Get the Squeeze You Need - Vasopressor Use in the ED

Vasopressors are not interchangeable, and early agent choice matters in ED shock resuscitation. Norepinephrine and epinephrine are first-line for most shock states, while blood pressure targets, second-agent timing, arterial line decisions, and peripheral pressor safety all change with the physiology in front of you.

ED Vasopressor Strategy

• First-line inopressor choice: Norepinephrine and epinephrine are the default first-line pressors for most shock states because they raise systemic vascular resistance while supporting cardiac output.
• Anaphylaxis pressor exception: Epinephrine is the first-line vasopressor in anaphylactic shock, with added mast-cell stabilization that makes it more than just a blood pressure drug.
• Goal-directed pressure targets: Pressors need a defined endpoint: a MAP above 65 is common, but many patients benefit from tracking both MAP and systolic blood pressure against their pathology-specific goal.
• Second-agent timing: If you have already uptitrated the initial pressor twice, think about adding a second agent rather than reflexively chasing the dose higher. We get into the practical sequencing in the episode.
• Preferred add-on agents: Vasopressin is the usual second agent in vasodilatory shock, while dobutamine fits low-output states and phenylephrine has a niche when tachycardia makes beta-agonism undesirable.
• Steroids and dose ceilings: There is no evidence-based vasopressor ceiling in the literature, and stress-dose steroids are reasonable when escalating pressors still are not achieving the hemodynamic goal.

Lines Monitoring and Safety

• Peripheral pressor safety: Peripheral vasopressors are supported for up to 24 hours when the IV is larger than 20 gauge and placed proximal to the antecubital fossa.
• IO bridge access: Intraosseous access can safely serve as an initial bridge for vasopressor delivery when central access is delayed in a crashing patient.
• When arterial lines help: Not every patient on vasopressors needs an arterial line; it becomes more useful as titration intensity rises and blood pressure precision starts to matter more.
• Vasopressin line caveat: Vasopressin is different from catecholamines here: peripheral use is discouraged because extravasation lacks an antidote and digital ischemia is a real complication.
• Dopamine harms: Dopamine is difficult to titrate and has higher mortality than alternative pressors, plus its diuretic effect can falsely reassure you about renal perfusion. That bedside reasoning is worth hearing in the chapter.

References:

1. Legrand, M., Zarbock, A. Ten tips to optimize vasopressors use in the critically ill patient with hypotension. Intensive Care Med 48, 736–739 (2022).  PMID: 35504977