Welcome to Critical Care Time, a new critical care-focused column from ACEP Now.

My goal in this column is to share tips, tricks, and emerging concepts from the intensive care unit (ICU) that you can use on your next shift in the emergency department (ED). Whether you are acutely resuscitating a critically ill patient or managing a boarding ICU patient, my goal is to give you practical knowledge from critical care-trained emergency physicians who know what it is like to work in the ED.

If there are topics that you want me to cover, don’t hesitate to reach out. This column is for you!

For this inaugural column, I wanted to start with a topic near and dear to my heart: push-dose vasopressors in the ED. I know I am not the only one to have my stomach drop while listening to the blood pressure cuff cycle again and again before displaying a number far lower than what I was  hoping for. Mastering the use of push-dose pressors ensures that feeling is short-lived by giving you tools to rapidly and appropriately manage sudden hypotension.

What is a Push-Dose Pressor?

To keep it simple, a push-dose pressor is any vasopressor administered as an IV push—essentially, a bolus of pressor.¹ Push-dose pressors can come in handy in three situations:

1. Anticipated transient hypotension. Perhaps you have decided to perform procedural sedation with propofol, a known vasodilator. Having a push-dose pressor at the ready will ensure that you can counteract any transient hypotension that occurs after administration of the medication. Anesthesiologists do this all the time after bolusing propofol for induction of anesthesia.
2. Known hypotension, as a bridge to a continuous infusion of a pressor. Your patient is sick and already severely hypotensive, but you are waiting for a nurse to obtain a pressor from the pharmacy, or for your pharmacist to compound the bag. Using push-dose pressors can be your lifeline while waiting for the infusion bag to arrive.
3. Unanticipated hypotension. Finally, you may find yourself in an unexpected situation where you need a pressor immediately, but do not have any readily available in your location. You can use medications found in the crash cart to quickly create a push-dose pressor.

Common Vasopressors

Click to enlarge.

So, what pressor do you use? Let’s review the most common:

• Phenylephrine (Neo-Synephrine or “Neo”). Phenylephrine is the prototypical push-dose pressor and is classically given by anesthesiologists after induction. A pure a₁– agonist, phenylephrine gives you peripheral vasoconstriction but no increase in cardiac output. Perfect for someone who has vasodilated or in need of increased afterload, phenylephrine is a great choice for unstable atrial fibrillation with rapid ventricular response or after a bolus of propofol. However, because it does not give you any increase in cardiac output, it isn’t an optimal choice for someone with myocardial depression. Typical dosing of phenylephrine is 50-200 micrograms every three to five minutes. (When a patient is acutely unstable, I set the blood pressure cuff to cycle every three to five minutes. This way, you can give another dose with each cycle of the cuff!)
• Epinephrine (“epi”). Epinephrine has more balanced a₁ and b Because of this, it will give you both peripheral vasoconstriction from the a₁ and an increase in heart rate (chronotropy) and contractility (inotropy) from the b₁. However, because of the b₁ effect, tachydysrhythmias are a common side effect.² Epinephrine has the advantage of being easily accessible in most locations of the hospital, as it is stocked in code carts. Because of its availability, it has become the push-dose pressor of choice for many emergency physicians and for critical care transport.³ Typical dosing of epinephrine is 10-20 micrograms every three to five minutes.

Alternative Vasopressors

Phenylephrine and epinephrine are the most common push-dose pressors used in the ED. However, emerging evidence also suggests alternative agents as options.

• Norepinephrine (Levophed). Norepinephrine has become the go-to pressor for nearly all types of shock for several reasons. Unsurprisingly, it is also a fantastic push-dose pressor.⁴ It has more a₁ than b₁, so most of the blood pressure effect is from peripheral vasoconstriction. Although it has some b₁ to support patients with myocardial depression, it doesn’t tend to have as much arrhythmogenic effect as epinephrine, making it a great balanced pressor. Because norepinephrine has been widely adopted as the go-to pressor in the ED, infusion bags are generally readily available, and the enterprising emergency physician can draw a bolus dose directly from the bag (which will helpfully be labeled with the concentration). Dosing is similar to epinephrine, 10-20 micrograms every three to five minutes.

Although norepinephrine hasn’t historically had the same popularity as phenylephrine and epinephrine in the ED, I have found myself using it more often because of its balanced side-effect profile and easy availability.

• Vasopressin (“Vaso”). Vasopressin is a non-catecholamine vasopressor, acting primarily on the V₁ Because of its unique mechanism of action, it provides vasoconstriction but is generally less dependent on pH and may spare some of the pulmonary artery constriction seen with phenylephrine, a feature potentially desirable for patients with right heart decompensation or pulmonary hypertension. Use in the ED has mainly been described in case reports.⁵ Dosing is typically 0.4 to one unit once.

Perils and Pitfalls

Now that we have reviewed the common push-dose pressors and their dosing, what are the common perils and pitfalls? The most common, by far, is dosing. There have been a number of reports suggesting orders-of-magnitude errors; these tend to almost invariably result in overdoses.^1,6-8 Multiple sources will describe how to mix up push-dose pressors yourself.^9-11 For example, to make push-dose epinephrine from the code cart dose, you take the 1 mg in 10 mL syringe (1000 mcg in 10 mL = 100 mcg per mL), remove 1 mL (100 mcg) and then mix it into 9 mL of a saline flush, giving a final 10 mcg/mL concentration. However, that math is tricky even when you are relaxed, and mixing this under a high-stress, high-stakes scenario is a recipe for mistakes.¹² Instead, I suggest you work with the pharmacy to stock pre-made syringes and have them readily available.¹ These have the convenience of being compounded ahead of time and will have standardized concentrations.

Otherwise, the most common errors I have seen are trying to use a push-dose pressor when a continuous vasopressor is needed, and failing to diagnose or treat the underlying cause of the hypotension. If you intubate a profoundly hypotensive patient with propofol, no amount of push-dose pressor will be superior to resuscitating beforehand! Like peripheral administration of vasopressors, peripheral administration of push-dose pressors is safe; when administered into a large bore, well-functioning IV catheter, the risk of extravasation is minimal.^9,13,14

Over the last several years, I have seen a significant increase in the use of push-dose pressors in the ED. If you are not already doing so, hopefully, you can put these tips and tricks into action on your next shift!

Dr. Jansson is an assistant professor of emergency medicine at Harvard Medical School and an emergency and critical care physician at Brigham and Women’s Hospital in Boston. He practices in both the ED and ICU.

References

1. Holden D, Ramich J, Timm E, et al. Safety considerations and guideline-based safe use recommendations for “bolus-dose” vasopressors in the emergency department. Ann Emerg Med. 2018;71(1):83-92.
2. Tisdale JE, Patel R V, Webb CR, et al. Proarrhythmic effects of intravenous vasopressors. Vol. 29, Ann Pharmacother. 1995.
3. Nawrocki PS, Poremba M, Lawner BJ. Push dose epinephrine use in the management of hypotension during critical care transport. Prehospital Emergency Care. 2020;24(2):188-195.
4. Berkenbush M, Singh L, Sessa K, Saadi R. Scoping review: is push-dose norepinephrine a better choice? West J Emerg Med. 2024;25(5):708-714.
5. Nowadly CD, Catlin JR, Fontenette RW. Push-dose vasopressin for hypotension in septic shock. J Emerg Med. 2020;58(2):313-316.
6. Singer S, Pope H, Fuller BM, Gibson G. The safety and efficacy of push dose vasopressors in critically ill adults. Am J Emerg Med. 2022;61:137-142.
7. Cole JB, Knack SK, Karl ER, et al. Human errors and adverse hemodynamic events related to “push dose pressors” in the emergency department. J Med Toxicol. 2019;15(4):276-286.
8. Acquisto NM, Bodkin RP, Johnstone C. Medication errors with push dose pressors in the emergency department and intensive care units. Am J Emerg Med. 2017;35(12):1964-1965.
9. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132.
10. Weingart S. Push Dose Pressors. https://emcrit.org/wp-content/uploads/push-dose-pressors.pdf. Accessed March 5, 2025.
11. Browning B. Push-Dose Pressors. https://www.emdocs.net/push-dose-pressors/. Published: January 4, 2014. Accessed June 3, 2025.
12. Tilton LJ, Eginger KH. Utility of push-dose vasopressors for temporary treatment of hypotension in the emergency department. J Emerg Nurs. 2016;42(3):279-281.
13. Tian DH, Smyth C, Keijzers G, et al. Safety of peripheral administration of vasopressor medications: a systematic review. Emerg Med Australas. 2020;32(2):220-227.
14. Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the peripheral administration of vasopressor agents. J Intensive Care Med. 2019;34(1):26-33.