University of Wisconsin–Madison Medical College of Wisconsin

Choosing a Vasopressor for a Prehospital Emergency Medical System: Consideration for Agent Selection and Review of Pharmacologic Profiles, Efficacy, and Safety in Treatment of Shock

Ryan Feldman, PharmD; Matthew Stanton, PharmD; Matthew Chinn, MD; Thomas Grawey, DO; Benjamin Weston, MD, MPH

WMJ. 2020;119(4):240-247.

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Introduction: Prehospital medical teams encounter patients with varying states of shock that require the use of vasopressors for hemodynamic support during transport. Selection of a vasopressor is challenging due to the absent comparative literature in prehospital medicine, as well as practical limitation of use in an ambulance.

Areas Covered: This article discusses specific challenges in the delivery of vasopressor support for hemodynamically compromised patients in the prehospital environment. Discussion includes the current state of vasopressor use in prehospital medicine, use of a patient-specific agent selection or “one-vasopressor-fits-all” modality, as well as considerations for each vasopressor based on practical, pharmacologic, and comparative evidence-based evaluations.

Conclusions: There are currently many limitations to assessment of shock etiology in the prehospital setting. A “one-vasopressor-fits-all” strategy may be most feasible for most prehospital emergency medical services (EMS) systems. No clear difference in extravasation exists amongst agents. Based on current evidence, norepinephrine may be more efficacious and have a better safety profile than other vasopressors in cardiogenic, distributive, and neurogenic shocks. Due to its suitability for most shocks, norepinephrine is a reasonable agent for EMS systems to employ as a “one-size-fits-all” vasopressor.

Author Affiliations: Froedtert and The Medical College of Wisconsin (MCW), Department of Pharmacy, Milwaukee, Wis (Feldman, Stanton); MCW School of Pharmacy, Milwaukee, Wis (Feldman, Stanton); MCW Department of Emergency Medicine, Milwaukee, WI (Feldman, Stanton, Chinn, Grawey, Weston); MCW Emergency Medical Services (EMS) Section, Milwaukee, Wis (Chinn, Grawey, Weston).
Corresponding Author: Ryan Feldman, PharmD, 9200 W Wisconsin Ave, Milwaukee, WI, 53226; phone 414.805.0481; email
Funding/Support: None declared.
Financial Disclosures: None declared.
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