How to Mix Push-dose Epi: One out, one in — makes ten

Goal concentration: 10 mcg/mL

Step-by-Step Mixing:

1. Start with a 10 mL syringe of normal saline (NS)

• empty 1 mL to retain 9 mL of NS in the syringe.

2. Use the code cart 1:10,000 epi (100 mcg/mL)

• This is the standard “cardiac arrest epi” amp (usually 1 mg in 10 mL)…the 1:10,000 prefilled syringe used during ACLS

3. Withdraw 1 mL of the 1:10,000 epi (this gives you 100 mcg) using 3 mL syringe.

4. Inject that 1 mL (100 mcg) into your syringe of 9 mL NS.

• Now you have 10 mL of epinephrine at 10 mcg/mL — ready to use.

So what we just did is the mnemonic: One out, one in — makes ten

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• What’s the concentration of the code cart epi?

• How much do you withdraw?

• What do you inject it into?

• What’s the final concentration?

You should be able to say it out loud, now. If not — just repeat the podcast a couple of times to get it solid.

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How to Administer:

• Dose: 1–2 mL IV push every 1–5 minutes PRN hypotension

• That’s 5 to 20 micrograms per dose — meaning 0.5 to 2 mL of your push-dose epi, depending on the patient’s response.

• Titrate to clinical effect (aim for MAP >65 or ROSC support)

E-MOTIVE Mnemonic for Postpartum Hemorrhage: A Lifesaving Strategy

The E-MOTIVE mnemonic stands for a six-component bundle aimed at tackling postpartum hemorrhage (PPH), a major cause of maternal death, especially in low-resource settings. This approach, tested in a cluster-randomized trial across 80 hospitals in Kenya, Nigeria, South Africa, and Tanzania, was published in the New England Journal of Medicine in 2023. Here’s what E-MOTIVE stands for and why it matters:

• E – Early Detection: Uses a calibrated blood-collection drape to objectively measure blood loss after vaginal delivery. This ensures PPH (blood loss ≥500 ml) is identified quickly and accurately, unlike visual estimation, which can be unreliable.

• M – Massage: Uterine massage is performed to stimulate contractions and control bleeding, particularly for uterine atony, the most common cause of PPH.

• O – Oxytocic Drugs: Administers drugs like oxytocin to promote uterine contractions and reduce bleeding. These are critical for managing uterine atony effectively.

• T – Tranexamic Acid: An antifibrinolytic drug given to stabilize clots and reduce bleeding, especially when administered early after PPH onset.

• I – Intravenous Fluids: Provides fluids to maintain blood volume and prevent shock in women experiencing significant blood loss.

• V – Vaginal Examination and Escalation: Involves a thorough genital tract exam to identify trauma or retained tissue, with escalation to surgical or advanced care if bleeding persists.

• E – Effective Teamwork: Emphasizes communication, cooperation, and rapid response among healthcare providers to ensure all components are delivered promptly.

Why It’s a Game-Changer: The trial showed that E-MOTIVE reduced the risk of severe PPH (blood loss ≥1000 ml), laparotomy for bleeding, or maternal death by 60% compared to usual care.

PPH was detected in 93.1% of cases in the intervention group versus 51.1% in the control group, and the treatment bundle was used in 91.2% of cases versus 19.4%.

This bundle ensures evidence-based interventions are applied consistently and concurrently, saving lives by addressing PPH faster and more effectively.

E-MOTIVE is a practical, scalable solution, especially for low- and middle-income countries where PPH is deadliest. Its use of low-cost tools like the blood-collection drape makes it accessible, while the mnemonic simplifies training and implementation for healthcare teams under pressure.

This summary is based on the New England Journal of Medicine article.

This is a Neonatal Resuscitation Algorithm flowchart, specifically the NRP (Neonatal Resuscitation Program), published by the AHA in 2020. It provides a step-by-step guide for healthcare providers to follow during the resuscitation of a newborn immediately after birth, focusing on stabilizing the infant’s breathing, heart rate, and oxygenation.

Starting Point

• Antenatal Counseling and Team Briefing: Before birth, the team prepares and checks equipment.

• Birth: The process begins at the moment of birth.

Initial Assessment (Within the First Minute)

1 Term Gestation? Good Tone? Breathing or Crying?

◦ If Yes: The infant stays with the mother for routine care (warming, maintaining normal temperature, positioning airway, clearing secretions if needed, drying, and ongoing evaluation).

◦ If No: Proceed to resuscitation steps.

2 Apnea or Gasping? HR Below 100/min?

◦ If Yes:

▪ Start PPV (Positive Pressure Ventilation) using a SpO₂ monitor and consider an ECG monitor.

▪ Check if the heart rate (HR) is still below 100/min after PPV.

◦ If No:

▪ Check for Labored Breathing or Persistent Cyanosis.

3 Labored Breathing or Persistent Cyanosis?

◦ If Yes:

▪ Position and clear the airway, monitor SpO₂, and provide supplementary O₂ as needed. Consider CPAP (Continuous Positive Airway Pressure).

▪ Follow up with post-resuscitation care and team debriefing.

◦ If No: Continue with routine care as described earlier.

Further Resuscitation (If HR Remains Low)

4 HR Below 100/min After PPV?

◦ If Yes:

▪ Check chest movement and take corrective ventilation steps if needed (e.g., using an endotracheal tube (ETT) or laryngeal mask).

◦ If No: Monitor and continue care.

5 HR Below 60/min?

◦ If Yes:

▪ Intubate if not already done.

▪ Start chest compressions coordinated with PPV using 100% O₂.

▪ Use an ECG monitor and consider an umbilical venous catheter (UVC) for access.

◦ If No: Continue monitoring.

6 HR Still Below 60/min After Compressions?

◦ If Yes:

▪ Administer IV Epinephrine.

▪ If HR remains persistently below 60/min, consider hypovolemia (low blood volume) or pneumothorax (collapsed lung) as potential causes.

Additional Information

• Targeted Preductal SpO₂ After Birth: The chart lists target oxygen saturation (SpO₂) levels for a newborn at different time intervals post-birth:

◦ 1 min: 60%–65%

◦ 2 min: 65%–70%

◦ 3 min: 70%–75%

◦ 4 min: 75%–80%

◦ 5 min: 80%–85%

◦ 10 min: 85%–95%

Context

This algorithm is used in clinical settings, particularly in delivery rooms or neonatal intensive care units (NICUs), to guide healthcare providers in managing newborns who aren’t breathing adequately or have a low heart rate at birth. It emphasizes rapid assessment and intervention to ensure the infant stabilizes within the critical first minutes of life.