Start Peripheral Vasopressors Early in Shock!

It has been dogmatically believed that prolonged infusion of any vasopressor mandates placement of a central line.  However, available evidence doesn’t support this.

  1. Diluted solutions of all catecholamines are safe (except Vasopressin) to be administered peripherally via a well functioning 18-20G IV or larger in forearm (no hand/wrist/AC) .
  2. No old IVs (>72 hrs)
  3. Know how to treat extravasation


Anaphylaxis is a sudden, severe allergic reaction that may cause death. The single most effective treatment for an episode of anaphylaxis is administration of epinephrine. Epinephrine is a chemical that arrests the chain of reactions that causes the signs and symptoms of anaphylaxis.


Biphasic Anaphylaxis

The late phase response, as noted, refers to the recrudescence of symptoms after an apparent temporary resolution. Such patients are said to experience biphasic anaphylaxis. Biphasic anaphylaxis is recurrent anaphylaxis occurring 1 to 72 hours after resolution of an initial anaphylactic episode, though an outside limit of 78 hours has also been suggested. Estimates of biphasic anaphylaxis vary from <1% to 20% of patients; These recurrences can occur repeatedly after multiple temporary remissions.  Delayed epinephrine administration is also associated with an increased risk of developing a biphasic reaction, i.e., worsening symptoms after a period of improvement.

Biphasic anaphylaxis is associated with;

  • a more severe initial presentation of anaphylaxis (odds ratio [OR], 2.11; 95% CI, 1.23-3.61) or
  • repeated epinephrine doses (i.e., >1 dose of epinephrine) required with the initial presentation (OR, 4.82; 95% CI, 2.70-8.58)
  • wide pulse pressure (OR, 2.11; 95% CI, 1.32-3.37),
  • unknown anaphylaxis trigger (OR, 1.63; 95% CI, 1.14-2.33),
  • cutaneous signs and symptoms (OR, 2.54; 95% CI, 1.25-5.15), and
  • drug trigger in children (OR, 2.35; 95% CI, 1.16-4.76)

Prompt and adequate treatment of anaphylaxis appears central to reducing biphasic anaphylaxis risk. While the possibility of biphasic anaphylaxis should be emphasized in this higher risk group, it is important to educate all patients regarding the chance of a biphasic reaction as well as avoiding known triggers, identification of symptoms of anaphylaxis, the use of auto-injector epinephrine for the treatment of anaphylaxis, and timely follow-up with an allergist.

Adrenaline: It’s just a suggestion


Epinephrine and other ACLS drugs lead to more patients with ROSC but no increase in the number of patients with good neurologic outcomes after OHCA.

Something that’s very interesting is the actual 2015 ACLS recommendation for epinephrine. It reads, “it is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest.” This actually leaves room to not give the medication if the physician thinks it should be withheld.




In Anaphylaxis, IM Adrenaline (lateral thigh) is preferred over subcutaneous injection because it leads to a more rapid rise in plasma concentration. Only use IV if the patient has circulatory collapse – this can be done peripherally for a short time period if necessary…