The fear of giving epinephrine to a patient experiencing a myocardial infarction is that the effects of the epinephrine will increase the oxygen demand of an already ischemic heart. While this is true, there are situations where the benefits outweigh the risks. We would prefer the use of IV fluids in these patients unless profoundly hypotensive or if there is a contraindication to fluids, such as signs of volume overload. If IV fluids are contraindicated, fail, or if the patient is profoundly hypotensive (SBP <70), then push-dose epinephrine should be considered. While the use of epinephrine may increase myocardial oxygen demand, hypotension results in under-perfused coronary arteries which also worsens myocardial ischemia. This is a situation where there is a potential for harm either way, but we feel the benefit of correcting hypotension likely outweighs the risk of increased cardiac oxygen demand. As such, we do not recommend against the use of push-dose epinephrine in STEMI patients, but instead suggest it be used with caution when fluids have failed or if the hypotension is severe, per the Shock/Crashing Medical Patient AG.
