What is the recommended vasopressor and dosage for treating cardiogenic shock in the pre-hospital setting?

From the Guidelines

Norepinephrine is the recommended first-line vasopressor for cardiogenic shock in the pre-hospital setting. The dosage typically starts at 0.1-0.2 mcg/kg/min and is titrated up to 1-2 mcg/kg/min as needed to maintain a mean arterial pressure (MAP) of 65-70 mmHg 1. Administration requires an intravenous line, preferably central venous access, though peripheral administration can be used initially if necessary. Dopamine (5-15 mcg/kg/min) or epinephrine (0.05-0.5 mcg/kg/min) are reasonable alternatives when norepinephrine is unavailable.

When administering vasopressors, continuous cardiac monitoring, frequent blood pressure checks, and assessment of peripheral perfusion are essential. Norepinephrine is preferred because it provides potent vasoconstriction with less tachycardia than other agents, which is beneficial in cardiogenic shock where the heart is already compromised 1. The use of norepinephrine is supported by recent guidelines, including those from the European Society of Cardiology, which recommend its use in cardiogenic shock due to its effectiveness in improving hemodynamics and its relatively favorable side effect profile compared to other vasopressors 1.

Key considerations in the management of cardiogenic shock include:

• Immediate assessment and diagnosis
• Fluid challenge to ensure adequate filling status
• Use of inotropic agents and vasopressors as needed
• Continuous monitoring of organ perfusion and hemodynamics
• Consideration of device therapy, such as intra-aortic balloon pump or percutaneous left ventricular assist device, in cases of inadequate response to medical therapy 1.

Remember that vasopressors are temporary support measures while arranging rapid transport to a facility capable of definitive treatment, as the underlying cause of cardiogenic shock requires immediate intervention such as revascularization for myocardial infarction.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. Each mL of this dilution contains 4 mcg of the base of LEVOPHED Give this solution by intravenous infusion. After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs

The recommended vasopressor for treating cardiogenic shock in the pre-hospital setting is norepinephrine (IV).

• The initial dose is 8 mcg to 12 mcg of base per minute, which can be adjusted to maintain a low normal blood pressure.
• The average maintenance dose ranges from 2 mcg to 4 mcg of base per minute. 2

From the Research

Vasopressor Indicated for Cardiogenic Shock in Pre-Hospital Setting

• The recommended vasopressor for treating cardiogenic shock in the pre-hospital setting is norepinephrine 3, 4, 5, 6.
• Norepinephrine is associated with minimal adverse effects and appears to be associated with the best outcome in network meta-analyses 5.
• The use of norepinephrine is recommended as first-line vasopressor agent by various guidelines 5.
• Epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death 5, 6.
• Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension 5.

Dosage of Norepinephrine

• The dosage of norepinephrine is not specified in the provided studies, but it is recommended to use it as a temporary bridge to recovery, mechanical circulatory support, or heart transplantation 3.
• The use of norepinephrine should be individualized and based on the hemodynamic response 5.

Comparison with Other Vasopressors

• Norepinephrine may be more efficacious and have a better safety profile than other vasopressors in cardiogenic, distributive, and neurogenic shocks 4.
• A "one-vasopressor-fits-all" strategy may be most feasible for most prehospital emergency medical services (EMS) systems, with norepinephrine being a reasonable agent to employ 4.