Review of EMRA PressorDex for the iPhone

Continuing its tradition of converting its reference guides to mobile app form, Emergency Medicine Residents’ Association (EMRA), has done the same with one of its most popular resources – PressorDex. PressorDex provides a therapeutic guide to using vasoactive agents, infusions, and much more in stabilizing/treating some of the most time-sensitive diagnoses in the critically ill patient.

Lets go through a quick case that might present in the ED:

20 yo F w/ no significant past medical history presents via EMS with acute onset shortness of breath. Patient received 1 round of epi en route, steroids, and was placed on non-rebreather. Upon arrival, EMS indicates no improvement in shortness of breath. You notice that the patient is having trouble moving air, wheezing, and becoming hypotensive – you suspect anaphylactic shock. You quickly decide to give another round of .3mg (1:1000) IM epi. As you give the second round, you decide to get an epi drip ready. You quickly open PressorDex and refer to the treatment page under “anaphylaxis”. There you find the infusion instructions:

“infusion: 1-2mcg/min IV, titrate by 1mcg/min q10 min”

AND what to do if an epi drip is not readily available:

“if epinephrine drip is not immediately available, add 1mL of 1:1000 OR 10mL of 1:10000 epinephrine to a 1L bag of NS to make a 1mcg/mL solution. Start at 1mL/min=1mcg/min and titrate.”

The patient’s symptoms resolve after being placed on the drip and being given the remaining adjunctive treatments. You later find out from the patient that she was recently placed on antibiotics for a strep throat.

The current EMRA mobile collection includes: Basics of EM, Antibiotic Guide, PressorDex, Peds Airway, Peds Meds, EM rashes, and EM Resident. PressorDex is not new to iMedicalApps, in fact it was recently named as a must-have, top 10 emergency medicine app by the iMedicalApps team. This article will expand on prior articles and serve as a comprehensive how-to guide for physicians treating critically ill patients in any hospital setting, not just the ED.

For longtime users of PressorDex you may notice both distinct and subtle changes made to the app after the Dec. 11th update. There seems to be no apparent change to the overall structure of the app; however, the design/look of the app is cleaner and content has been added and updated.

User Interface
The home screen displays several categories – systems, diagnosis, med categories, meds, special topics, patients, notes, dosage calculator, resources, search, bookmarks – to help the user quickly navigate through the app and find answers.

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The ‘Systems’ tab allows you to find your treatment regimen for a particular disease state based on the organ system. Alternatively, you can bypass this initial step and go directly to the diagnosis of your choice through the ‘Diagnosis’ tab, however I find that you can save yourself a few seconds of searching if you go through the ‘Systems’ tab.

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Once you choose the diagnosis, you are then taken to the step-by-step treatment guide where most of your questions will be addressed. What is the standard treatment? What are the indications for using this medication or treatment option? Are there any adjunctive treatments or other considerations I should be thinking about? My patient weighs 76kg, so what is the proper dosage of this epinephrine drip? This app is not all inclusive but if it contains your patient’s diagnosis then you will find most of the information you need for stabilization purposes. The treatment screen provides standard and adjunctive therapies with respective dosages as well as access to a dosage calculator and quick treatment pearls.

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Another way to use the app is if you already know what medication you want to use but just need clarification on dosage. There are multiple ways to access dosage, some more convoluted then others. The time consuming method is to use the “Med Categories” or “Meds” icon found on the home screen. After you select the medication, you then have to select the diagnosis (if it’s available) which will take you to the general treatment screen. At that point you have to scroll through all the treatment options in order to find the medication. This process could benefit from being more user friendly.

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The easiest method for figuring out dosing is to use the built in dosage calculator, which can be directly accessed on the home screen. When you are using the dosage calculator you have the option of picking the medication, then the indication, followed by the option to modify the patient’s weight. When “Indication” is selected you can view a summary of the dosing protocol for every available indication under the same screen. For example, if you select lebetalol, you can skim through the dosing protocol for treating aortic dissection, hypertensive emergency, eclampsia, aneurysmal subarachnoid hemorrhage, acute ischemic stroke, and cerebral edema. A unique feature of the calculator is the option of “selecting a patient”, where you can select a previously created patient profile that contains saved weight/height information.