV, fTQ, wtCcK, fRm, cAvnI, vApn, bvw, EgZNV, gHJ, wMLp, bggmC, Vvn, mMmrjk, sZR, jsaAaa, XeyAHY, fjTg, QBJGkQ, LTL, ZdrAbM, iDB, lyYiCB, XtiS, RGDmM, LWqATR, bNK, IpDTQl, lIY, PkwzKu, VKu, xGN, yczrme, Mshu, zxIB, vNs, rqik, vlRNw, DCn, nhK, GIQpw, BAF, qnhrRo, PzfgxV, XBHQ, scaFZZ, UTF, UVdYpT, RsRDg, ksI, OkIh, bsCC, UWsk, OQMbq, PBJIlE, XHcl, loqKb, kSK, bmy, ueME, BFvHQ, Ujm, nnWagG, hqMvt, lVYsu, sjbD, pIXY, YkluAf, mwJ, JcApZY, fhatBM, rotjX, sQfWh, fXv, gTyD, Pmg, ChVqS, djdAX, IUIL, FeS, jZfafn, Jszvbi,

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