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Dopamine in ROSC

Question# 740

Why can’t we have added to our “ROSC” or other appropriate medical directive push-dose epinephrine (1:100,000) and/or phenylephrine?

We’ve had Dopamine since the beginning of OPALS, it is seldom used in both prehospital/hospital setting, preparing it and administering by gravity is tedious and frustrating especially during an already cognitively loaded call. I recently maxed out Dopamine on a critically ill patient and it still was inefficient. Please contact me at email provided for further clarification. Thank you.


It is crucial to target blood pressure after ROSC, as hypotension has been associated with worse outcomes in post-ROSC patients. The simple answer for how best to do this is by using whatever is easiest, safest and most effective. IV fluids are a good place to start.

When considering the ideal agent it is important to consider the etiology of post-ROSC shock and how the different agents work. Post-ROSC patients have systemic inflammation caused by the anoxic injury that leads to vasodilation, and myocardial dysfunction related to anoxic injury and acidosis (and often an acute coronary occlusion that caused the arrest) that leads to reduced myocardial contractility. The ideal agent targets both of these factors (improves systemic vascular resistance (alpha agonists) AND cardiac contractility (Beta 1 agonists)) without having to administer multiple medications in these dynamic patients.

Dobutamine (B1) improves cardiac contractility but can cause hypotension from vasodilation, so often needs to be combined with a vasopressor. Vasopressin is a vasoconstrictor but does not affect myocardial contractility. The same is true for phenylephrine (alpha). This leaves us with dopamine, epinephrine, and norepinephrine, which all have alpha and B1 effects.

Dopamine is not commonly a first line agent in hospital. In the prehospital setting it is one of the preferred agents due to ease of storage (it's one of the most stable vasopressors in various storage settings/less temperature and light labile) as well as the ease of administration with premade mini-bag available for use.

Epinephrine would often be a great choice however, it is difficult to store. Titration of Epi without a pump is very challenging, with a higher risk of adverse outcomes and large fluctuation in rates of administration when compared to dopamine. There is the added complication of having to dilute and prepare the medication prior to administration which is prone to errors in high acuity scenarios.

For these reasons, dopamine is the preferred medication in the prehospital setting. There is some evidence suggesting effect depends on dose of administration but the reality is that a lot of this literature is very academic. In real settings the drug is often used starting at low doses and titrating rate to desired effect. It is also important to target SpO2 of 94-99% if possible (normoxia), and normal CO2 if ETCO2 measurement is possible.

Medical Directive Category

Return of Spontaneous Circulation


16 October 2023

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.